Competency Standard Derivation for Point-of-Care Ultrasound Image Interpretation for Emergency Physicians.

STUDY OBJECTIVE: Because number-based standards are increasingly controversial, the objective of this study was to derive a performance-based competency standard for the image interpretation task of point-of-care ultrasound (POCUS). METHODS: This was a prospective study. Operating on a clinically-relevant sample of POCUS images, we adapted the Ebel standard-setting method to derive a performance benchmark in 4 diverse pediatric POCUS applications: soft tissue, lung, cardiac and focused assessment with sonography in trauma (FAST). In Phase I (difficulty calibration), cases were categorized into interpretation difficulty terciles (easy, intermediate, hard) using emergency physician-derived data. In Phase II (significance), a 4-person expert panel categorized cases as low, medium, or high clinical significance. In Phase III (standard setting), a 3x3 matrix was created, categorizing cases by difficulty and significance, and a 6-member panel determined acceptable accuracy for each of the 9 cells. An overall competency standard was derived from the weighted sum. RESULTS: We obtained data from 379 emergency physicians resulting in 67,093 interpretations and a median of 184 (interquartile range, 154, 190) interpretations per case. There were 78 (19.5%) easy, 272 (68.0%) medium, and 50 (12.5%) hard-to-interpret cases, and 237 (59.3%) low, 65 (16.3%) medium, and 98 (24.5%) cases of high clinical significance across the 4 POCUS applications. The panel determined an overall performance-based competency score of 85.0% for lung, 89.5% for cardiac, 90.5% for soft tissue, and 92.7% for FAST. CONCLUSION: This research provides a transparent chain of evidence that derived clinically relevant competency standards for POCUS image interpretation.

The practical integration of a hybrid model of ultrasound-guided peripheral venous access in a large apheresis center.

BACKGROUND: Apheresis treatments require adequate venous access using peripheral intravenous (PIV) catheterization or central venous catheters (CVC). Ultrasound-guided PIV (USGPIV) can be used to decrease the need of CVC insertions for apheresis procedures. METHOD: A hybrid model of USGPIV and standard of care (SOC) for PIV access was developed. Nurses performed USGPIV on all patients considered for PIV access if felt SOC PIV access was not possible. Information was collected regarding nurses' confidence with access, number of attempts required, site of access, complications, and need for CVC. RESULTS: In all, 226 PIV access attempts were made during a 2-month period. All apheresis procedure types were represented. A total 65% were accessed by SOC and 35% by USGPIV. USGPIV was successful on first try on 90% draw/inlet access and 87% successful on first try on return access. Access above the antecubital fossa was required in 31% of USGPIV for draw/inlet veins, and 22% of return veins. Nurses' confidence with accessing PIV was increased by USGPIV, based on 7-point Likert scale assessments. During the recording period, 2/226 (0.9%) apheresis procedures required a CVC. In a separate cohort of only hematopoietic progenitor cell collections, CVC insertion was required in 44/238 (18.5%) patients, in 7 months prior to adoption of USGPIV and 5/152 (3.3%) patients in 7 months following adoption of USGPIV. CONCLUSION: A hybrid model of using SOC and USGPIV for PIV access for apheresis procedures resulted in decreased need for CVC access, high levels of successful initial access attempts, and increased nursing confidence in PIV access.

Emergency medicine resident perceptions of simulation-based training and assessment in competence by design.

OBJECTIVES: With the launch of competence by design (CBD) in emergency medicine (EM) in Canada, there are growing recommendations on the use of simulation for the training and assessment of residents. Many of these recommendations have been suggested by educational leaders and often exclude the resident stakeholder. This study sought to explore their experiences and perceptions of simulation in CBD. METHODS: Qualitative data were collected from November 2020 to May 2021 at McMaster University and the University of Toronto after receiving ethics approval from both sites. Eligible participants included EM residents who were interviewed by a trained interviewer using a semi-structured interview guide. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory. RESULTS: A total of seventeen residents participated. Thematic analysis revealed three major themes: 1) impact of CBD on resident views of simulation; 2) simulation's role in obtaining entrustable professional activities (EPAs) and filling educational gaps; and 3) conflicting feelings on the use of high-stakes simulation-based assessment in CBD. CONCLUSIONS: EM residents strongly support using simulation in CBD and acknowledge its ability to bridge educational gaps and fulfill specific EPAs. However, this study suggests some unintended consequences of CBD and conflicting views around simulation-based assessment that challenge resident perceptions of simulation as a safe learning space. As CBD evolves, educational leaders should consider these impacts when making future curricular changes or recommendations.

RéSUMé: OBJECTIFS: Avec le lancement de la compétence par conception (CPC) en médecine d'urgence (MU) au Canada, il existe des recommandations croissantes sur l'utilisation de la simulation pour la formation et l'évaluation des résidents. Beaucoup de ces recommandations ont été suggérées par des leaders éducatifs et excluent souvent la partie prenante résidente. Cette étude visait à explorer leurs expériences et leurs perceptions de la simulation dans la CPC. MéTHODES: Des données qualitatives ont été collectées de novembre 2020 à mai 2021 à l'Université McMaster et à l'Université de Toronto après avoir reçu l'approbation éthique des deux sites. Les participants éligibles étaient des résidents en MU qui ont été interviewés par un interviewer formé à l'aide d'un guide d'entretien semi-structuré. Toutes les interviews ont été enregistrées, transcrites, codées et regroupées en thèmes. L'analyse des données a été guidée par la théorie ancrée constructiviste. RéSULTATS: Au total, dix-sept résidents ont participé. L'analyse thématique a révélé trois thèmes majeurs : (1) l'impact de la CPC sur les opinions des résidents sur la simulation ; (2) le rôle de la simulation dans l'obtention des activités professionnelles confiables (APC) et le comblement des lacunes éducatives ; et (3) des sentiments contradictoires sur l'utilisation de l'évaluation basée sur la simulation à hauts enjeux dans la CPC. CONCLUSIONS: Les résidents en MU soutiennent fortement l'utilisation de la simulation dans la CPC et reconnaissent sa capacité à combler les lacunes éducatives et à remplir des APC spécifiques. Cependant, cette étude suggère quelques conséquences imprévues de la CPC et des opinions divergentes sur l'évaluation basée sur la simulation qui remettent en question les perceptions des résidents de la simulation comme un espace d'apprentissage sécuritaire. À mesure que la CPC évolue, les leaders éducatifs devraient tenir compte de ces impacts lorsqu'ils apportent des changements ou des recommandations curriculaires futurs.

Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation.

Background: Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods: We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results: Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions: Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.

Introduction: La Société canadienne de cardiologie (SCC) et l'Association canadienne des médecins d'urgence (ACMU) ont publié des documents pour orienter la prise en charge de la fibrillation auriculaire (FA). En 2021, l'ACMU a actualisé sa liste de vérification sur la FA. Avant cette actualisation, les recommandations des deux organismes différaient sur plusieurs points importants, notamment le laps de temps suggéré avant la cardioversion, les facteurs qui déterminent l'admissibilité à la cardioversion, et l'amorce du traitement anticoagulant après la cardioversion. On ignore si les médecins d'urgence (MU) connaissent ou adhère à un, à deux ou à aucun de ces documents. Méthodes: Nous avons évalué la connaissance qu'ont les MU de ces documents, leur adhésion et leur pratique grâce à un questionnaire pilote soumis aux MU de cinq services des urgences de trois provinces. Résultats: Parmi les 166 participants à l'enquête, 123 (74,1 %) y ont répondu. La majorité (64,7 %) travaillait dans un établissement universitaire, 38,8 % étaient des femmes, et le nombre médian d'années de pratique était de 10,0. La plupart (93,1 %) connaissaient au moins un des documents; 45,7 % connaissaient les deux. La connaissance rapportée était plus élevée pour les lignes directrices de la SCC (77,6 %) que pour les lignes directrices de l'ACMU (61,2 %). L'adhésion des répondants variait, mais 40,5 % utilisaient des parties des deux documents. La variabilité considérable de la pratique était observée lorsque les recommandations étaient contradictoires. Bien que son utilisation ne soit pas recommandée par l'un ou l'autre de ces organismes, la moitié des répondants (50,0 %) signalaient utiliser le score CHA2DS2-VASc comme outil d'évaluation du risque d'accident vasculaire cérébral. Conclusions: Bien que la plupart des MU interrogés connaissaient au moins un document sur la FA des organismes, plusieurs signalaient utiliser des parties des deux documents. Lorsque les recommandations étaient contradictoires, les MU étaient divisés sur la prise de décision. Ces résultats confirment la nécessité d'améliorer le consensus entre les organismes et d'améliorer davantage l'application des connaissances.

In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis.

OBJECTIVES: The primary objective of this systematic review was to determine the accuracy of point-of-care ultrasonography (POCUS) in diagnosing abscess in emergency department (ED) patients with skin and soft tissue infections (SSTI). The secondary objective was the accuracy of POCUS in the paediatric population subgroup. SETTING: Prospective studies set in emergency departments. PARTICIPANTS: Emergency department patients (adult and paediatric) presenting with SSTI and suspected abscess. PRIMARY AND SECONDARY OUTCOME MEASURES: This systematic review was conducted according to Cochrane Handbook guidelines, and the following databases were searched: PubMed, MEDLINE, EMBASE and the Cochrane database of systematic reviews (1946-2015). We included prospective cohort and case-control studies investigating ED patients with SSTI and abscess or cellulitis, a defined POCUS protocol, a clearly defined gold standard for abscess and a contingency table describing sensitivity and specificity. Two reviewers independently ascertained all potentially relevant citations for methodologic quality according to QUADAS-2 criteria. The primary outcome measure was the sensitivity and specificity of POCUS for abscess. A preplanned subgroup (secondary) analysis examined the effects in paediatric populations, and changes in management were explored post hoc. RESULTS: Of 3028 articles, 8 were identified meeting inclusion criteria; all were rated as good to excellent according to QUADAS-2 criteria. Combined test characteristics of POCUS on the ED diagnosis of abscess for patients with SSTI were as follows: sensitivity 96.2% (95% CI 91.1% to 98.4%), specificity 82.9% (95% CI 60.4% to 93.9%), positive likelihood ratio 5.63 (95% CI 2.2 to 14.6) and negative likelihood ratio 0.05 (95% CI 0.01 to 0.11). CONCLUSIONS: A total of 8 studies of good-to-excellent quality were included in this review. The use of POCUS helps differentiate abscess from cellulitis in ED patients with SSTI. TRIAL REGISTRATION NUMBER: CRD42015017115.

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study.

UNLABELLED: Introduction Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one's peers provides a de facto standard. METHODS: A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient- and provider-level factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge. RESULTS: All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively. CONCLUSIONS: Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.