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Introduction: Emergency department-based intensive care units (ED-ICU) address the increasing demand for critical care services and represent a transformative approach to the specialty’s management of critically ill patients within emergency medicine. However, data on their financial impact and operational effects remain limited. Methods: We conducted a retrospective, quasi-experimental study at an urban, academic ED with approximately 90,000 annual visits. In July 2019, a nine-bed ED-ICU model, referred to as “Next Pod,” was implemented. We analyzed Current Procedural Terminology (CPT) coding data and professional revenue (charges billed and payments received) for 35 weeks before and after the intervention (November 2018–March 2020). The intervention involved repurposing a nine-bed ED area and adjusting physician and nursing staffing models. We compared critical and non-critical care CPT coding proportions and professional revenue using the Student t-test.Results: During the study period, there were 38,283 ED visits pre-implementation and 36,424 visits post-implementation. Across the entire ED, critical care coding significantly increased following implementation (CPT 99291: 6.2 - 8.8% [total percentage increase of 41.94%]; 99292: 0.5 - 1.0% [total percentage increase of 100%]). Encounters where 99292 was billed multiple times increased by 128.1% (32 vs 73). Non-critical care coding (99282, 99283) decreased 23% (9.1% vs 7.0%, P< .001) / 29.6% (16.2 vs 11.4, P < .001), respectively. There was a non-statistically significant increase in 99284. Higher acuity codes (99285) increased by 10% (31.7% vs. 34.9%, P < .001). Average ED charges per visit increased by$40 (95% CI $ 37.2 – $45.5) post-implementation. Conclusion: The implementation of an ED-ICU was associated with significant increases in critical care and high-acuity coding, as well as enhanced professional revenue. These findings suggest that ED-ICU models can improve both fiscal performance and operational efficiency. Further research is needed to explore the contributions of resource allocation, documentation improvements, and care practices to these outcomes.

•HPV epidemiology, vaccination coverage, administration, and safety were common in online CME.•Strategies to increase vaccination and address parent concerns were less common.•Future CME should focus on pragmatic approaches to improving vaccine delivery. Addressing low HPV vaccination coverage will require U.S. health care providers to improve their recommendation practices and vaccine delivery systems. Because readily available continuing medical education (CME) could be an important tool for supporting providers in this process, we sought to assess the content of web-based CME activities related to HPV vaccination. We conducted a content analysis of web-based CME activities about HPV vaccination available to U.S. primary care providers in May-September 2016. Using search engines, educational clearinghouses, and our professional networks, we identified 15 activities eligible for study inclusion. Through a process of open coding, we identified 45 commonly occurring messages in the CME activities, which we organized into five topic areas: delivering recommendations for HPV vaccination, addressing common parent concerns, implementing office-based strategies to increase HPV vaccination coverage, HPV epidemiology, and guidelines for HPV vaccine administration and safety. Using a standardized abstraction form, two coders then independently assessed which of the 45 messages each CME activity included. CME activities varied in the amount of content they delivered, with inclusion of the 45 messages ranging from 17% to 86%. Across activities, the most commonly included messages were related to guidelines for HPV vaccine administration and safety. For example, all activities (100%) specified that routine administration is recommended for ages 11 and 12. Most activities (73%) also noted that provider recommendations are highly influential. Fewer activities modeled examples of effective recommendations (47%), gave specific approaches to addressing common parent concerns (47%), or included guidance on office-based strategies to increase coverage (40%). Given that many existing CME activities lack substantive content on how to change provider practice, future activities should focus on the practical application of interpersonal and organizational approaches for improving HPV vaccine delivery in the clinical setting.

Fibromuscular dysplasia (FMD) is a rare systemic vascular disease that has been found to present as a renal infarction (RI) in only a handful of cases.  We present a case of a 53-year-old Vietnamese patient presenting for sharp, severe left-sided abdominal pain of two-day duration associated with a migraine headache. On presentation, she was afebrile, and her vital signs were stable. Laboratory investigations were significant for mildly elevated leukocytosis but were otherwise normal. CT abdomen and pelvis with contrast revealed a left-sided renal infarct. The patient was then admitted to the hospital and started on therapeutic anticoagulation. A transthoracic echocardiogram was obtained and revealed no vegetation. CT angiography of the abdomen was pursued and was significant for mild beading within the mid-right and left renal arteries, consistent with fibromuscular dysplasia. Our patient was diagnosed with renal infarction in the setting of fibromuscular dysplasia, a combination that has been reported only a few times. Interestingly, our patient also had mild FMD based on imaging, making it even more of an unusual cause of renal infarction. This case highlights the connection between these two diseases and the need for more studies to characterize the association between them.