Assessment of Written Feedback for Emergency Medicine Residents.

OBJECTIVES: An essential component of resident growth is a learning environment with high-quality feedback. Criteria have been developed for characterizing and assessing written feedback quality in internal medicine residents by Jackson et al. Our primary goal was to describe feedback characteristics and assess the quality of written feedback for emergency medicine (EM) residents. Our secondary goals were to evaluate the relation between feedback quality and objective outcome measures. METHODS: This retrospective study was conducted between July 1, 2016 and July 1, 2018. EM residents with an Accreditation Council for Graduate Medical Education composite score (ACS), an in-service score, and written evaluations completed by an attending physician or EM resident in each of the 2 years of the study period were included. RESULTS: Overall, most of the evaluations contained 1 (21%), 2 (23%), or 3 (17%) feedback items. Feedback tended to be positive (82%) and the feedback quality of the evaluations was more likely to be high (44%). There was an association between feedback quality and ACS change (P < 0.0001), but not in-service score change (P = 0.63). Resident evaluations were more likely than attending evaluations to correlate with ACS change (P < 0.00001). CONCLUSIONS: The written evaluations contained few individual feedback items. Evaluations generally focused on the feedback characteristics of professionalism and interpersonal communication. The general feedback quality of evaluations tended to be high and correlated with an increase in ACSs.

Intravenous Thrombolysis at 3.5 Hours From Onset of Pediatric Acute Ischemic Stroke.

Acute thrombolysis has a proven benefit for adults presenting with acute ischemic stroke, but data within the pediatric population are extremely limited. We report the case of a 14-year-old girl who presented with right-sided weakness and ataxia, loss of sensation, and altered mental status. Magnetic resonance imaging with diffusion-weighted imaging showed an acute lesion in the distribution of the left posterior cerebral artery, and magnetic resonance angiogram demonstrated occlusion of the third branch of the left posterior cerebral artery. With parental consent, clinicians decided to infuse an adult dose of weight-adjusted intravenous alteplase at 3.5 hours from onset of symptoms, with subsequent improvement in National Institutes of Health Stroke Scale score from 11 to 3. Computed tomography angiogram at 24 hours showed recanalization of the occluded vessel with no evidence of intracranial hemorrhage. Stroke Scale score at discharge was 3, with modified Rankin Scale scores at discharge of 1 and at 90 days of 0. This case highlights the importance of magnetic resonance imaging in diagnosing pediatric acute ischemic stroke and suggests consideration of thrombolysis in select confirmed pediatric stroke cases. However, a rigorous evidence base is lacking, and clinical trials have not been successful in recruiting patients.

Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis.

GOAL: To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis. MATERIALS AND METHODS: Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT). FINDINGS: No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032). CONCLUSIONS: Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.