We aimed to assess physicians' perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. MethodsThis was a cross-sectional survey study of American emergency medicine (EM) physicians with a selfadministered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs' listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. ResultsThere were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). ConclusionBarriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.

Introduction During a hospital-based active shooter (AS) event, clinicians may be forced to choose between saving themselves or their patients. The Hartford Consensus survey of clinicians and the public demonstrated mixed feelings on the role of doctors and nurses in these situations. Our objective was to evaluate the effect of simulation on ethical dilemmas during a hospital-based AS simulation. The objective was to determine whether a hospital-based AS event simulation and debrief would impact the ethical beliefs of emergency physicians relating to personal duty and risk. Methods Forty-eight emergency physicians and physicians-in-training participated in this cohort study based in an urban academic hospital. Simulation scenarios presented ethical dilemmas for participants (eg, they decided between running a code or hiding from a shooter). Surveys based upon the Hartford Consensus were completed before and after the simulation. Questions focused on preparedness and ethical duties of physicians to their patients during an AS incident. We evaluated differences using a chi-squared test. Results Preparedness for an AS event significantly improved after the simulation (P = 0.0001). Pre-simulation, 56% of participants felt that doctors/nurses have a special duty like police to protect patients who cannot hide/run, and 20% reported that a provider should accept a very high/high level of personal risk to protect patients who cannot hide/run. This was similar to the findings of the Hartford Consensus. Interestingly, post-simulation, percentages decreased to 25% (P = 0.008) and 5% (P = 0.041), respectively. Conclusion Simulation training influenced ethical beliefs relating to the duty of emergency physicians during a hospital-based AS incident. In addition to traditional learning objectives, ethics should be another important design consideration for planning future simulations in this domain.

Introduction: The use of innovative strategies for teaching, such as flipped classroom and assembly line education, has become increasingly popular to engage learners. Residency education has been incorporating these methods to master content, develop critical skills, and improve professionalism.Methods: We created a three-part immersion experience to teach Emergency Medical Services (EMS) concepts to emergency medicine residents. Residents participated in a mass casualty incident (MCI) in which they were tasked to triage patients and allocate resources in a hospital to treat 11 victims properly. The second portion was to manage a cardiac arrest scenario in the field with the tools our EMS colleagues had available. Lastly, they were asked to create short, high-yield lectures about topics related to EMS.Results: Pre-and post-test surveys were used to assess the effectiveness of the experience in teaching residents core EMS topics. It was determined that residents not only felt more prepared for an MCI, but they also were more comfortable with their skills as a result of participating in this activity.Conclusion: Our study further highlights the benefits of non-traditional techniques in residency education. The use of immersion experiences was unique and overall a positive experience for learners. The techniques used in this activity allowed residents to gain confidence in more challenging topics for emergency physicians. This format could be applied to many more topics in the future as an innovative education technique.

Introduction Multitasking is a core competency in emergency medicine. Simulation has been shown to be an effective method of education, which allows learners to prepare for real-world challenges in a controlled environment. Methods In this study, trainees were given a scenario that simulated the experience of managing two patient encounters within a time metric while addressing interruptions that take place in a typical ED. Residents were evaluated using an internally developed scoresheet, which assessed task-switching abilities, documentation skills, and adherence to door to disposition time metric. Residents were asked to evaluate their experience with a survey. Results All the participants reported that they would translate some of the skills learned to their daily clinical practice. Five out of six residents reported improvements in their skills as a result of the task-switching training. The following three common themes were pervasive in the debrief discussion: (1) the residents felt the added pressure of the door-to-disposition metric, (2) the objectives of the simulation did not fit within their pre-constructed concept of a successful simulation equating to establishing the correct diagnosis, and (3) the interruptions were very realistic. Discussion Emergency physicians are interrupted approximately every 9-14 minutes, and this number increases with the number of patients being managed simultaneously. By developing a safe, simulated training environment, we sought to transfer key strategies for improving focus and learning to prioritize while also helping them to identify how certain pressures and interruptions affected their stress levels and concentration.

Methods: A retrospective, multi-center cohort study of adult patients who required hospitalization between March 01, 2020 and July 01, 2020 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was conducted. All data was abstracted from two rural and one urban ED in Arizona. Research assistants who were blinded to the study hypothesis were trained on proper data abstraction prior to collection. With adherence to a quality-controlled protocol and structured abstraction tool, research assistants manually collected patient demographics, intake laboratory values, initial vital signs, ICU admissions, and mortality. Data was collected using a one-to-one allocation ratio based upon ethnicity for each site. Comparisons between rural and urban populations were completed using chi-square, Mann-Whitney U, and independent samples T-tests.Results: A total of 304 patients (175 urban and 129 rural) with confirmed SARS-CoV-2 infection were admitted to the hospital during the study period. Patients presenting to a rural ED were more likely to be admitted to the ICU (24 urban vs 39 rural; OR ¼ 2.1; p¼0.01). Of those hospitalized, a total of 137 (43.9%) were female (87 [47.5%] urban and 50 [38.8%] rural). The median age of patients hospitalized from the urban cohort was 67 years old (IQR¼25) and from the rural cohort was 63 years (IQR¼28).Of those studied, 43 (14.1%) patients expired from COVID-19 with 24 (13.1%) patients in the urban cohort and 19 (14.7%) in the rural cohort (p¼0.06). Those in the rural population presented to the ED 7.0 (IQR 7) days from initial symptoms onset and those in the urban population 5 (IQR 4) (p¼0.005). Patients treated at urban EDs had a higher systolic blood pressure (138.6 mmHg vs 130.3 mmHg; p¼0.01) but lower oxygen saturation (91.7% vs 93.1%; p¼0.04) than those treated at a rural ED. When intake laboratory values were considered, patients treated in an urban ED had a statistically significant lower white blood cell count and ferritin level as compared to those at a rural ED but a higher hemoglobin, hematocrit, and calcium level (Table ).Conclusion: Rural patients with COVID-19 exhibit a delay in presentation to their local ED, producing atypical prognostic laboratory measures when compared to urban centers. This delay may contribute to symptom exacerbation and a higher rate of critical care admissions among rural patients.