BackgroundHigh-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions. The degree to which high fidelity simulation elicits acute emotional and physiologic stress among participants – and the influence of acute stress on clinical performance in the simulation setting – remain areas of active exploration. We examined the relationship between residents’ self-reported anxiety and a proxy of physiologic stress (heart rate) as well as their clinical performance in a simulation exam using a validated assessment of non-technical skills, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS).MethodsThis was a prospective observational cohort study of emergency medicine residents at a single academic center. Participants managed a simulated clinical encounter. Anxiety was assessed using a pre- and post-simulation survey, and continuous cardiac monitoring was performed on each participant during the scenario. Performance in the simulation scenario was graded by faculty raters using a critical actions checklist and the Ottawa GRS instrument.ResultsData collection occurred during the 2011 academic year. Of 40 eligible residents, 34 were included in the analysis. The median baseline heart rate for participants was 70 beats per minute (IQR: 62 – 78). During the simulation, the median maximum heart rate was 140 beats per minute (IQR: 137 – 151). The median minimum heart rate during simulation was 81 beats per minute (IQR: 72 – 92), and mean heart rate was 117 beats per minute (95% CI: 111 – 123). Pre- and post-simulation anxiety scores were equal (mean 3.3, IQR: 3 to 4). The minimum and maximum Overall Ottawa GRS scores were 2.33 and 6.67, respectively. The median Overall score was 5.63 (IQR: 5.0 to 6.0). Of the candidate predictors of Overall performance in a multivariate logistic regression model, only PGY status showed statistical significance (P = 0.02).ConclusionsSimulation is associated with physiologic stress, and heart rate elevation alone correlates poorly with both perceived stress and performance. Non-technical performance in the simulation setting may be more closely tied to one’s level of clinical experience than to perceived or actual stress.

The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS).Methods: We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC.Results: We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (!85%). In the very-lowand low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS. Conclusion:The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

Key Points Question Can an electronic health record–linked clinical decision support tool reduce the use of diagnostic imaging in children and adolescents with emergency department visits for acute abdominal pain? Findings In this cluster randomized trial of 17 emergency departments caring for 5940 patients, the clinical decision support tool did not lead to an overall reduction in the use of computed tomography or ultrasonography. In 1 health care system, the clinical support tool was associated with a significant reduction in diagnostic imaging among patients at low or moderate risk of appendicitis. Meaning These findings suggest that more research is needed to determine whether clinical decision support tools promote more appropriate imaging in patients with acute abdominal pain.

Objectives Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. Methods This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right‐sided or diffuse abdominal pain using a Web‐based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c‐statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. Results Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c‐statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low‐risk strata (appendicitis rate = 1.1% in gestalt 1%–10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). Conclusion Physician gestalt for acute appendicitis diagnosis performed well, especially in low‐risk patients and when employed by experienced physicians.