Background: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction (MI) or to exclude major adverse cardiac events (MACE) among Emergency Department (ED) patients with possible acute coronary syndrome (ACS). However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with HEART scores for excluding MACE in a multisite US cohort. Methods: A prospective cohort study was conducted at 8 US sites, enrolling adult ED patients with symptoms suggestive of ACS and without ST-elevation on electrocardiogram. Baseline and 1-hour blood samples were collected and hs-cTnT (Roche, Basel Switzerland) measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, MI, and coronary revascularization) at 30-days was adjudicated. The proportion of patients with initial hs-cTnT measures <LOQ and risk based on a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. Results: Among 1,462 participants with initial hs-cTnT measures, 46.4% (678/1,462) were women and 37.1% (542/1,462) were African American with a mean age of 57.6 (SD±12.9) years. MACE at 30-days occurred in 14.4% (210/1,462). Initial hs-cTnT measures <LOQ occurred in 32.8% (479/1,462), yielding a NPV of 98.3% (95%CI: 96.7-99.3%) for 30-day MACE. A low risk HEART score with an initial hs-cTnT < LOQ occurred in 20.1% (294/1,462) yielding a NPV of 99.0% (95%CI: 97.0-99.8%) for 30-day MACE. A 0/1-h algorithm was complete in 1,430 patients, ruling-out 57.8% (826/1,430) with a NPV of 97.2% (95%CI: 95.9-98.2%) for 30-day MACE. Adding a low HEART score to the 0/1-h algorithm ruled-out 30.8% (441/1430) with a NPV of 98.4% (95%CI: 96.8-99.4%) for 30-day MACE. Conclusions: In a prospective multisite US cohort, an initial hs-cTnT 99% for 30-day MACE when used alone or with a HEART score. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02984436

Because healthcare providers may be experiencing moral injury (MI), we inquired about their healthcare morally distressing experiences (HMDEs), MI perpetrated by self (Self MI) or others (Others MI), and burnout during the COVID-19 pandemic. Participants were 265 healthcare providers in North Central Florida (81.9% female, M_age = 37.62) recruited via flyers and emailed brochures that completed online surveys monthly for four months. Logistic regression analyses investigated whether MI was associated with specific HMDEs, risk factors (demographic characteristics, prior mental/medical health adversity, COVID-19 protection concern, health worry, and work impact), protective factors (personal resilience and leadership support), and psychiatric symptomatology (depression, anxiety, and PTSD). Linear regression analyses explored how Self/Others MI, psychiatric symptomatology, and the risk/protective factors related to burnout. We found consistently high rates of MI and burnout, and that both Self and Others MI were associated with specific HMDEs, COVID-19 work impact, COVID-19 protection concern, and leadership support. Others MI was also related to prior adversity, nurse role, COVID-19 health worry, and COVID-19 diagnosis. Predictors of burnout included Self MI, depression symptoms, COVID-19 work impact, and leadership support. Hospital administrators/supervisors should recognize the importance of supporting the HCPs they supervise, particularly those at greatest risk of MI and burnout.

Objectives. To assess the impact of a scribe program on an academic, tertiary care facility. Methods. A retrospective analysis of emergency department (ED) data, prior to and after scribe program implementation, was used to quantitatively assess the impact of the scribe program on measures of ED throughput. An electronic survey was distributed to all emergency medicine residents and advanced practice providers to qualitatively assess the impact of the scribe program on providers. Results. Several throughput time measures were significantly lower in the postscribe group, compared to prescribe implementation, including time to disposition. The left without being seen (LWBS) decrease was not statistically significant. A total of 30 providers responded to the survey. 100% of providers indicated scribes are a valuable addition to the department and they enjoy working with scribes. 90% of providers indicated scribes increase their workplace satisfaction and quality of life. Conclusions. Through evaluation of prescribe and postscribe implementation, the postscribe time period reflects many throughput improvements not present before scribes began. Scribe Program implementation led to improved ED throughput for discharged patients with further system-wide challenges needing to be addressed for admitted patients.

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Cervical vertebral AV fistulae are uncommon vascular lesions involving abnormal communication between the extradural vertebral artery and surrounding venous structures. We examine the case of a female evaluated in the emergency department with a vertebral AV fistula presenting classically as pulsatile tinnitus and later successfully treated with standard endovascular techniques. A discussion on the etiology, pathophysiology, and management of vertebral AV fistulae follows.