Assessing resident and attending error and adverse events in the emergency department.

BACKGROUND: There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula OBJECTIVES: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings. METHODS: Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test. RESULTS: Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups. CONCLUSIONS: Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.

Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage.

BACKGROUND: Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI). METHODS: Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018. INCLUSION CRITERIA: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm). EXCLUSION CRITERIA: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion. OUTCOMES: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits. RESULTS: 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring. CONCLUSIONS: ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

Year-to-year trends in emergency medicine morbidity and mortality cases.

BACKGROUND: Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings. METHODS: All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed. RESULTS: 350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001). CONCLUSIONS: There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.

The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department.

BACKGROUND: Acute appendicitis is common in the adult emergency department (ED). Computed tomography (CT) scan is frequently used to diagnose this condition, but ultrasound (US)-commonly used in pediatric diagnosis-may also have a role. OBJECTIVES: Review the clinical utility and define the frequency and diagnostic accuracy of US to diagnose appendicitis in an adult population in the ED setting. METHODS: Retrospective cohort study of patients who underwent appendiceal US in an academic, tertiary ED from July 2013-October 2015. RESULTS: There were 174 patients included, of which 39 (22%) had pathology-confirmed appendicitis. There were 25 patients who had an US scan that was positive for appendicitis, 146 (84%) were indeterminate, and 3 (1.7%) were negative. Among patients with a positive US, 25/25 (100%, 95% confidence interval [CI] 84-100%) had appendicitis, 32/146 (22%, 95% CI 16-29%) with an indeterminate US had appendicitis, and 0/3 (0%, 95% CI 0-6.2%) with a negative US had appendicitis. In the 28 definitive cases, US had a sensitivity of 64%, specificity of 2%, positive predictive value of 100%, and negative predictive value of 100%. The likelihood ratio positive and negative were 173 and 0, respectively. CONCLUSION: Our initial data suggest that an US that shows appendicitis seems to be reliable; however, a high prevalence of indeterminate studies limits the diagnostic utility as a universal approach in adult patients in the ED setting. Larger studies are needed to identify which patient populations would benefit from US as the initial imaging modality, what factors contribute to the large numbers of indeterminate results, and if any interventions may reduce the number of indeterminate results.

Cultural Competency Training in Emergency Medicine.

BACKGROUND: The Emergency Department is widely regarded as the epicenter of medical care for diverse and largely disparate types of patients. Physicians must be aware of the cultural diversity of their patient population to appropriately address their medical needs. A better understanding of residency preparedness in cultural competency can lead to better training opportunities and patient care. OBJECTIVE: The objective of this study was to assess residency and faculty exposure to formal cultural competency programs and assess future needs for diversity education. METHODS: A short survey was sent to all 168 Accreditation Council for Graduate Medical Education program directors through the Council of Emergency Medicine Residency Directors listserv. The survey included drop-down options in addition to open-ended input. Descriptive and bivariate analyses were used to analyze data. RESULTS: The response rate was 43.5% (73/168). Of the 68.5% (50/73) of residency programs that include cultural competency education, 90% (45/50) utilized structured didactics. Of these programs, 86.0% (43/50) included race and ethnicity education, whereas only 40.0% (20/50) included education on patients with limited English proficiency. Resident comfort with cultural competency was unmeasured by most programs (83.6%: 61/73). Of all respondents, 93.2% (68/73) were interested in a universal open-source cultural competency curriculum. CONCLUSIONS: The majority of the programs in our sample have formal resident didactics on cultural competency. Some faculty members also receive cultural competency training. There are gaps, however, in types of cultural competency training, and many programs have expressed interest in a universal open-source tool to improve cultural competency for Emergency Medicine residents.

The Integration of Electronic Medical Student Evaluations Into an Emergency Department Tracking System is Associated With Increased Quality and Quantity of Evaluations.

BACKGROUND: Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. OBJECTIVES: To determine whether electronic medical student evaluations (EMSEs) provide more evaluations and content when compared to paper shift card evaluations. METHODS: This before and after cohort study was conducted over a 2.5-year period at an academic hospital affiliated with a medical school and emergency medicine residency program. EMSEs replaced the paper shift evaluations that had previously been used halfway through the study period. A random sample of the free text comments on both paper and EMSEs were blindly judged by medical student clerkship directors for their helpfulness and usefulness. Logistic regression was used to test for any relationship between quality and quantity of words. RESULTS: A total of 135 paper evaluations for 30 students and then 570 EMSEs for 62 students were collected. An average of 4.8 (standard deviation [SD] 3.2) evaluations were completed per student using the paper version compared to 9.0 (SD 3.8) evaluations completed per student electronically (p < 0.001). There was an average of 8.8 (SD 8.5) words of free text evaluation on paper evaluations when compared to 22.5 (SD 28.4) words for EMSEs (p < 0.001). A statistically significant (p < 0.02) association between quality of an evaluation and the word count existed. CONCLUSIONS: EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.

Practicing emergency physicians report performing well on most emergency medicine milestones.

BACKGROUND: The Accreditation Council for Graduate Medical Education's Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings. OBJECTIVE: Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones. METHODS: An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them. RESULTS: Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001). CONCLUSIONS: Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

An analysis of potentially avoidable neurosurgical transfers to a tertiary-care level I trauma center.

OBJECTIVE: Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed. METHODS: This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test. RESULTS: A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001). CONCLUSIONS: This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis.

BACKGROUND: Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD: The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS: In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS: Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Characterizing malpractice cases involving emergency department advanced practice providers, physicians in training, and attending physicians.

OBJECTIVE: The objective was to evaluate available characteristics and financial costs of malpractice cases among advanced practice providers (APPs; nurse practitioners [NPs] and physician assistants [PAs]), trainees (medical students, residents, fellows), and attending physicians. METHODS: This study was a retrospective analysis of claims occurring in the emergency department (ED) from January 1, 2010, to December 31, 2019, contained in the Candello database. Cases were classified according to the provider type(s) involved: NP, PA, trainee, or cases that did not identify an extender as being substantially involved in the adverse event that resulted in the case ("no extender"). RESULTS: There were 5854 cases identified with a total gross indemnity paid of $1,007,879,346. Of these cases, 193 (3.3%) involved an NP, 513 (8.8%) involved a PA, 535 (9.1%) involved a trainee, and 4568 (78.0%) were no extender. Cases where a trainee was involved account for the highest average gross indemnity paid whereas no-extender cases are the lowest. NP and PA cases differed by contributing factors compared to no-extender cases: clinical judgment (NP 89.1% vs. no extender 76.8%, p < 0.0001; PA 84.6% vs. no extender, p < 0.0001), documentation (NP 23.3% vs. no extender 17.8%, p = 0.0489; PA 25.9% vs. no extender, p < 0.0001), and supervision (NP 22.3% vs. no extender 1.8%, p < 0.0001; PA 25.7% vs. no extender p < 0.0001). Cases involving NPs and PAs had a lower percentage of high-severity cases such as loss of limb or death (NP 45.6% vs. no extender 50.2%, p = 0.0004; PA 48.3% vs. no extender, p < 0.0001). CONCLUSIONS: APPs and trainees comprise approximately 21% of malpractice cases and 33% of total gross indemnity paid in this large national ED data set. Understanding differences in characteristics of malpractice claims that occur in emergency care settings can be used to help to mitigate provider risk.

Cervical spine injuries in children, part I: mechanism of injury, clinical presentation, and imaging.

BACKGROUND: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. OBJECTIVES: This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. DISCUSSION: Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. CONCLUSION: With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.

Cervical spine injuries in children, part II: management and special considerations.

BACKGROUND: The diagnosis and management of cervical spine injury is more complex in children than in adults. OBJECTIVES: Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. DISCUSSION: Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. CONCLUSION: With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.

Procedural training models among emergency medicine residency programs.

OBJECTIVE: Optimal training methods remain controversial for rarely performed emergency procedures. Previous research has failed to demonstrate the superiority or inferiority of live anesthetized animal models (LAA) as compared to other modalities. Most of the data on LAA use comes from military contexts; less information is available for civilian emergency medicine (EM) training. We sought to characterize the prevalence of LAA use among civilian EM residency programs and reasons for its use or discontinuation. METHODS: Survey study of program directors of EM residency programs accredited by the Accreditation Council for Graduate Medical Education. A 16-item questionnaire was electronically delivered to program directors, including program region, current and historical use of LAA, and attitudes regarding the optimal procedural training modalities. RESULTS: Of 179 survey recipients, 83 completed the survey (46.4%). Twelve programs (14.3%) currently use LAA, and 17 programs (20.5%) report previous LAA use. Reasons for discontinuing LAA use included ethical concerns, financial and logistical limitations, political pressures, and feeling that there were superior or equivalent alternative models available. Programs that currently use LAA were more likely to rank LAA as being the most preferable training modality while programs that do not currently use LAA were more likely to rank human cadavers as the most preferable modality. CONCLUSION: Despite a lack of data showing educational outcomes-driven differences between LAA and alternative training models, LAA use is declining among civilian EM residencies. Despite this, disagreement exists among programs that do and do not use LAA regarding the most optimal procedural training.

Correlation of attending and patient assessment of resident communication skills in the emergency department.

BACKGROUND: Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills. METHODS: This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement. RESULTS: During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26). CONCLUSIONS: Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes.

BACKGROUND: Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population. OBJECTIVE: To report our experience with protocol implications and patient outcome. METHODS: Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed. RESULTS: Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations. CONCLUSION: Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

Morbidity and Mortality conference in Emergency Medicine.

BACKGROUND: Morbidity and Mortality conferences (M&M) are used to meet many of the Core Competencies required by the Accreditation Council of Graduate Medical Education for residency training programs. This study seeks to describe and quantify different types of M&M conferences among Emergency Medicine (EM) training programs. METHODS: A confidential survey was e-mailed to the Program Directors (PD) or Assistant PD of all United States (US) Emergency Medicine residency training programs with functional e-mail addresses listed in the Society for Academic Emergency Medicine residency catalog. Descriptive statistics and 95% confidence (CI) intervals are reported. RESULTS: Of 124 surveys sent out, 89 (72%) completed surveys were returned. There were 88 programs (99%, CI 93-100%) that reported having an M&M. Conferences are held monthly at 67% (CI 57-76%) of programs. Cases for discussion are identified by an EM attending, quality assurance committee, or resident (70%, 57%, and 48%, respectively). Half of programs reported that > 40% of the cases involve systems errors. Twenty percent of programs report that > 40% of the cases involve deaths. Consultants are invited at 44% of programs, and 20% of programs specifically invite radiologists. If a medical error is identified in the M&M, 79% (70-86%) of programs have a protocol for addressing the error. CONCLUSION: EM training programs almost uniformly have an M&M, but these conferences vary in frequency, content, and attendance. Future studies are needed to investigate resident and faculty perceptions of M&M, its educational impact, and ways to improve the conference.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events.

OBJECTIVE: Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. METHODS: We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. RESULTS: EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%-7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%-2.9%). CONCLUSION: A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients.

BACKGROUND: Base deficit (BD) and lactate are used as markers of mortality, injury severity, and resource utilization in the general trauma population. No study has defined the role of these markers in the triage and management of the normotensive injured elderly patient. METHODS: Retrospective cohort study of the trauma registry from a Level I trauma Center during the period of January 1, 2000 through December 31, 2006. Inclusion criteria were age > or = 65 years, initial systolic blood pressure > or = 90 mm Hg; blunt mechanism of trauma. Lactate was categorized as 0 to 2.4 mmol/L (normal), 2.5 to 4.0 mmol/L (moderately elevated), or > 4.0 mmol/L (severely elevated). BD was categorized as > 0 mEq/L (normal), 0 to -6 mEq/L (moderate), or < -6 mEq/L (severe). The primary outcome was inhospital mortality. RESULTS: Mean lactate was higher in nonsurvivors compared with survivors (2.8 mm/L +/- 1.8 mm/L vs. 2.0 mm/L +/- 1.0 mm/L, p < 0.001). Normal, moderately elevated, and severely elevated lactate was associated with mortality rates of 15% (95% confidence interval [CI] 12-18.8%), 23.4% (95% CI 2-32.4%), and 39.6% (95% CI 26.5-52.8%), respectively. Compared with the normal lactate group, patients in the severely elevated lactate group had 4.2 increased odds of death. BD was more abnormal in nonsurvivors compared with survivors (-2.3 mEq/L +/- 5.2 mEq/L vs. 0.28 mEq/L +/- 1.0 mEq/L, p < 0.001). Normal, moderate, and severe BD were associated with mortality rates of 14% (95% CI 10.3-17.1%), 27% (95% CI 20.1-34.2%), and 40% (95% CI 24.9-54.1%), respectively. Compared with the normal BD group, patients in the severe group had 4.1 increased odds of death. CONCLUSIONS: Both lactate and BD were associated with significantly increased mortality in normotensive elderly blunt trauma patients. However, because of the high baseline mortality rates in elderly trauma patients, "normal" lactate does not offer complete reassurance to the clinician.