Posts (153)

May 10, 2019 · Mayo Clinic EM at SAEM19

Wednesday May 15, 2019

TOP 100 abstract: 17 Pediatric Opioid Use in the Emergency Department: A 10-Year National Trend Study
Larissa Shiue, Sheagleigh Funni, Jonathan Inselman, Molly Jeffery, M. Fernanda Bellolio, Jana Anderson
Time: 1:00 PM-2:30 PM
Location: St. Thomas B- ORAL presentation

117 Subgroup Effects of a Shared Decision Making Intervention in Children With Minor Head Trauma
Rachel Michelle Skains, James L. Homme, Anupam B. Kharbanda, Leah Tzimenatos, Jeffery P. Louie, Daniel M. Cohen, Lise E. Nigrovic, Jessica J. Westphal, Nilay Shah, Jonathan Inselman, Michael J. Ferrara, Jeph Herrin, Victor M. Montori, Nathan Kuppermann, and Erik P. Hess
Time: 1:00 PM-2:30 PM
Location: Antigua B-Lightning Oral

158 Electronic Medical Record Phenotyping Accurately Identifies Opioid Use Disorder in the Emergency Department
Daniel P. Nogee, David Chartash, Hyung Paek, James D. Dziura, William K. Ross, Eric Boccio, Molly M. Jeffery, Cynthia A. Brandt, Katherine C. Couterier, and Edward R. Melnick
Time: 4:30 PM-5:30 PM
Location: Antigua B-Lightning Oral

Thursday May 16, 2019

587 Impact of Scribes on Throughput Metrics and Billing During an Electronic Medical Record Transition
Emily Schwartz, Laura Walker, Kristine Thompson, Christine Lohse, Ryan Monroe, Karen Koch, Thomas Hellmich, Heather Heaton
Time: 8:00-9:30 AM
Location: Montego A ePoster

208 External Validation of Emergency Department Derived Delirium Prediction Models Using a Hospital-Wide Cohort
Sangil Lee, Karisa Harland, Nickolas M Mohr, Grace Matthews, Erik Hess, M. Fernanda Bellolio, Jin H Han, Michelle Weckmann, Ryan Carnahan
Time: 9:00 AM-10:00 AM
Location: Jamaica A- Lighting Oral

649 Formative Evaluation for Emergency Department-Initiated Buprenorphine User-Centered Decision Support
Jessica M. Ray, Osama M. Ahmed, Yauheni Solad, Matthew J. Maleska, Shara Martel, Molly M. Jeffery, Tim Platts-Mills, Erik P. Hess, Gail D’Onofrio, and Edward R. Melnick
Time: 1:00– 2:30 PM
Location: Montego A ePoster

687 Women in the Pipeline: Chief Residents in Emergency Medicine
Laura E. Walker, Heather Heaton, Nicole Battaglioli, Annie Sadosty
Date: Thursday May 16, 2019
Time: 3:00-4:00 PM
Location: Montego A ePoster

Friday May 17, 2019

343 Rates of Emergency Department return among patients with dementia
Jessica A. Stanich, Molly M. Jeffery, Susan M. Bower, Laura E. Walker, Ronna L. Campbell, Paul Takahashi, M. Fernanda Bellolio
Time: 9:00 AM-10:00 AM
Location: Antigua A-Lightning Oral

784 Efficacy of Retreats on Resident Wellness as Measured by Maslach Burnout Index Analysis
Shelby Hopp, Kristyn McLeod, Emily Schwartz, Jim Colletti, Christine Lohse, M. Fernanda Bellolio
Time: 11:00 AM – 12:30 PM
Location: Montego A-ePoster

Sep 23, 2018 · Mayo Clinic at ACEP Scientific Assembly 2018


Sunday Sep 30

All day

ACEP Council Meeting

Venk Bellamkonda, Heather Heaton and David Nestler



Monday Oct 1



QI, operations and administrative job opportunities (EMRA). Ranch Santa Fe, N Tower. 3rd Floor.

Venk Bellamkonda.

4:00pm – 5:00pm


Clinical features associated with nonhistaminergic and histaminergic angioedema in emergency department patients

Lucas Oliveira J. e Silva, Xiao-wei Liu, Ronna L. Campbell, David W. Barbara, Kiran Goyal, Ana Castaneda-Guarderas, Benjamin J. Sandefur.


Tuesday Oct 2

9:00am – 10:15am


Predictors of 30-day return visits among octogenarians presenting to the Emergency Department

Fernanda Bellolio, Jessica Stanich, Laura Walker, Ronna Campbell, Nataly Espinoza, Molly Jeffery.

EMF. Paths of ED Care: Facilitating shared decision-making in goals of care discussions in the acute setting

Laura Walker, M. Fernanda Bellolio, Mike Wilson, Bjorg Thorsteinsdotti, Kevin Shaw, Ian Hargraves, Erik Hess


Everyone loves a popsicle— a simple and affordable intervention to improve patient satisfaction

Jacob Voelkel, Ryan Finn, M. Fernanda Bellolio, Jeff Wiswell.


The satisfaction of empathy. QIPS Lecture.

Ashley Sievers. Convention Center, Upper Level, Room 10.



10:45am – 12:00pm


Validation of the Elderly Risk Assessment Index in the Emergency Department

Nataly Espinoza, Laura Walker, Jessica Stanich, Molly Jeffery, Ronna Campbell, Paul Takahashi, M. Fernanda Bellolio.


Prevalence of Pediatric Pain-Related Visits and Opioid use in the Emergency Department

Jana Anderson, Shealeigh Funni, Molly M. Jeffery, M. Fernanda Bellolio.



4:00 pm- 5:00 pm


Effectiveness and safety of droperidol in an emergency department in United States

Charlene M. Gaw, Daniel Cabrera, M. Fernanda Bellolio, Alicia E. Mattson, Molly M. Jeffery.



5:00pm – 6:00pm.


The Impact on ED Visits with a Telemedicine Program Interfacing with a Nurse Triage Call Line

Christopher Russi, Kerie Olson,  Debra Cox, Elizabeth Fogelson, Alex Beuning, Skip Powell, Peter Smars


Sep 23, 2018 · Effect of the Head CT Choice Decision Aid in Parents of Children With Minor Head Trauma

Authors: Erik Hess, MD (UAB)

Comment on: Hess, Homme et al. Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head TraumaA Cluster Randomized Trial. JAMA Open.

Each year, 450,000 children present to U.S emergency departments for evaluation of head trauma.  Physicians obtain head computed tomography (CT) scans in 37%-50% of these patients, with less than 10% showing evidence of traumatic brain injury and only 0.2% that require neurosurgical treatment.  In order to avoid unnecessary CT scans and to limit radiation exposure, the Pediatric Emergency Care Applied Research Network (PECARN) developed 2 clinical prediction rules, one for children less than 2 years of age and one for children 2-18 years of age. Each of these clinical prediction rules consist of 6 readily available factors that can be assessed from the history and physical examination.  If none of these risk factors are present, a CT scan is not indicated.  If either of 2 high risk factors such as altered mental status or signs of a skull fracture are present, CT scanning is indicated.  If 1 or 2 non-high risk factors such as vomiting or a history of loss of consciousness are present, then either CT scanning or observation are recommended, depending on considerations such as parental preference, clinician experience and/or symptom progression.  This study designed a decision aid, “Head CT Choice” to educate parents about the difference between a concussion – which does not show up on a CT scan – and a more serious brain injury causing bleeding in or around the brain.  The decision aid also shows parents their child’s risk for a serious brain injury – less than 1% risk in the majority of patients in the trial – and what to observe their child at home for should they opt not to obtain a CT scan, along with the advantages and disadvantages of CT scanning versus home observation.  This trial did not observe a difference in the rate of head CT scans obtained in the ED but did find that parents who were engaged in shared decision-making using Head CT Choice were more knowledgeable about their child’s risk for serious brain injury, has less difficulty making the decision because they were clearer about the advantages and disadvantages of the diagnostic options, had greater trust in their clinician and were more involved by their clinician in decision-making.  Parents also less frequently sought additional testing within 1 week of the emergency department visit.

Aug 2, 2018 · The opioid epidemic

Author: Molly Jeffery PhD @mollyjeffery

Commentary about: Jeffery at al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 2018.

With all the attention that is being paid to opioid prescribing over the past few years, we wanted to know whether we’re moving the needle: are fewer people taking opioids now than a few years ago?

Surprisingly, we found that the percentage of people who take opioids hasn’t changed much since the rates started to level off in about 2012. Specifically, among commercially insured people—people who generally get their health insurance from their or a family members’ employer—and people aged 65 and older who have Medicare Advantage insurance, we have seen very little change in the proportion of people taking prescribed opioids.

In the third population we looked at—people with long-term disabilities who have Medicare Advantage—we saw minor changes, but use has been nearly flat since 2012. And in all three groups, use was higher in 2016 than at the beginning of the study in 2007.

What does this mean?  The United States uses opioids in a way no other country does. We use nearly twice as much opioids per person as the next closest countries (Canada and Germany), and about 7 times as much as the UK. We don’t know the ideal level of opioid use that balances risks and benefits to patients and societies, but it seems pretty clear that we in the US are above that ideal level.

To change that, we need to address two different problems. First, we need to do a better job with opioids for acute pain, and there may be a role for emergency medicine in that effort. In earlier work (

), we found that first-time opioid prescriptions (that is, prescriptions for people who haven’t taken opioids in at least 6 months) written in the emergency department were for shorter durations and lower doses than first-time prescriptions written in other settings. Still, researchers at UPenn have found substantial national variation ( in the proportion of people being treated for ankle sprains in the ED, with state rates as high as 40% and as low as 3%.

Some health systems have had success reducing opioid prescriptions by instituting voluntary prescribing guidelines. Here at Mayo Clinic, the department of orthopedic surgery looked at their data on opioid prescribing after surgery and developed a voluntary guideline that resulted in a nearly 50% reduction in the volume of opioids prescribed after hip and knee replacement surgeries  (doi: 10.1007/s11999.0000000000000292). And this was accomplished without an increase in the proportion of patients requesting refills. In other words, the new lower prescribing does not seem to have negatively impacted patient pain control.

The second problem we need to address is opioid prescribing for chronic pain. Our study found that in the commercially insured population, the 3% of opioid use episodes that represented long-term use were associated with 62% of all opioids dispensed to that group. The scientific evidence suggests that on average, long-term opioid use is not an effective treatment for chronic pain ( Some patients are able to achieve improved functioning and pain reduction when using opioids long term, but most are not. We desperately need more effective treatments for chronic pain and better access to non-opioid treatments we already have. For example, multidisciplinary pain programs have been found to help patients with chronic pain improve function and pain management, but they can be expensive and difficult to access, with some insurers reluctant to cover them. (

Some have suggested that we need laws or policies to cut off access to high dose or long-term opioid therapy. The trouble with that is that there is no such thing as a one-size-fits-all treatment plan for pain. Different types of pain respond to different treatments, and so do different patients. Policies that require the insurance company to sign off on an opioid dose above some level can have an unfair impact on patients with fewer resources. If you have the cash to pay, you can fill that high dose prescription written by your physician. But if you need your insurance company to pay, you may have to leave the pharmacy without your medication. You may have to spend substantial time on the phone to get the treatment approved. You may have to wait until the physician and insurance company contact each other. It’s not the right way to treat people.

Reducing prescribed opioid use is going to take time to do humanely and effectively. It will take partnership between providers and patients, but it can be done.

Jun 14, 2018 · Blockchain: A new technology for health professions education

Author: Eric Funk, MD @efunkem


This is commentary of Funk et al. Blockchain Technology: A Data Framework to Improve Validity, Trust, and Accountability of Information Exchange in Health Professions Education. Academic Medicine. In press.

Since the inception of Bitcoin in 2009, the use of blockchains has steadily gained attention. What began as mild interest from computer scientists has now grown to a fervor pitch. The initial impacts have been seen in the world of finance and are now spreading to many other sectors. More recently, thought leaders and entrepreneurs have begun to explore how the idea of blockchain could be used to improve healthcare. The obvious progression of this idea is to explore how blockchain will influence the education and training of healthcare workers. In our recent paper in Academic Medicine, we have laid out a basic framework for how blockchain could impact healthcare education.

Healthcare education has a long history of adopting new technological innovations in order to improve student’s learning. This has included MOOCs, digital platforms, and the #FOAMed movement. Using blockchains to improve education is the logical next step.

What is blockchain?

It’s a new way of storing data. Most people don’t think about how their data is stored, but it has a large impact on how the data can be used. In a blockchain, a recording of every transaction between users during a time period is group together in a “block”. These blocks are then “chained” together in chronological order. The recording of transactions and linking of blocks are done with advanced mathematics. Fortunately, it is not necessary for end-users to understand all of the technical concepts in order to benefit from using a blockchain (just as it is not necessary to know how to build an engine in order to drive a car). The chain of blocks is completely open and can be inspected by anyone to see the entire history of interactions. Since every single person involved can inspect the blockchain, it is nearly impossible to change the record of events.

How can blockchain allow educators to better track their impact?

It has traditionally been very difficult for clinical educators to get credit for their work, especially compared to their peers who focus primarily on research output. Recording this information in the blockchain will easily allow educators to track their impact as their students ultimately become educators themselves, and pass along their knowledge to each subsequent class of students. It will also allow for easy tracking of the most utilized and most effective learning modules.

How can blockchain make CBME (competency based medical education) and EPAs (Entrustable Professional Activities) better?

The blockchain can serve as a digital ledger of the behaviors that are critical for assessment. This will allow learners to easily see how they compare to their peers at various other universities or institutions. One significant improvement is that this system allows for asynchronous evaluation of milestones, that are completed independent of location. It better allows learners to progress through the required knowledge at their own pace.

How can blockchain improve credentialing?

Using a blockchain allows for one decentralized database of information. Anyone who has recently applied for medical licenses in multiple states or gone through the process of applying for hospital privileges will be able to appreciate this benefit. Rather than combing through information that is scattered across multiple different sources, a decentralized blockchain will be able to efficiently store this information. There will be easily accessible proof of completing a degree, diplomas, certifications in other states, procedure logs, etc… rather than trusting unverified information coming from various sources.

These ideas represent the potential benefit that blockchain could bring to medical education. They do not represent a prediction of the future or a magical solution for all the problems facing educators and students. Many blockchain platforms already exist that could be used to implement these ideas (Ardor and Ethereum being a few of the more technologically advanced and accessible blockchain platforms), or new ones could be created. The next step in exploring these ideas will be for developers and forward-thinking educators to join forces and begin producing real-life products that allow for implementation of these ideas. The future is bright.




May 22, 2018 · Addressing the Active Shooter Challenge through In-situ Simulation

Author: Mark Mannenbach, MD. @MMannenbach

Commentary on: Mannenbach et al. An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department. in Disaster Medicine and Public Health Preparedness

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for this low-frequency, but extremely high stakes event.  Engagement of all emergency department personnel can be very challenging due to a variety of barriers including perception of lack of time, likelihood of occurrence, or interference with actual patient care

Our department chose to utilize an in situ simulation training model as a component of active shooter education for our academic emergency medicine practice.  Although a variety of modalities can be utilized for this type of training, we felt that an in situ model allowed for our emergency department personnel to engage actively in the experience.  We did so with some hesitation as we felt that the experience may be “too realistic” for some members of the department.  However, we felt that this approach allowed for the greatest degree of engagement and ownership of the need for awareness and personal decision-making.

We were intentional in our inclusion of as many disciplines as possible for each scenario session.  Leaders from physician, nursing, security, registration, laboratory medicine, and radiology technology were chosen to participate in the planning process.

We utilized both mannequins and live standardized patients to specifically address the need for incorporation of real patients as a factor for emergency department personnel to consider as they processed their reactions and plans for the scenario.

These scenarios were conducted in care areas of our emergency department where actual patients were not present at the time.  The scenarios were also conducted at a time when the attending physicians were present for a mandatory monthly meeting to improve their involvement in the process outside of their usual clinical assignments.

Debriefing occurred after each of the brief 10 minute scenarios and included feedback and direction from physician and security experts in regard to the preferred approach of “RUN, HIDE, FIGHT” when faced with an active shooter situation.  Careful attention was paid by those overseeing the scenarios to allow for identification of the triggering of any emotional or psychological stress as a result of participation.

With this approach and planning, we were able to include nearly all of the attending physicians as well as many resident physicians, nursing staff, and other emergency department personnel over the course of several months.

The feedback from the participants was overwhelmingly positive in terms of increased awareness, educational value, and planning for an actual event.  Those involved felt that the scenarios created realism without undue stress.

Although our approach may not be translated exactly to other emergency departments, we hope that our approach and lessons learned can be applied by others and they are planning and preparation for these potentially devastating events.

As recent as this week, several reports have emerged about US emergency departments are not ready for “mass tragedy”. Our article highlights the need to develop explicit training about events potentially leading to mass casualties.


Further details of our work can be found in an upcoming issue of Disaster Medicine and Public Health Preparedness.

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