Multimodular Ultrasound Orientation: Residents' Confidence and Skill in Performing Point-of-care Ultrasound.

Introduction The objectives of this study were to determine if a multimodular introductory ultrasound course improved emergency medicine intern confidence in performing a point-of-care ultrasound and if our educational objectives could be met with our chosen structure. Methods This is a prospective, observational study evaluating three consecutive incoming emergency medicine residency classes from three residency programs. A one-day introductory ultrasound course was delivered. The course consisted of 1) flipped classroom didactics, 2) in-person, case-based interactive teaching sessions, and 3) check-listed, goal-driven, hands-on instruction. Results Over three years, 73 residents participated in this study. There was no significant difference in performance on the written test (p = 0.54) or the skills assessment (p = 0.16) between years. Performance on the written pre-test was not a predictor of performance on the skills test (R2 = 0.028; p = 0.19). Prior to training, residents were most confident in performing a focused assessment with sonography for trauma examination (median confidence 5.5 (interquartile range (IQR): 3 - 7) on a 10-point Likert scale where 1 represents low confidence and 10 represents high confidence). They reported the lowest confidence in performing a cardiac ultrasound (3 (IQR: 2 - 6)). Following training, residents reported increased confidence with all applications (p < 0.001). Eighty-five percent (confidence interval (CI): 73, 92) of residents agreed that the online ultrasound lectures effectively teach point-of-care ultrasound applications and 98% (CI: 88, 100) agreed that case-based interactive sessions helped them understand how ultrasound changes the management of acutely ill patients. Conclusions A written test of knowledge regarding the use of point-of-care ultrasound does not correlate with procedural skills at the start of residency, suggesting that teaching and evaluation of both types of skills are necessary. Following a multimodular introductory ultrasound course, residents showed increased confidence in performing the seven basic ultrasound applications. Residents reported that an asynchronous curriculum and case-based interactive sessions met the learning objectives and effectively taught point-of-care ultrasound applications.

How well will you FIT? Use of a modified MMI to assess applicants' compatibility with an emergency medicine residency program.

PURPOSE: Emergency medicine residency programs have evaluated the use of Multiple Mini Interviews (MMIs) for applicants. The authors developed an MMI-style method called the Fast Interview Track (FIT) to predict an applicant's 'fit' within an individual residency program. METHODS: Applicants meet with up to five residents and are asked one question by each. Residents score the applicant using a Likert scale from 1 to 5 on two questions: 'How well does the applicant think on his/her feet?' and 'How well do you think the applicant will fit in here?'. To assess how well these questions predicted a resident's 'fit', current residents scored fellow residents on these same questions. These scores were compared with the residents' interview FIT scores. A postmatch survey of applicants who did not match at this program solicited applicants' attitudes toward the FIT sessions. RESULTS: Among the junior class, the correlation between interview and current scores was significant for question 1 (rho=0.5192 [p=0.03]) and question 2 (rho=0.5753 [p=0.01]). Among seniors, Spearman's rho was statistically significant for question 2, though not statistically significant for question 1. The chi-square measure of high scores (4-5) versus low scores (1-3) found a statistically significant association between interview and current scores for interns and juniors. Of the 29 responses to the postmatch survey, 16 (55%) felt FIT sessions provided a good sense of the program's personality and only 6 (21%) disagreed. Nine (31%) felt FIT sessions positively impacted our program's ranking and 11 (38%) were 'Neutral'. Only two (7%) reported that FIT sessions negatively impacted their ranking of our program. CONCLUSIONS: FIT provided program leadership with a sense of an applicant's 'fit' within this program. Interview day scores correlated with scores received during residency. Most applicants report a positive experience with FIT sessions. FIT provides a useful tool to recruit applicants who fit with the residency program.

Physician documentation of sepsis syndrome is associated with more aggressive treatment.

INTRODUCTION: Timely recognition and treatment of sepsis improves survival. The objective is to examine the association between recognition of sepsis and timeliness of treatments. METHODS: We identified a retrospective cohort of emergency department (ED) patients with positive blood cultures from May 2007 to January 2009, and reviewed vital signs, imaging, laboratory data, and physician/nursing charts. Patients who met systemic inflammatory response syndrome (SIRS) criteria and had evidence of infection available to the treating clinician at the time of the encounter were classified as having sepsis. Patients were dichotomized as RECOGNIZED if sepsis was explicitly articulated in the patient record or if a sepsis order set was launched, or as UNRECOGNIZED if neither of these two criteria were met. We used median regression to compare time to antibiotic administration and total volume of fluid resuscitation between groups, controlling for age, sex, and sepsis severity. RESULTS: SIRS criteria were present in 228/315 (72.4%) cases. Our record review identified sepsis syndromes in 214 (67.9%) cases of which 118 (55.1%) had sepsis, 64 (29.9%) had severe sepsis, and 32 (15.0%) had septic shock. The treating team contemplated sepsis (RECOGNIZED) in 123 (57.6%) patients. Compared to the UNRECOGNIZED group, the RECOGNIZED group had a higher use of antibiotics in the ED (91.9 vs.75.8%, p=0.002), more patients aged 60 years or older (56.9 vs. 33.0%, p=0.001), and more severe cases (septic shock: 18.7 vs. 9.9%, severe sepsis: 39.0 vs.17.6%, sepsis: 42.3 vs.72.5%; p<0.001). The median time to antibiotic (minutes) was lower in the RECOGNIZED (142) versus UNRECOGNIZED (229) group, with an adjusted median difference of -74 minutes (95% CI [-128 to -19]). The median total volume of fluid resuscitation (mL) was higher in the RECOGNIZED (1,600 mL) compared to the UNRECOGNIZED (1,000 mL) group. However, the adjusted median difference was not statistically significant: 262 mL (95% CI [ -171 to 694 mL]). CONCLUSION: Patients whose emergency physicians articulated sepsis syndrome in their documentation or who launched the sepsis order set received antibiotics sooner and received more total volume of fluid. Age <60 and absence of fever are factors associated with lack of recognition of sepsis cases.

Emergency ultrasound fellowship training: a novel team-based approach.

OBJECTIVES: To describe our experience with implementation of a novel team-based emergency ultrasound (EUS) fellowship training program. METHODS: We conducted a retrospective review at an academic medical center. All emergency department (ED) faculty and residents were divided into 3 teams, and a fellow was assigned to each team. Each fellow was responsible for ultrasound (US) education of their team members and faculty credentialing. Additionally, each fellow was assigned to one of these specific responsibilities every month: (1) education, (2) quality assurance/billing, and (3) equipment. The fellows also received a checklist at the beginning of the fellowship training, which outlined research, reading, teaching, and scanning requirements. RESULTS: With a team-based approach, all US examinations were reviewed for quality control within 1 week after the scans were performed. The number of US examinations billed by faculty increased by 180%. The US billing revenue increased by 60% during the study period. Fifteen additional faculty members were credentialed to use US in the ED. Compliance with bedside documentation of US findings increased from 30% to 90%. There was increased resident engagement, and the number of scans performed by residents increased by 130%. There was also a substantial decrease in the funds required to replace damaged transducers. CONCLUSIONS: A team-based EUS fellowship training program had a substantial impact on US use in the ED, quality control review, faculty credentialing, US billing revenue, compliance with documentation, and resident US education.

Ultrasound competency assessment in emergency medicine residency programs.

OBJECTIVES: In the Model of the Clinical Practice of Emergency Medicine (EM), bedside ultrasound (US) is listed as one of the essential procedural skills. EM milestones released by Accreditation Council for Graduate Medical Education and American Board of Emergency Medicine require residents to demonstrate competency in bedside US. The purpose of this study was to assess the current methods used by EM residency training programs to evaluate resident competency in bedside US. METHODS: This was a cross-sectional survey study. A questionnaire on US education and competency assessment was electronically sent to all EM residency program directors and emergency US directors. The survey consisted of questions regarding the US rotation, structure of US curriculum, presence of US fellowship, image archiving, quality assurance methods, feedback, competency assessment tools, and frequency of assessment. The survey responses are reported as the percentages of total respondents along with 95% confidence intervals (CIs). RESULTS: A total of 124 of 161 EM residency programs participated in this study, representing a 77% response rate. Twenty-six percent (95% CI = 18% to 34%) of programs assess competency only at the end of the US rotation. Eight percent (95% CI = 3% to 13%) assess competency only every 6 months, and 13% (95% CI = 7% to 19%) assess competency only annually. Eight percent (95% CI = 3% to 13%) assess competency only during the final year of training. Thirty percent (95% CI = 22% to 38%) of programs assess competency with a combination of the above intervals, and 16% (95% CI = 10% to 22%) do not assess US competency. Fourteen percent (95% CI = 8% to 20%) use objective structured clinical examinations (OSCEs), and 21% (95% CI = 14% to 28%) use standardized direct observation tools (SDOTs) to assess resident competency in US. Approximately one-third (33%, 95% CI = 24% to 41%) of standardized testing for US competency is conducted with multiple-choice questions. Thirty percent (95% CI = 21% to 38%) administer practical examinations to assess US skills. CONCLUSIONS: Currently, a majority of EM residency programs assess resident competency in bedside US. However, there is significant variation in the methods of competency assessment.

Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact.

OBJECTIVES: The aim of this study was to determine the fiscal impact of implementation of a novel emergency department (ED) point-of-care (POC) ultrasound billing and reimbursement program. METHODS: This was a single-center retrospective study at an academic medical center. A novel POC ultrasound billing protocol was implemented using the Q-path Web-based image archival system. Patient care ultrasound examination reports were completed and signed electronically online by faculty using Q-path. A notification was automatically sent to ED coders from Q-path to bill the scans. ED coders billed the professional fees for scans on a daily basis and also notified hospital coders to bill for facility fees. A fiscal analysis was performed at the end of the year after implementing the new billing protocol, and a before-and-after comparison was conducted. RESULTS: After implementation of the new billing program, there was a 45% increase in the ED faculty participation in billing for patient care examinations (30%-75%). The number of ultrasound examinations billed increased 5.1-fold (4449 vs 857) during the post implementation period. The total units billed increased from previous year for professional services to 4157 from 649 and facility services to 3266 from 516. During the post implementation period, the facility fees revenue increased 7-fold and professional fees revenue increased 6.34-fold. After deducting the capital costs and ongoing operational costs from approximate collections, the net profits gained by our ED ultrasound program was approximately $350000. CONCLUSIONS: Within 1 year of inception, our novel POC ultrasound billing and reimbursement program generated significant revenue through ultrasound billing.

Ability of emergency physicians with advanced echocardiographic experience at a single center to identify complex echocardiographic abnormalities.

OBJECTIVES: To determine the ability of emergency physicians to detect complex abnormalities on point-of-care (POC) echocardiograms. METHODS: Single-blinded, nonrandomized, cross-sectional study. Twenty-five different emergency medicine clinical scenarios (video clips and digital images) covering a variety of echocardiographic abnormalities were presented to a group of emergency physician sonologists. The echocardiographic abnormalities included right ventricular dysfunction, left ventricular systolic dysfunction, diastolic dysfunction, regional wall motion abnormalities, Doppler abnormalities of pericardial tamponade physiology, left ventricular hypertrophy, hypertrophic cardiomyopathy, and aortic abnormalities. All emergency physician sonologists were blinded to the study hypothesis. They reviewed echocardiography video clips and images individually, and their interpretations were compared with the criterion standard (expert echocardiographer interpretations). RESULTS: A total of 200 echocardiography studies (video clips and images) were independently reviewed by 8 emergency physician sonologists with varying POC echocardiography experiences. Emergency physicians accurately identified left ventricular systolic dysfunction 94% of the time, diastolic dysfunction (100%), and right ventricular dysfunction 80% of the time. Regional wall motion abnormalities were detected only 50% of the time. Doppler echocardiographic abnormalities of pericardial tamponade physiology were accurately identified 57% of the time. Emergency physicians who performed more than 250 POC echocardiograms were found to be more accurate in identifying complex echocardiographic abnormalities. CONCLUSIONS: Our study results suggest that with increased experience, emergency physicians can accurately identify most of complex echocardiographic abnormalities.

Does the experience of the writer affect the evaluative components on the standardized letter of recommendation in emergency medicine?

BACKGROUND: The Standardized Letter of Recommendation (SLOR) was developed in an attempt to standardize the evaluation of applicants to an emergency medicine (EM) residency. OBJECTIVE: Our aim was to determine whether the Global Assessment Score (GAS) and Likelihood of Matching Assessment (LOMA) of the SLOR for applicants applying to an EM residency are affected by the experience of the letter writer. We describe the distribution of GAS and LOMA grades and compare the GAS and LOMA scores to length of time an applicant knew the letter writer and number of EM rotations. METHODS: We conducted a retrospective review of all SLORs written for all applicants applying to three EM residency programs for the 2012 match. Median number of letters written the previous year were compared across the four GAS and LOMA scores using an equality of medians test and test for trend to see if higher scores on the GAS and LOMA were associated with less experienced letter writers. Distributions of the scores were determined and length of time a letter writer knew an applicant and number of EM rotations were compared with GAS and LOMA scores. RESULTS: There were 917 applicants representing 27.6% of the total applicant pool for the 2012 United States EM residency match and 1253 SLORs for GAS and 1246 for LOMA were analyzed. The highest scores on the GAS and LOMA were associated with the lowest median number of letters written the previous year (equality of medians test across groups, p < 0.001; test for trend, p < 0.001). Less than 3% received the lowest score for GAS and LOMA. Among letter writers that knew an applicant for more than 1 year, 45.3% gave a GAS score of "Outstanding" and 53.4% gave a LOMA of "Very Competitive" compared with 31.7% and 39.6%, respectively, if the letter writer knew them 1 year or less (p = 0.002; p = 0.005). Number of EM rotations was not associated with GAS and LOMA scores. CONCLUSIONS: SLORs written by less experienced letter writers were more likely to have a GAS of "Outstanding" (p < 0.001) and a LOMA of "Very Competitive" (p < 0.001) than more experienced letter writers. The overall distribution of GAS and LOMA was heavily weighted to the highest scores. The length of time a letter writer knew an applicant was significantly associated with GAS and LOMA scores.

Alternative methods to central venous pressure for assessing volume status in critically ill patients.

INTRODUCTION: Early goal-directed therapy increases survival in persons with sepsis but requires placement of a central line. We evaluate alternative methods to measuring central venous pressure (CVP) to assess volume status, including peripheral venous pressure (PVP) and stroke volume variation (SVV), which may facilitate nurse-driven resuscitation protocols. METHODS: Patients were enrolled in the emergency department or ICU of an academic medical center. Measurements of CVP, PVP, SVV, shoulder and elbow position, and dichotomous variables Awake, Movement, and Vented were measured and recorded 7 times during a 1-hour period. Regression analysis was used to predict CVP from PVP and/or SVV, shoulder/elbow position, and dichotomous variables. RESULTS: Twenty patients were enrolled, of which 20 had PVP measurements and 11 also had SVV measurements. Multiple regression analysis demonstrated significant predictive relationships for CVP using PVP (CVP = 6.7701 + 0.2312 × PVP - 0.1288 × Shoulder + 12.127 × Movement - 4.4805 × Neck line), SVV (CVP = 14.578 - 0.3951 × SVV + 18.113 × Movement), and SVV and PVP (CVP = 4.2997 - 1.1675 × SVV + 0.3866 × PVP + 18.246 × Awake + 0.1467 × Shoulder = 0.4525 × Elbow + 15.472 × Foot line + 10.202 × Arm line). DISCUSSION: PVP and SVV are moderately good predictors of CVP. Combining PVP and SVV and adding variables related to body position, movement, ventilation, and sleep/wake state further improves the predictive value of the model. The models illustrate the importance of standardizing patient position, minimizing movement, and placing intravenous lines proximally in the upper extremity or neck.

Would earlier microbe identification alter antibiotic therapy in bacteremic emergency department patients?

BACKGROUND: Although debate exists about the treatment of sepsis, few disagree about the benefits of early, appropriately targeted antibiotic administration. STUDY OBJECTIVES: To determine the appropriateness of empiric antimicrobial therapy and the extent to which therapy would be altered if the causative organism for sepsis was known at the time of administration. METHODS: This was a retrospective cohort study, conducted in an academic Emergency Department (ED), on consecutive positive blood cultures between November 1, 2008 and February 1, 2009. Blood cultures and the appropriateness of administered antimicrobial therapy were evaluated. Therapy choices were categorized based on whether or not a physician, complying with antimicrobial guidelines, would have made changes to empiric antibiotic therapy had the causative organism initially been known. RESULTS: There were 90 positive blood cultures obtained from 84 patients. Of these, 21.1% (n=19) were considered contaminants. The final categorization of empiric antibiotics given in the ED for the remaining blood culture results were: 1) therapy would be changed to narrower-spectrum antibiotics (n=34, 55.7%); 2) therapy would be changed because the organism was not covered (n=13, 21.3%); and 3) therapy would remain the same (n=14, 23.0%). There was 90.2% inter-rater agreement for these classifications (p<0.0001), with a kappa of 0.84. Polymerase chain reaction analysis had a statistically significant advantage (p<0.0001) over Infectious Disease Society of America protocols in facilitating accurate antimicrobial therapies. CONCLUSION: This study confirms the need for more rapid and accurate laboratory methods for bloodstream pathogen identification.

A randomized controlled trial comparing the Arctic Sun to standard cooling for induction of hypothermia after cardiac arrest.

CONTEXT: Hypothermia improves neurological outcome for comatose survivors of out-of-hospital cardiac arrest. Use of computer controlled high surface area devices for cooling may lead to faster cooling rates and potentially improve patient outcome. OBJECTIVE: To compare the effectiveness of surface cooling with the standard blankets and ice packs to the Arctic Sun, a mechanical device used for temperature management. DESIGN, SETTING, AND PATIENTS: Multi-center randomized trial of hemodynamically stable comatose survivors of out-of-hospital cardiac arrest. INTERVENTION: Standard post-resuscitative care inducing hypothermia using cooling blankets and ice (n=30) or the Arctic Sun (n=34). MAIN OUTCOME MEASURES: The primary end point was the proportion of subjects who reached a target temperature within 4h of beginning cooling. The secondary end points were time interval to achieve target temperature (34 degrees C) and survival to 3 months. RESULTS: The proportion of subjects cooled below the 34 degrees C target at 4h was 71% for the Arctic Sun group and 50% for the standard cooling group (p=0.12). The median time to target was 54 min faster for cooled patients in the Arctic Sun group than the standard cooling group (p<0.01). Survival rates with good neurological outcome were similar; 46% of Arctic Sun patients and 38% of standard patients had a cerebral performance category of 1 or 2 at 30 days (p=0.6). CONCLUSIONS: While the proportion of subjects reaching target temperature within 4h was not significantly different, the Arctic Sun cooled patients to a temperature of 34 degrees C more rapidly than standard cooling blankets.