Point of Care Ultrasound to Expedite Emergency Department Disposition

Objectives: We sought to evaluate the impact of the implementation of student billable notes on professional level of service (PLOS) in our Emergency Departments.Methods: The primary outcome of interest was PLOS which was measured in three levels, '3 or less', '4', or '5.'A one-level increment in PLOS pre-vs post-implementation of student billable notes was studied.Billing note attributes were summarized using frequencies and percentages, and unadjusted differences were evaluated using Fisher's Exact tests.Ordinal logistic regression was used to estimate the odds of a billing note having a one-level increment in PLOS during the two billing periods, adjusting for chief complaint categories.Results: Differences in proportions of notes based on chief complaint and billing level were identified to allow for appropriate modeling.Odds ratios (OR) and 95% confidence intervals (95% CI) corresponding to billing period and all chief complaint categories were reported for the full model and a final model.Notes collected after the implementation of student billing notes had about one-fifth of the odds of having a higher-level (e.g., '4' or '5') PLOS than prior to implementation.Adjusting for billing period, billing notes with psychiatric, chest pain/shortness of breath, syncope, and generalized weakness chief complaints had higher PLOS levels, and fever chief complaints had lower. Conclusions:The two-stage model building approach was effective in constructing a parsimonious final model and identified subtle differences in billing in the two time periods stratified by chief complaint type.This information highlights the limited effect of student billable notes on ED coding levels, and provides opportunity to limit financial impact while increasing student learning in this domain.Limitations to the study include convenience sampling and a relatively small sample number that allows for only moderate effect size estimates.