Comparison of a formatted versus traditional sign out process for physicians in the emergency department

a b s t r a c t

Introduction: Frequent interruptions, critically ill patients, and high patient turnover can make Emergency Department (ED) physician transitions of care (TOCs) challenging. Currently, there is no strict format for TOC in the ED. We structured a formatted ED TOC and evaluated the comparative effects from traditional TOC practice on the perceived quality of sign-out among physicians working in the ED. Methods: We performed a prospective pre/post-interventional study utilizing convenience sampling in an urban community teaching hospital. The primary outcome was perceived quality of sign-out, as evaluated by the in- coming physician one-hour after TOC, using the handoff-Clinical Evaluation Exercise (h-CEX) score with a 9-point scale for each category: Organized/Efficient, Communications Skills, Included Pertinent Information, Clin- ical Judgment, Patient Focused, Setting, and Overall Sign-Out Quality. Additional evaluation of unexpected tasks and errors from TOC w performed.

Results: We included 344 patient TOC observed, of which 147 (43%) were formatted interventions while 197 (57%) were standard TOCs. After analysis in a random effects model, statistically significant improvements among resident physicians were seen for the formatted TOC: patient focused (mean difference 0.40), setting (mean difference 1.05), and overall (mean difference 0.68). The rate of unexpected tasks and errors were higher in the standard TOC, though not statistically significant.

Conclusion: Resident physicians saw improvement in several h-CEX categories with a formatted TOC. Consistent with prior studies, a formatted TOC for emergency medicine should be strongly considered, especially among learners.

(C) 2022

  1. Introduction

The physician transition of care (TOC) process, commonly referred to as “sign-out,” is essential to safe and efficient clinical care, as well as patient satisfaction. Errors in the process, such as omitted information, transfer of erroneous information, and misinterpretation of verbal com- munication can result in delays in patient care and adverse events or even death [1]. Indeed, a study by the Joint Commission on Accredita- tion of Healthcare organizations named physician communication er- rors as responsible for over 60% of sentinel events [2]. Resultantly, the Joint Commission [3] and the Accreditation Council for Graduate

* Corresponding author.

E-mail address: [email protected] (B.E. Schwartz).

Medical Education [4] both put forth recommendations for implemen- tation of a standardized approach for team hand off-communications.

The atmosphere of the emergency department (ED), often with fre- quent interruptions, critically ill and Agitated patients, and high patient turnover converge to make ED TOC challenging [5-7]. Currently, there is no standardly agreed upon format for TOC in the ED: a study by Sinha et al. found that 89.5% of polled academic EDs have no formalized sign-out process, despite the fact that 72.3% of program directors affirm that a more formalized sign-out process would improve patient care and reduce Medical error [8]. Multiple studies have evaluated applying a standardized format for TOC in the ED, but no formatted TOC tools to this point have been validated for the ED [9-12].

This study sought to compare the effect of formatting ED TOC on the perceived quality of sign-out by physicians working in the ED as well as


0735-6757/(C) 2022

the formatted TOC’s effect on the quantity of self-reported physician un- expected tasks and patient-related errors. To evaluate the TOC’s ob- served, we utilized the modified handoff-Clinical Evaluation Exercise (h-CEX) tool, currently one of the few validated instruments to quanti- tatively evaluate transitions of care [13-15]. The h-CEX tool utilizes a 9-point rating score, with an overall sign out quality score as well as 6 subdomains: organization, communication, content, clinical judgment, patient focused, and setting. We hypothesized that a formatted TOC would have higher perceived overall quality scores, as well as decrease the number of self-reported unexpected tasks and errors resulting from TOC, regardless of Experience level, for both attending and resident phy- sicians working in the ED. To encourage physicians to utilize a formatted TOC we developed a format that required minimal additional educa- tional training for its use.

  1. Methods
    1. Study design and setting

We conducted a prospective pre/post-interventional study of physi- cians and residents working in the acute/main side of the ED at an urban community hospital in XXX, with approximately 42,000 visits per year from October 1, 2018 to May 10, 2019. Working at the site were 23 full-time and 7 part-time emergency medicine (EM) attendings, all with American Board of Emergency Medicine eligibility or certification. Additionally, our site helps train EM residents from the XXX (including postgraduate year [PGY] 1-3 EM residents, PGY 4 EM/pediatrics resi- dents, and PGY 4 EM/internal medicine residents), as well as Family Medicine residents (PGY-1-3) and Internal Medicine Residents (PGY-1 and PGY-3) from the same community hospital in which the study was conducted. In each month, there are typically 3-4 emergency med- icine residents, 1-2 internal medicine residents, and 1 family medicine resident rotating through the emergency department. When overlap- ping resident coverage allowed, typically in the evening shift, a resident would sign out to another resident; otherwise, the TOC occurred from attending-to-attending physician. All participating physicians were consented prior to enrollment in our study. The study was approved by our institutional review board and the study’s principles were in ac- cordance with the Declaration of Helsinki.

    1. Physician selection

Using convenience sampling, TOC between physicians was evalu- ated and data was recorded on a data collection form (Supplementary Fig. 1) by trained research assistants (RAs).

    1. Study measures

To limit error, the data collected by the RAs, other than the total time of each sign-out process, was binary. Prior to implementation of the study, RAs were trained on each of the data points through didactic ses- sions, watched 3 recorded asynchronous videos of a sign-out process, and were required to pass a test based on a video recorded sign-out, maintaining a kappa of >0.7 prior to being eligible to enroll physicians in the study. A modified h-CEX scale (Fig. 1) was filled out by the physi- cian who received sign-out (“incoming physician”) 1 h after TOC. The incoming physician also completed a safety questionnaire 4 h after sign-out completion (Supplemental Fig. 2). These tools were provided to the incoming physician by RAs to assure they were completed at the appropriate times.

Our intervention (which we called a “formatted” TOC versus a rou- tine “standard” TOC) provided a format that physicians were requested to follow during sign-out (Fig. 2). We developed our formatted TOC after performing a literature review, consulting with content experts, and generating a flow map of current state TOC (Supplemental Fig. 3). This current state flow map helped us to generate a gaps assessment

and a formatted TOC was developed, incorporating expert consensus and in conjunction with ED leadership and support [3]. We chose our formatted TOC over previously developed methods (ie. I-PASS) as it was hypothesized that our physician group would be more amenable to its adoption since required minimal additional training for the physi- cians included in the study.

An introductory email on the formatted sign-out was provided by the physician researchers prior to study initiation. Additional questions were answered about the study during the physician consenting pro- cess. Physicians’ sign-outs were observed for the month of September 2018 prior to our intervention, a 1-month acclimation intervention pe- riod was established during October, and post-intervention data was collected from November 1, 2018 until May 10, 2019. Among the pre- intervention format the most common type of handoff observed in- volved a physician face-to-face handoff with paper notes taken by the incoming physician.

RAs evaluated and documented whether the format was followed, and if it was followed for >80% of the sign-out. RAs collected data in- cluding: attending or resident physician signing out, PGY year and spe- cialty, time of sign-out at 6-h intervals starting at 6 am, whether the formatted TOC was used, method of sign-out (face to face at worksta- tion or bedside rounding), whether either or both physicians used a computer, whether there was confirmation of testing/imaging/medica- tions by either or both physicians, whether incoming physician made computer or paper documentation or both, whether “repeat back tech- nique” was used, whether clarification was needed, whether requests for additional information were made, time it took to complete the sign-out process in seconds using a stopwatch, and information on in- terruptions if there were any, including number and cause of interrup- tions as well as if any interruptions lasted >30 s.

Physicians that consented to the study were assigned a doctor iden- tification number, blinded to the physician, so that pre- and post- intervention comparisons could be analyzed.

Exclusion criteria included TOC utilizing the formatted sign-out for

<80% of the time and for data entries missing which type of sign-out, formatted or standard, was performed.

    1. Study outcomes

Our primary outcome was the mean h-CEX score between our for- matted TOC and a standard sign-out among physicians working in the ED.

Secondary outcomes include the number of self-reported unex- pected tasks completed after sign-out and patient errors that occurred, as well as mean time included in the TOC.

    1. Data collection and management

The data collected by the RAs was transferred from paper onto a standard database software (Microsoft Excel). Two independent RAs performed data entry and any discrepancies were adjudicated by the in- vestigator of the study.

    1. Sample size calculation

Assuming a normalized distribution, and applying t-test, with a 2-sided alpha of 0.05 and a beta of 0.80, an estimated 52 sign-outs, 26 for each grouping, were thought be needed to detect a change of 3 points for each category of the h-CEX assuming a SD of 1.5, as seen with prior studies [14,15].

    1. Analysis

Categorical data was reported as counts and percentages while com- parisons between the proportions of the groups were performed with Pearson Chi-square analysis. For continuous data, the mean and



Please circle a NUMBER or response for the below question

      1. Organization/ efficiency (?Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

Disorganized; Standardized sign-out;

rambling concise

1 2







7 8 9




Not face to face; Face-to-face sign-out

Understanding not confirmed; Understanding confirmed

No time for questions; Questions elicited

Responsibility for tasks unclear Responsibility for tasks clearly assigned

Vague Language Concrete language

      1. Content (? Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

Information omitted or irrelevant All essential information included

clinical condition omitted Clinical condition described

‘to dos’ lack plan, rationale ‘to dos’ have plan, rationale

      1. Clinical judgment (? Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

No recognition of sick patients sick patients identified

No anticipatory guidance anticipatory guidance

provided with action plan

      1. Patient Focused (? Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

hurried, inattentive focused on task

inappropriate comments re: patients, family, staff appropriate comments

      1. Setting (? Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

>= 5 interruptions no interruptions

noisy, chaotic minimal noise

Overall sign-out quality (? Check if not observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

Fig. 1. Physician evaluation of sign-out (Handoff-Clinical Evaluation Exercise), 1-h after sign-out. TO BE DISTRIBUTED TO PROVIDER (INCOMING Physician FROM SIGN-OUT).


standard deviation were calculated, while the groups were compared using the Mann-Whitney U test.

A logistic regression model with random effects was utilized to as- sess the effect of the type of sign-out process on sign-out variables. The random effects considered in all the models were the incoming physician, the outgoing physician, and their interaction. The conditional odds ratio (OR) with identical random effects for the intervention group

was compared to the standard sign-out and the confidence interval (CI) of these ORs were calculated, and corresponding p-values were also provided. A linear mixed model was used as a predictor of the treatment group to test its significance on the secondary outcome characteristics of sign-out. In all comparisons, p-value <=0.05 was considered statisti- cally significant. Statistical analyses were performed using the software SAS (Statistical Analysis Software 9.4, SAS Institute Inc).

For All Patients: Last Name, Patient/Bed Location, Active Patient or


Active patient sign-out to include:

        1. Chief complaint and relevant PMH
        2. ED course and relevant labs
        3. Diagnosis or likely diagnosis
        4. Pending activities
        5. Expected disposition

Admitted/Dispositioned patient sign-out to include:

  1. Chief complaint and relevant PMH
  2. Diagnosis
  3. Admitted team
  4. Code status if pertinent/known

Fig. 2. Formatted sign-out.

For All Patients: Last Name, Patient/Bed Location, Active Patient or Admitted/Dispositioned.

  1. Results

We included a total of 344 patient sign-out sessions, 147 (43%) of which were formatted and 197 (57%) standard sign-out sessions in the acute/main side of the ED over a period of 8 months (Fig. 3). 279 (81%) of the sign-outs were between American Board of Emergency Medicine eligible or certified emergency physicians, while 65 (19%) were between resident physicians of varying training levels from three specialties: EM, Internal Medicine, and Family Medicine.

Of the characteristics of the sign-out sessions collected, there were minimal significant differences between the standard and formatted TOC groupings aside from an increased interruptions per sign-out ses- sion in the formatted group (Table 1). There were no statistically signif- icant findings comparing the post-intervention formatted versus standard TOC in self-reported unexpected tasks (2 versus 9), or errors (0 versus 1). A random effects model (Supplemental Table 1) for sign- outs did not reveal any prominent findings, as evaluated with an OR and resultant CIs between the standard and formatted TOC groupings for various items: number of interruptions, time of day of sign-out, phy- sician training level, or means of recalling or recording data.

Among the 7 categories on the h-CEX scale filled by incoming physi- cians there was significant differences in scoring for the formatted TOC



Sign-outs Observed by Research Assistants (n =416)


Total Sign-outs During Time Period

(n =1,105)

Fig. 3. CONSORT diagram showing the derivation of the study sample XXX Acute/Main Side Emergency Department Observed Sign-outs: October 1, 2018 to May 10, 2019.

Formatted (n =147)

Standard (n =197)


Included Sign-outs (n =344)

Sign-outs excluded due to:

Formatted Sign-out Less Than 80%(n=66)

No Documented Sign-out Type (n=6)

Characteristics of sign-out for all patients.



Formatted N (%)

Standard N (%)


General characteristics

Total Number of Sign-Outs (N)


147 (43)

197 (57)

Sign-Out Physician Level of Experience, N (%)


Attending to Attending


121 (43)

158 (57)

Resident to Resident


26 (40)

39 (60)

Outgoing resident specialty, N (%)




17 (43)

23 (57)



3 (75)

1 (25)



5 (26)

14 (74)

Outgoing PGY Level, N (%)




10 (50)

10 (50)



5 (31)

11 (69)



10 (37)

17 (63)

Incoming Resident Specialty, N (%)




16 (35)

30 (65)



3 (50)

3 (50)



6 (55)

5 (45)

Incoming PGY Level, N (%)




4 (33)

8 (67)



8 (35)

15 (65)



13 (46)

15 (54)

Time of Day of Sign-Out, N (%)


6 am-12 pm


30 (38)

48 (62)

12 pm-6 pm


48 (50)

48 (50)

6 pm-12 am


41 (36)

74 (64)

12 am-6 am


28 (51)

27 (49)

Sign-out location and documentation

Location, N (%)


Bedside Rounding


0 (0)

1 (100)

Face to Face


146 (43)

194 (57)



1 (100)

0 (0)

Documentation by Incoming Physician, N (%) Used Paper Notes


134 (42)

186 (58)



13 (57)

10 (43)

Used Computer


7 (37)

12 (63)



140 (43)

185 (57)

support materials during sign-out

Used a Computer, N (%)

Outgoing Physician


18 (33)

36 (67)



128 (44)

160 (56)

Incoming Physician


49 (40)

75 (60)



98 (45)

121 (55)

Reviewed EMR for Confirmation, N (%)

Outgoing Physician


54 (43)

73 (57)



87 (42)

118 (58)

Incoming Physician


60 (43)

81 (57)



83 (44)

107 (56)

Interactive techniques used by incoming physician

Used Repeat Back Technique, N (%)


80 (44)

103 (56)



62 (45)

75 (55)

Requested an Opportunity for Clarification, N (%)


7 (47)

8 (53)



140 (43)

184 (57)

Requested Additional Information, N (%)


22 (46)

26 (54)



124 (43)

166 (57)


Total Number of Interruptions (N)






116 (44)

149 (56)

Interruptions per Sign-Out Session (Median +- IQR)


2 (3)

2 (2)



Total Sign-Out Duration in seconds (Median +- IQR)


676 (555)

664 (435)


Number of Interruptions Lasting >30 s, N (%)


54 (49)

56 (51)



56 (42)

78 (58)

Notable events due to communication errors

Encountered Patient Errors (N)








Performed Unexpected Tasks (N)








EM Emergency Medicine; EMR Electronic Medical Record; FM Family Medicine; IM Internal Medicine; PGY Postgraduate year.

* Mann-Whitney U test performed; all other p-values are based on a Chi-Square Test.

Table 2

Primary outcome characteristics of sign-out, standard versus formatted.

Handoff-clinical evaluation exercise scores

Physician experience level



Mean difference, formatted vs standard


Incoming Physician Response (Mean +- SD) Organized/Efficient Patient Presentation


7.42 (1.19)

7.18 (1.28)




7.44 (1.13)

7.36 (1.25)




7.35 (1.44)

6.46 (1.17)



Communication Skills


7.55 (1.08)

7.42 (1.12)




7.52 (1.03)

7.53 (1.07)




7.69 (1.32)

6.97 (1.18)



Included Pertinent Information


7.45 (1.16)

7.28 (1.25)




7.45 (1.08)

7.40 (1.21)




7.46 (1.50)

6.79 (1.30)



Clinical Judgment


7.54 (1.11)

7.46 (1.17)




7.56 (0.97)

7.62 (1.04)




7.42 (1.63)

6.82 (1.43)



Patient Focused Presentation


7.56 (1.09)

7.40 (1.08)




7.50 (1.09)

7.87 (1.06)




7.48 (1.05)

7.08 (1.16)



Setting during Sign-Out


6.79 (1.63)

6.77 (1.43)




6.65 (1.64)

6.85 (1.46)




7.50 (1.41)

6.45 (1.22)



Overall Sign-Out Quality


7.44 (1.13)

7.23 (1.23)




7.43 (1.12)

7.54 (1.22)




7.37 (1.21)

6.68 (1.14)



Interruptions and sign-out duration Interruptions per Sign-Out Session


2.62 (1.84)

2.16 (1.95)




2.74 (1.85)

2.45 (2.01)




1.87 (1.68)

0.94 (0.98)



Sign-Out Duration (Mean +- SD)


787.62 (455.37)

739.20 (388.79)




840.14 (471.79)

783.42 (410.05)




543.19 (259.02)

560.08 (209.49)



* Statistical tests between Standard vs. Formatted Sign-Outs performed via Linear Mixed Model with Random Effects, p-value <=0.05 in bold and p-value <=0.1 in italic.

among residents were noted for (Table 2): patient focused (mean differ- ence + 0.40), setting (mean difference + 1.05), and overall (mean dif- ference + 0.68). Interestingly, the mean number of interruptions was higher for the resident formatted TOC (1.9 [+- 1.7]) than in the standard TOC (0.94 [+- 0.98]).

  1. Discussion

This study evaluated the comparison of a formatted sign-out on TOC quality, as perceived by physicians working in the ED. Positive h-CEX scores were more prominently seen for the resident physicians with the formatted TOC including for h-CEX categories: patient focused, set- ting, and overall. Most of the comparative differences between the stan- dard and formatted TOC in subjective scoring was seen among the resident grouping, which is consistent with previous studies evaluating a formatted checklist in improving resident sign-out [16,17]. Attending sign-out did not reflect significant change between the standard and formatted TOC, which may be consistent with past literature noting de- creased error in TOC in attending physicians with >1.5 years of experi- ence [18]. Only one of the attendings in our cohort had <1.5 years of experience. It may be that experienced attendings did not find signifi- cant benefit in a formatted sign-out that was similar to their routine practice.

No definitive conclusions in evaluating the number of self-reported

unexpected tasks completed after sign-out or any self-reported patient errors that occurred could be made due to the low frequency of positive reporting among our physician groupings as well as due to our sample size.

The h-CEX tool was used due to its modified design that helps assess communication quality in a concise manner. Physicians reported it was quick and easy to use and did not require additional teaching by its users to perform [15,19,20].

We attempted to standardize the format of sign-out, to provide an expected framework for physicians in the ED to provide TOC. In contrast

to SBAR, SHOUT, IPASS, and SIGNOUT [9], we utilized an individually tai- lored framework for our ED, as “the standardized protocol for handoffs needs to be tailored to discipline and organization” [3]. Our formatted TOC had only slight modifications compared to the process we noted on the “current state” flow map prior to initiation of the study. During the FoCUS group session consensus was given to modify our TOC, asking physicians to start each patient summary with whether the patient was actively being managed (“active”) or being managed under the care of another physician team (“dispositioned”). Additional changes to our typical TOC framework included providing details on the patient’s code status if known, particularly for admitted patients boarding in the ED. Lastly, a change from standard practice was to include the ex- pected disposition for “active” patients. We performed only minimal modifications to the pre-existing framework for TOC to encourage utili- zation of a formatted TOC that was minimally intrusive to previous phy- sician practice.

During this study we focused on implementing a successful format for sign-out. This is likely just one of the many important facets required to significantly improve TOC in the ED. Indeed, Cheung 2009 et al. de- tailed that in addition to a standard format for sign-out, other critical components/model components of handoffs are: single versus multidis- ciplinary handoff, handoff location, use of written aids, use of mnemon- ics, and computer assisted handoff [21]. They also note strategies for sign-out improvement including scheduling shift overlap to minimize the number of unnecessary handoffs, provide a succinct overview, com- municate outstanding tasks, anticipate changes, have a clear plan, make information readily available for direct review, encourage questioning and discussion of assessments, account for all patients, and signal a clear moment in TOC. It is unlikely given the wide variation of clinical practice that our formatted tool is the single best fit for ED sign-out, but consistent with past literature, it does seem likely that a formatted sign-out is a significant improvement over the wide variation in prac- tices of TOC, and some uniformity and agreement on a TOC format would be useful to the field of EM.

    1. Limitations

Our study had several limitations. This was a single center study with convenience sampling of physicians of different training and expe- rience levels including Family Medicine, Internal Medicine, and EM phy- sicians. We did not stratify resident or attending years of experience which may influence the quality of sign-out.

Physicians were aware of being observed during sign-out, and it is

unclear if this may have driven some physicians to consider using the formatted TOC framework over the standard TOC. Additionally, a Haw- thorne effect may have occurred. While no statistical findings were seen for the overall amount of time in sign-out for a formatted TOC, the num- ber of patients and Complexity of patients was not accounted for, and it is possible that a type I error resulted from unrecorded differences between cohorts in patient load and complexity. Due to the nature of the staffing pattern, less resident sign outs were available for observa- tion than attending sign outs.

The h-CEX scale had a significantly negative skew. There was poten- tial bias for evaluating colleagues in a socially desirable manner. We attempted to limit this by having the h-CEX scale completed 1-h after sign-out, to ensure the outgoing physician had physically left, as well as by de-identifying the sign-out data entry. Interestingly, when per- forming our random effect model, physician-physician interaction was a significant confounder, suggesting that pre-existing physician schemas (ie. Physician A always gives good sign-outs) play a significant role in subjective rating scales. While we performed training of our RAs prior to enrolling physicians, we did not assess the accuracy of informa- tion passed on during sign-out or the patient complexity communicated as it was felt this was outside the expertise level of RAs to assess.

  1. Conclusion

We utilized a formatted TOC to evaluate for perceived differences in quality of sign-out for physicians working in the ED. Resident physicians saw positive score increased in several h-CEX categories with a format- ted sign-out that required minimal didactic training to implement.

Our sample was not large enough to make conclusions about reduc- tions in unexpected tasks or errors, however, previous studies show standardization in the process of communications and TOCs reduces errors [22,23].

While a one-size-fits-all approach may not function for TOC’s in all EDs, a one-size-fits-most may be a possibility. Further studies should focus on validating a tool to identify and measure unexpected physician tasks, resultant errors, as well as patient centered outcomes for objec- tive evaluation of sign-out improvement, and to assist in the standardi- zation of EM TOC.

Conflict of interest

The authors have no conflicts of interest to declare.

Prior presentations

This work has not been presented before.

Funding statement

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Brad E. Schwartz: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Pro- ject administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Tareq Al-Salamah: Writing – review &

editing, Writing – original draft, Visualization, Supervision, Resources, Project administration, Methodology, Investigation, Data curation, Conceptualization. Priyanka Gandhi: Writing – review & editing, Writ- ing – original draft, Project administration, Investigation, Data curation. Brett Walters: Writing – review & editing, Writing – original draft, For- mal analysis, Data curation. Lidia Signorella: Writing – review & editing, Writing – original draft, Project administration, Investigation, Data curation. Yusuf Mastoor: Writing – review & editing, Writing – original draft, Project administration, Investigation, Data curation. Nirmal Jacob: Writing – review & editing, Writing – original draft, Supervision, Project administration, Investigation, Data curation. Raul Cruz Cano: Writing – review & editing, Writing – original draft, Valida- tion, Software, Formal analysis, Data curation.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2022.06.005.


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