A consensus list of ultrasound competencies for graduating emergency medicine residents.

Objectives: Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method. Methods: We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%. Results: Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus. Conclusion: Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.

ECPR2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA. METHODS: We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. RESULTS: Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26). CONCLUSION: We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.

Interprofessional experiences to bridge the medical school to residency transition: a pilot program.

Interprofessional experiences during medical school are often delivered during pre-clinical years, but less is known about the value of clinical students. Our institution implemented a specialty-specific interprofessiona curriculum during Residency Preparation Courses (RPCs) for senior students including didactics, clinical experiences, and a simulated paging curriculum. Our aim was to determine whether this intervention improved perceptions of interprofesiona roles. We distributed anonymous surveys before (pre-survey) and after (post-survey, collected within 2 weeks of course completion) the RPC to 90 students with questions related to interprofessional roles using a 5-point scale (1 = strongly disagree, 5 = strongly agree). Three months after the start of residency, we sent follow-up surveys inquiring about the usefulness of RPC components (1 = not at all useful, 5 = extremely useful). Response rates were 84.4% pre-survey, 63.3% post-survey, and 41.1% follow-up survey. Post-surveys indicated improvement in self-reported ability in all domains: understanding one's contributions to interprofessional teams (3.9 to 4.4, p < .0001), understanding other team members' contributions (3.9 to 4.4, p < .0001), learning from interprofessional team members (4.2 to 4.6, p = .0002), accounting for interprofessional perspectives (4.2 to 4.6, p < .0001), and co-developing effective care plans (3.9 to 4.4, p < .0001). Follow-up surveys rated clinical experiences as slightly-to-moderately useful (2.3 ± 1.0) and paging curriculum very-to-extremely useful (4.3 ± 1.0). This study demonstrates the value of interprofessional education for advanced students.

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine.

OBJECTIVES: Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. METHODS: A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. RESULTS: The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. CONCLUSIONS: The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.

Rapid Dissemination of a COVID-19 Airway Management Simulation Using a Train-the-Trainers Curriculum.

PROBLEM: The most effective way to train clinicians to safely don and doff personal protective equipment (PPE) and perform aerosol-generating procedures (AGPs), such as intubations, is unknown when clinician educators are unavailable, as they have been during the COVID-19 pandemic. Proper PPE and airway management techniques are critical to prevent the transmission of respiratory illnesses such as COVID-19. APPROACH: In March 2020, the authors implemented a structured train-the-trainers curriculum to teach PPE techniques and a modified airway management algorithm for suspected COVID-19 patients. A single emergency medicine physician trainer taught 17 subsequent emergency medicine and critical care physician trainers the proper PPE and airway management techniques. The initial trainer and 7 of the subsequent trainers then instructed 99 other emergency medicine resident and attending physicians using in situ simulation. Trainers and learners completed retrospective pre-post surveys to assess their comfort teaching the material and performing the techniques, respectively. OUTCOMES: The surveys demonstrated a significant increase in the trainers' comfort in teaching simulation-based education, from 4.00 to 4.53 on a 5-point Likert scale (P < .005), and in teaching the airway management techniques through simulation, from 2.47 to 4.47 (P < .001). There was no difference in the change in comfort level between those learners who were taught by the initial trainer and those who were taught by the subsequent trainers. These results suggest that the subsequent trainers were as effective in teaching the simulation material as the initial trainer. NEXT STEPS: Work is ongoing to investigate clinician- and patient-specific outcomes, including PPE adherence, appropriate AGP performance, complication rate, and learners' skill retention. Future work will focus on implementing similar train-the-trainers strategies for other health professions, specialties, and high-risk or rare procedures.

The Carbon Footprint of Residency Interview Travel.

BACKGROUND: Over the last decade, medical student residency applicants have shown a substantial increase in the number of interviews attended, which is associated with a significant increase in travel. The carbon footprint associated with residency interviews has not been well documented prior to this investigation, and is a critical issue related to climate health. OBJECTIVE: The purpose of this study is to document the carbon footprint associated with travel to residency interviews of the applicants from a single institution. METHODS: Graduating medical students from the University of Michigan Medical School were surveyed in 2020 to gather information regarding travel related to residency interviews. A validated carbon emissions calculator was used to determine the associated carbon footprint. RESULTS: Response rate was 103 of 174 (59%). Average interviews per student across all specialties was 14.39 interviews per student. The overall class average for total carbon footprint per student was calculated as 3.07 metric tons CO2, making the class average carbon footprint per interview 0.21 metric tons CO2. If we extrapolate the results of our study to all residents, the resulting CO2 emissions approach 51 665 metric tons CO2 per year, which is equivalent to the amount of CO2 produced by 11 162 passenger cars in 1 year. CONCLUSIONS: Medical education leaders could help reduce the carbon footprint by encouraging a reduction in number of in-person interviews attended by applicants.

An Ultrasound-Guided Regional Anesthesia Elective for Emergency Medicine Residents.

Audience: This ultrasound-guided regional anesthesia elective is designed for emergency medicine residents. Length of Curriculum: The proposed length of this curriculum is over one week. Introduction: Ultrasound-guided regional anesthesia (UGRA) is a useful tool in the emergency department (ED) for managing painful conditions, and many programs have identified that these are useful skills for emergency providers; however, only about 53% of programs report teaching UGRA as part of their core curriculum, and there currently are no widely available or peer reviewed nerve block curricula designed for emergency medicine residents. Educational Goals: To deliver an immersive 1-week elective to provide residents a strong foundation in principles of UGRA and an introduction to 14 nerve block procedures applicable to care provided in the ED. Educational Methods: The educational strategies used in this curriculum include: instructional videos, written and online independent learning materials, one-on-one teaching at the bedside with an emergency ultrasound fellow, simulation of nerve block techniques using a femoral nerve block task trainer, and performance of supervised nerve block procedures on patients in the ED. Research Methods: All residents provided feedback through an online survey after completing the elective. Results: Eight residents completed the elective in the first year of implementation. Following completion of the UGRA curriculum, 8/8 (100%) of residents reported increased level of confidence in performing UGRA. In addition, 8/8 (100%) of residents reported they were "likely" or "very likely" to incorporate UGRA into their future EM practice. All 8 (100%) residents responded they were "very likely" to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7). Discussion: An elective in ultrasound-guided regional anesthesia can be successfully incorporated into an emergency medicine training program. The curriculum was successful in providing focused training in UGRA and resulted in increased resident confidence in performing nerve block procedures. Topics: Ultrasound-guided regional anesthesia, nerve block, resident, elective, pain.

A Social Network Analysis of the Western Journal of Emergency Medicine Special Issue in Educational Research and Practice.

INTRODUCTION: Scholarship and academic networking are essential for promotion and productivity. To develop education scholarship, the Council of Emergency Medicine Directors (CORD) and Clerkship Directors of Emergency Medicine (CDEM) created an annual Special Issue in Educational Research and Practice of the Western Journal of Emergency Medicine. The objective of this study was to evaluate the network created by the special Issue, and explore changes within the network over time. METHODS: Researchers used bibliometric data from Web of Science to create a social network analysis of institutions publishing in the first four years of the special issue using UCINET software. We analyzed whole-network and node-level metrics to describe variations and changes within the network. RESULTS: One hundred and three (56%) Accreditation Council for Graduate Medical Education-accredited emergency medicine programs were involved in 136 articles. The majority of institutions published in one or two issues. Nearly 25% published in three or four issues. The network analysis demonstrated that the mean number of connections per institution increased over the four years (mean of 5.34; standard deviation [SD] 1.27). Mean degree centralization was low at 0.28 (SD 0.05). Network density was low (mean of 0.09; SD 0.01) with little change across four issues. Five institutions scored consistently high in betweenness centrality, demonstrating a role as connectors between institutions within the network and the potential to connect new members to the network. CONCLUSION: Network-wide metrics describe a consistently low-density network with decreasing degree centralization over four years. A small number of institutions within the network were persistently key players in the network. These data indicate that, aside from core institutions that publish together, the network is not widely connected. There is evidence that new institutions are coming into the network, but they are not necessarily connected to the core publishing groups. There may be opportunities to intentionally increase connections across the network and create new connections between traditionally high-performing institutions and newer members of the network. Through informal discussions with authors from high-performing institutions, there are specific behaviors that departments may use to promote education scholarship and forge these new connections.

In-situ Simulation Use for Rapid Implementation and Process Improvement of COVID-19 Airway Management.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic presents unique challenges to frontline healthcare workers. In order to safely care for patients new processes, such as a plan for the airway management of a patient with COVID-19, must be implemented and disseminated in a rapid fashion. The use of in-situ simulation has been used to assist in latent problem identification as part of a Plan-Do-Study-Act cycle. Additionally, simulation is an effective means for training teams to perform high-risk procedures before engaging in the actual procedure. This educational advance seeks to use and study in-situ simulation as a means to rapidly implement a process for airway management in patients with COVID-19. METHODS: Using an airway algorithm developed by the authors, we designed an in-situ simulation scenario to train physicians, nurses, and respiratory therapists in best practices for airway management of patients with COVID-19. Physician participants were surveyed using a five-point Likert scale with regard to their comfort level with various aspects of the airway algorithm both before and after the simulation in a retrospective fashion. Additionally, we obtained feedback from all participants and used it to refine the airway algorithm. RESULTS: Over a two-week period, 93 physicians participated in the simulation. We received 81 responses to the survey (87%), which showed that the average level of comfort with personal protective equipment procedures increased significantly from 2.94 (95% confidence interval, 2.71-3.17) to 4.36 (4.24-4.48), a difference of 1.42 (1.20-1.63, p < 0.001). There was a significant increase in average comfort level in understanding the physician role with scores increasing from 3.51 (3.26-3.77) to 4.55 (2.71-3.17), a difference of 1.04 (0.82-1.25, p < 0.001). There was also increased comfort in performing procedural tasks such as intubation, from 3.08 (2.80-3.35) to 4.38 (4.23-4.52) after the simulation, a difference of 1.30 points (1.06-1.54, p < 0.001). Feedback from the participants also led to refinement of the airway algorithm. CONCLUSION: We successfully implemented a new airway management guideline for patients with suspected COVID-19. In-situ simulation is an essential tool for both dissemination and onboarding, as well as process improvement, in the context of an epidemic or pandemic.

Defining a Theory-Driven Ultrasound Curriculum for Prehospital Providers.

Advances in point-of-care ultrasound technology have allowed for the extension of emergency medicine ultrasound beyond the walls of the emergency department. Emergency medical system providers may benefit from the use of ultrasound. It has previously been shown that with a brief introductory course, novices can obtain and correctly interpret focused ultrasound examinations. The purpose of this study was to design a theory-driven point-of-care ultrasound curriculum to assess and develop ultrasound skill in prehospital providers. The resultant curriculum outlined in this paper encompasses a large array of skills that may be useful for different prehospital services to use to develop curriculum for their own needs.

Is It Learning or Scutwork? Medical Students Adding Value in the Emergency Department.

In busy emergency departments (EDs), it can be difficult for faculty to teach students amid pressure to provide patient care and conduct research. As a result, medical student teaching may be an afterthought rather than a priority, and there is a lack of focus on how students spend their time during clinical shifts in the ED. Students want to contribute to departmental workflow, but can be hampered by systems limitations and lack of clinical knowledge. One solution is for faculty and medical students to partner to add value to patient care in the ED. However, faculty and students must be wary of the distinction between activities that add value and "scutwork," tasks that involve little learning and do not require medical expertise. In this perspective, the student, resident, and faculty authors discuss learner and educator perspectives for how medical students can be productive contributors to patient care in the ED without being subjected to scutwork. They also recommend ideas for productive student activities that promote learning, contrasted with examples of scutwork to avoid. Definitions of value-added activities and scutwork depend on the learner's experience level and interests and are subject to debate. However, if medical students can be engaged in learning while also providing meaningful contributions to patient care, students, educators, and patients stand to benefit.

#DidacticsRevolution: Applying Kotter's 8-Step Change Management Model to Residency Didactics.

INTRODUCTION: Leading change effectively is critical to advancing medical education. Residency didactics often require change in order to meet stakeholder's needs. Kotter's change management model (KCMM) is an 8-step method for implementing change that can be applied to educational initiatives. This innovation improved an emergency medicine residency didactics curriculum through application of KCMM. METHODS: An initiative to improve residency didactics curriculum was titled the "Didactics Revolution" and implemented according to KCMM: establish a sense of urgency, form a powerful guiding coalition, create a vision, communicate the vision, empower others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change, and institutionalize new approaches. Data from the Annual Program Review was utilized to assess the impact of the KCMM strategy. RESULTS: The percentage of residents who agreed or strongly agreed that lectures provide a valuable learning experience increased from 39.1% in the year prior to 88.0% in the year during the implementation (p < .001), and remained relatively high at 73.5% in the year following. The percentage of residents who agreed or strongly agreed that they felt well-prepared for the written boards increased from 60.9% in the year prior to 92.0% in the year during the implementation (p = .01) and remained high at 73.5% in the year following. CONCLUSION: Residency didactics can be improved through the use of KCMM, a change management model originally developed in the corporate context.

Increasing Education Research Productivity: A Network Analysis.

INTRODUCTION: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time. METHODS: Publications from a single institution's medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group. RESULTS: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015-2019, there were 78 publications involving 116 unique institutions. CONCLUSION: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms. Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

Understanding the Struggles to Be a Medical Provider: View Through Medical Student Essays.

BACKGROUND: The clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment. OBJECTIVE: The purpose of this study was to examine medical students' reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity. METHODS: Students rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains. RESULTS: The first domain was Patient-Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients' interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the "gray zone," in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%). CONCLUSIONS: The reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians.

Impact of Doximity Residency Rankings on Emergency Medicine Applicant Rank Lists.

INTRODUCTION: This study investigates the impact of the Doximity rankings on the rank list choices made by residency applicants in emergency medicine (EM). METHODS: We sent an 11-item survey by email to all students who applied to EM residency programs at four different institutions representing diverse geographical regions. Students were asked questions about their perception of Doximity rankings and how it may have impacted their rank list decisions. RESULTS: Response rate was 58% of 1,372 opened electronic surveys. This study found that a majority of medical students applying to residency in EM were aware of the Doximity rankings prior to submitting rank lists (67%). One-quarter of these applicants changed the number of programs and ranks of those programs when completing their rank list based on the Doximity rankings (26%). Though the absolute number of programs changed on the rank lists was small, the results demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency programs. CONCLUSION: While applicants do not find the Doximity rankings to be important compared to other factors in the application process, the Doximity rankings result in a small change in residency applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather than objective outcome criteria, thus has the potential to be detrimental to students, programs, and the public. We feel it important for specialties to develop consensus around measurable training outcomes and provide freely accessible metrics for candidate education.

Medical student milestones in emergency medicine.

OBJECTIVES: Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency-based medical education prompted by the Accreditation Council for Graduate Medical Education (ACGME) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency-based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency-based milestones for fourth-year medical students completing their emergency medicine (EM) clerkships (regardless of whether the students were planning on entering EM) using a rigorous method to attain validity evidence. METHODS: A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. RESULTS: Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges (AAMC) core entrustable professional activities for entering residency to improve content validity. CONCLUSIONS: This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth-year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency.

Treatment of dialysis catheter-related Enterococcus bacteremia with an antibiotic lock: a quality improvement report.

BACKGROUND: Catheter-related bacteremia (CRB) is a frequent complication of tunneled dialysis catheters, and Enterococcus is a common infecting organism. CRB may be treated by instilling an antibiotic lock into the catheter lumen in conjunction with systemic antibiotics. The efficacy of this approach in Enterococcus bacteremia is unknown. DESIGN: Quality improvement report. SETTING & PARTICIPANTS: 64 catheter-dependent hemodialysis outpatients with vancomycin-sensitive Enterococcus bacteremia treated with a uniform antibiotic lock protocol. Clinical outcomes were tracked prospectively. QUALITY IMPROVEMENT PLANS: Patients received intravenous vancomycin for 3 weeks in conjunction with a vancomycin lock instilled into both catheter lumens after each dialysis session. MEASURES: Treatment failure was defined as persistent fever 48 hours after initiation of antibiotic therapy or recurrent Enterococcus bacteremia within 90 days. A clinical cure was defined as fever resolution without recurrent bacteremia. Major infection-related complications within 6 months were documented. RESULTS: Treatment failure occurred in 25 patients (39%) because of persistent fever in 10 and recurrent bacteremia in 15. Treatment success occurred in 39 patients (61%). A serious complication of Enterococcus CRB occurred in 4 of 64 patients (6%); endocarditis in 1 and osteomyelitis in 3. The frequency of serious complications was 16% (4 of 25 patients) in those with treatment failure compared with 0% (0 of 39 patients) in those with treatment success (P = 0.01). LIMITATIONS: This was a single-center study. We did not measure serum vancomycin. CONCLUSIONS: An antibiotic lock protocol permits catheter salvage in 61% of hemodialysis patients with Enterococcus CRB. Serious complications occur in 6% of patients and are more common in those with treatment failure.

Disparities in fistula maturation persist despite preoperative vascular mapping.

BACKGROUND AND OBJECTIVES: Failure to mature (primary failure) of new fistulas remains a major obstacle to increasing the proportion of dialysis patients with fistulas. This failure rate is higher in women than in men, higher in older than in younger patients, and higher in forearm than in upper arm fistulas. These disparities in the frequency of failure to mature may be due in part to marginal vessels in the high-risk groups and should be reduced by routine preoperative vascular mapping. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective, computerized database was queried retrospectively to evaluate the frequency of primary fistula failure in 205 hemodialysis patients for whom preoperative mapping was obtained. The association between clinical characteristics and risk for primary fistula failure was analyzed by univariate and multiple variable regression analysis. RESULTS: The overall primary fistula failure rate was 40% (82 of 205 patients). On multiple variable logistic regression, three clinical factors were associated with an increased risk for failure to mature among patients who underwent preoperative vascular mapping: Female gender, age > or =65 yr, and forearm location. The primary fistula failure rate varied from 22% in younger men with an upper arm fistula to 78% in older women with a forearm fistula. Dynamic preoperative vascular measurements (change in peak systolic velocity and resistive index after tight fist clenching) did not differ between patients with mature and immature forearm fistulas. CONCLUSION: Disparities in fistula maturation persist despite the use of routine preoperative vascular mapping.