Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.

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we performed a multi-center survey study at 9 emergency medicine residencies nationally, administering the MBI and four additional validated wellness instruments. Quality of Life (QOL) was assessed by a single-item linear analog scale assessment: "How would you rate your overall quality of life during the past week?" High QOL was defined as >80, moderate 60-80, and low <60. Work-Life Balance was assessed with the question "My work schedule leaves me enough time for my personal/family life." Responses of strongly agree and agree were categorized as positive for work-life balance. Career satisfaction was assessed by a single-question: "If given the opportunity to revisit your career choice, would you choose to become a physician again?" Responses of "likely" and "very likely" were categorized as positive for career satisfaction. Provider depression was screened using the first two items of the Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument. A "yes" response to either question was considered a positive screen for depression.Results: A total of 261/334 residents responded, for a total response rate of 78%. Data were analyzed using Pearson's correlation, chi-square, or t-test as appropriate for continuous or categorical variables. Residents' impressions of their quality of life was significantly correlated to burnout indices with lower QOL being associated with higher emotional exhaustion (r ¼ -0.437, p<0.0001), higher depersonalization (r ¼ -0.18, p<0.005), and lower personal accomplishment (r ¼ 0.347, p<0.001). Scores on the work-life balance rating correlated with MBI emotional exhaustion (p<0.001) and depersonalization (p<0.009) though not personal accomplishment. The feeling of having made an appropriate career choice was significantly associated with lower emotional exhaustion (p<0.0001), lower depersonalization (p<0.005), and higher personal accomplishment (p<0.05). The prevalence of a positive depression screen in our survey sample was 40%. Screening positive for symptoms of depression was also significantly associated with higher emotional exhaustion, higher depersonalization, and lower personal achievement (all p<0.0001).Conclusions: In this multi-center survey study of emergency medicine residents we found that increasing levels of burnout were associated with perceived lower quality of life, poor work-life balance, lower satisfaction with the choice of medicine as a career, and a higher rate of screening positive for depression. Use of the Quality of Life Scale, Work Life Balance rating, assessment of career satisfaction, and Primary Care Evaluation of Mental Disorders instrument in addition to the MBI may provide a more global assessment of resident wellness and inform decisions about targeted wellness interventions. These findings also support the development of a formal wellness curriculum that can be incorporated into resident education.