The effect of performance incentives on resident documentation in an emergency medicine residency program.

We sought to improve resident chart documentation in an academic emergency department using an incentive. A stipend for educational expenses was offered to residents for documenting charts above specific threshold Evaluation & Management (E&M) levels. Comparisons were made with historical levels. Twenty-two residents participated over 4 months (70% received the stipend). Documentation levels increased significantly from 2.86 and 3.04 during historical controls to 3.31 during the study period (p < 0.05). Fifty-six percent of charts were documented at 99284 or 99285 during the study period compared to 39% and 23% in the control periods (p < 0.05). Three months after the plan (with no incentives), documentation continued to improve, with 59% documented at 99284 or 99285. Mean collection per patient was $48.05 for the study period and $42.36 and $35.86 for the historical periods (p < 0.05). Implementation of a resident incentive program to enhance chart documentation may considerably improve documentation and resident education in proper chart documentation.

Vaccine information statements. Revolutionary but neglected educational advances in healthcare in the United States.

The purpose of this report is to provide further information about vaccine information statements (VISs) that are revolutionary but neglected educational advances in the United States. Because the use of VISs is mandated by the Federal Government in every individual being immunized, it is the goal of this report to further awaken health professionals and society to the mandatory use of these superb educational statements. With the passage of the National Childhood Vaccine Injury Act of 1986, the Federal Government required that VISs would be given to all vaccine recipients. As of September 2001, the VISs that must be used are diphtheria, tetanus, pertussis, (DTaP); diphtheria, tetanus (Td); measles, mumps, rubella (MMR); polio (IPV); hepatitis B; Haemophilus influenzae type b (Hib); varicella; and pneumococcal conjugate. Copies of the VISs are available at www.cdc.gov/nip/publications/VIS. The National Childhood Vaccine Injury Act of 1986 mandated that all health care providers report certain adverse events that occur following vaccination. As a result, the Vaccine Adverse Events Reporting System (VAERS) was established by the FDA and the Centers for Disease Control and Prevention (CDC) in 1990. In order to reduce the liability of manufacturers and healthcare providers, the National Childhood Vaccine Injury Act of 1986 established the National Vaccine Injury Compensation Program (NVICP). This program is intended to compensate those individuals who have been injured by vaccines on a no-fault basis. While the use of VISs has been mandated since 1996, a national survey of private practice office settings has revealed that many immunized patients do not receive the VISs. When these forms were used, physicians rarely initiated discussions regarding contraindications to immunizations or the National Vaccine Injury Compensation Program. Fortunately, the state boards of medical examiners, like the one in Oregon, are taking a strong stand for the use of VISs, with the warning that failure to use a VIS may result in disciplinary action. Our nation and practicing physicians must be awakened to the importance of the use of VISs to ensure that every vaccinated individual receives this statement at the time of vaccination.

Scientific basis for the selection of emergency medical examination gloves for emergency medical technicians, paramedics, firefighters, and emergency department personnel. An update.

The use of powder-free natural rubber or latex-free emergency medical examination gloves is especially important to emergency medical technicians, paramedics, firefighters, and emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics, and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent codes and standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA-approved gloves. There are four well-defined goals of this report that will assist emergency medical services, fire departments, and hospitals in the selection and purchase of emergency medical examination gloves. First, we will review again the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. As of September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed in NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 2003 Edition.

Society for Academic Emergency Medicine survey of the Association of American Medical Colleges Council of Academic Societies.

The Society for Academic Emergency Medicine (SAEM) surveyed the Council of Academic Societies (CAS) organizations to obtain useful information to project SAEM goals into the year 2010. The objective of this work was to understand common and varying organizational operations and identify opportunities. The authors reviewed CAS organizations' mission statements, operating budgets, modes of communications, products, meeting formats, foundations, endowment funds, staff structures, headquarters, advocacy activities (services), top challenges, and most significant changes anticipated the next ten years. The survey methodology was used to gain insight into modes of operation of CAS organizations and enable SAEM to review its own operations and identify potential organizational changes based on the experiences of others. Individual CAS organizations might similarly benefit by reviewing the results of the survey and comparing themselves with others.

Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States.

There is a global epidemic of hepatitis B virus (HBV) infections affecting more than 350 million people worldwide. This collective review provides the rationale for a comprehensive strategy to eliminate transmission of HBV in the United States. The virologic characteristics of HBV include three forms of HBV surface antigen (HBsAg), HBV core antigen (HbcAg), as well as a circulating peptide, the HBV e antigen (HBeAg). The year 2002 was the 20th anniversary of the use in the United States of the world's first vaccine against HBV. Our prevention strategy involves making HBV vaccine a part of the routine vaccination schedules for all infants in the United States. Hepatitis B immune globulin (HBIG) is another useful adjunct for prophylaxis that provides temporary protection (i.e., 3-6 months) and is recommended in only certain postexposure settings. The routes for administration of HBV vaccine and HBIG are intramuscular sites that differ according to the age of the individual. Following routine HBV vaccination in adults and children, prevaccination and postvaccination serologic testing is not recommended because of the relatively low rate of HBV infection and the low cost of the vaccine. Postexposure prophylaxis for HBV with serologic testing is, however, necessary for all hospital personnel exposed to blood or body fluids. In addition, infants born from mothers not immunized to HBV or those who are infected with HBV also require comprehensive postexposure prophylaxis with serologic testing. Comprehensive immunization strategies with serologic testing must be implemented for all groups that have a high risk of HBV infection. Finally, vaccine information statements (VIS) must be carefully integrated in this comprehensive disease prevention strategy, which is designed to prevent the transmission of HBV in the United States.

Scientific basis for selection of emergency medical examination gloves for emergency medical technicians, paramedics, firefighters, and emergency department personnel.

Dusting powders were first applied to gloves to facilitate donning. After 1980, manufacturers devised innovative techniques to manufacture gloves without dusting powders. It has been well documented that the powders on gloves present a health hazard to patients, as well as healthcare workers. First, these powders elicit tissue toxicity in every tissue in the body. Second, these powders serve as carriers of latex allergen and may precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powders have caused a growing number of emergency medical technicians, paramedics, firelighters, and hospitals to abandon the use of powdered emergency medical examination gloves, using only powder-free gloves. Powder-free latex as well as non-latex gloves are now available to emergency medical technicians, paramedics, firefighters, and emergency department personnel. The use of powder-free natural rubber latex-free gloves is especially important to emergency medical technicians, paramedics, firefighters, as well as emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent Codes and Standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA approved gloves. It is the purpose of this report to review the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance Standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. In September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed

Management and prevention of tetanus.

The World Health Organization was committed to eliminating neonatal tetanus by 1995. Three years after this date, the infection killed over 400,000 babies a year, even though a safe, effective vaccine had been available for most of this century. The frequency of tetanus in the developing world epitomizes the healthcare disparity between the developed and the developing world. Consequently, the priority of the medical profession must be prevention, with the development of simpler immunization schedules with longer protection. Consequently, the purpose of this collective review is to provide an overview to the management of tetanus as well as to review the immunization strategy that will prevent this potentially deadly illness. Tetanus is caused by Cloistridium tetani, which is an obligate anaerobic, gram-positive rod that is motile and readily forms endospores. Although C. tetani is located everywhere, the disease is encountered largely in underdeveloped, overcrowded, and economically disadvantaged countries. C. tetani is widespread in the feces of domestic animals and humans, while spores of C. tetani are abundant in soil and in the environment surrounding the habitation of humans and animals. Tetanus usually follows deep penetrating wounds where anaerobic bacterial growth is facilitated. Three basic forms of tetanus may be distinguished: local, cephalic, and generalized. At least 80% of the cases are the generalized form. In the adult patient, the most characteristic sign of generalized tetanus is lockjaw, or trismus. The diagnosis of tetanus is most frequently made on clinical manifestations, rather than on bacteriologic findings. The three objectives of management of tetanus are: (1) to provide supportive care until the tetanospasmin that is fixed in tissue has been metabolized; (2) to neutralize circulating toxin; and (3) to remove the source of tetanospasmin. Because there is essentially no immunity to tetanus toxoid, the only effective way to control tetanus is by prophylactic immunization.

Quantifying palpation techniques in relation to performance in a clinical prostate exam.

This paper seeks to quantify finger palpation techniques in the prostate clinical exam, determine their relationship with performance in detecting abnormalities, and differentiate the tendencies of nurse practitioner students and resident physicians. One issue with the digital rectal examination (DRE) is that performance in detecting abnormalities varies greatly and agreement between examiners is low. The utilization of particular palpation techniques may be one way to improve clinician ability. Based on past qualitative instruction, this paper algorithmically defines a set of palpation techniques for the DRE, i.e., global finger movement (GFM), local finger movement (LFM), and average intentional finger pressure, and utilizes a custom-built simulator to analyze finger movements in an experiment with two groups: 18 nurse practitioner students and 16 resident physicians. Although technique utilization varied, some elements clearly impacted performance. For example, those utilizing the LFM of vibration were significantly better at detecting abnormalities. Also, the V GFM led to greater success, but finger pressure played a lesser role. Interestingly, while the residents were clearly the superior performers, their techniques differed only subtly from the students. In summary, the quantified palpation techniques appear to account for examination ability at some level, but not entirely for differences between groups.

Using a prostate exam simulator to decipher palpation techniques that facilitate the detection of abnormalities near clinical limits.

INTRODUCTION: Prostate carcinoma (and other prostate irregularities and abnormalities) is detected in part via the digital rectal examination. Training clinicians to use particular palpation techniques may be one way to improve the rates of detection. METHODS: In an experiment of 34 participants with clinical backgrounds, we used a custom-built simulator to determine whether certain finger palpation techniques improved one's ability to detect abnormalities smaller in size and dispersed as multiples over a volume. The intent was to test abnormality cases of clinical relevance near the limits of size perceptibility (ie, 5-mm diameter). The simulator can present abnormalities in various configurations and record finger movement. To characterize finger movement, four palpation techniques were quantitatively defined (global finger movement, local finger movement, average intentional finger pressure, and dominant intentional finger frequency) to represent the qualitative definitions of other researchers. RESULTS: Participants who used more thorough patterns of global finger movement (V and L) ensured that the entire prostate was searched and detected more abnormalities. A higher magnitude of finger pressure was associated with the detection of smaller abnormalities. The local finger movement of firm pressure with varying intensities was most indicative of success and was required to identify the smallest (5-mm diameter) abnormality. When participants used firm pressure with varying intensities, their dominant intentional finger frequency was about 6 Hz. CONCLUSIONS: The use of certain palpation techniques does enable the detection of smaller and more numerous abnormalities, and we seek to abstract these techniques into a systematic protocol for use in the clinic.

A simulation course on lifesaving techniques for third-year medical students.

BACKGROUND: The University of Virginia School of Medicine discontinued animal vivisection in February 2004 for teaching lifesaving procedures to third-year medical students. Consequently, a 1-day course using simulation technology was developed to meet objectives previously covered in the animal laboratory. The authors sought to evaluate the course and hypothesized that the students' confidence in lifesaving procedures as well as their acceptance of simulation technology as a teaching tool would increase. METHODS: The course was designed in a two-session format. The first session (first half of the day) concentrated on individual procedure skills, utilizing part-task trainers. The second session (second half of the day) used a Medical Education Technologies Inc. (METI) Emergency Care Simulator (ECS) full-body patient simulator to present a major trauma scenario. The study design was a prospective, pretest-posttest study without a control group. A 10-question pre and post survey used a Likert scale to explore students' confidence in their skills as well as their acceptance of simulation technology. A course evaluation used a similar Likert scale for evaluation of the course substations, the trauma scenario, and students' self-assessment of their skill levels as well as a 100% point scale for an overall rating of the course. RESULTS: A total of eight 1-day courses were successfully held over 2 years with a total enrollment of 240 students utilizing 20 instructors inclusive of faculty, residents, and other emergency medicine health care providers. For the pre and post survey results, there was a significant increase in students' confidence in performing lifesaving procedures as well as their acceptance of simulation as a teaching tool (P < 0.05 for each question with pre n = 222 and post n = 226). For the course evaluation results (n = 190), all of the course substations were rated in the good to excellent range and the course received an overall score of 97.55 +/- 7.23% out of 100%. Furthermore, students reported a significant increase in their skill level (P < 0.05). CONCLUSION: This lifesaving techniques course utilizing simulation technology successfully covered objectives previously taught with animal vivisection, increased students' confidence levels in performing lifesaving procedures and was highly accepted by the medical students.

Hospital-based healthcare provider (nurse and physician) integration into an emergency medical services-managed mass-gathering event.

INTRODUCTION: This report describes not only the implementation of a coordinated emergency medical services-hospital-based healthcare team but also investigates the integration of nurse-physician teams at a mass gathering medical care event. METHODS: A review of resource utilization, patient encounters, and local ED census was performed during this period at a college football stadium. RESULTS: During this 4-year period, 1681 patients presented for medical care during 26 events with a total attendance of 1,544,244 (1.09 patients per thousand attendees [PT]). The majority of patient contacts were for minor complaints (1451, 87.6%), whereas 205 (12.4%) received full evaluations (focused history and physical examination most often with pulse oximetric and electrocardiographic monitoring). A total of 109 patients were transported (4.19 PT), representing 6.48% of all patients. Patient census for the event medical deployment increased from 0.44 PT in 2001 to 1.75 PT in 2004. The number and percent of patients transported also increased between 2001 (0.02 PT, 4.48%) and 2004 (0.12 PT, 6.67%). However, 118 (57.6%) patients who received full evaluations were able to be discharged by a physician, avoiding transport. Chief complaints and management of patients receiving full evaluations were consistent across this period, with altered mental status (52.7%) and chest pain (12.7%) as the most common complaints. Average ED census during this period was found to be significantly higher on event days (176.2) than nonevent days (161.2) (t = 8.04, P < .001), although this produced only a minor impact on the emergent care system. CONCLUSION: This study describes one potential deployment plan for a mass gathering medical event and suggests that the incorporation of physicians into a mass gathering setting may be associated with an absolute increase in patient census and transports, while decreasing the percent of patients transported. The impact on local emergency medical services and ED resources, although not specifically investigated in this study, was likely minimal.

The pediatric emergency department: a substitute for primary care?

OBJECTIVES: Pediatric emergency department (PED) patients often present with non-urgent complaints. We attempted to estimate the perceived degree of urgency of the visit and to identify reasons for seeking non-urgent care in the PED by patients and parents. METHODS: A prospective survey was completed by parents (for children 17 and younger) and patients (18-21) presenting to a suburban academic PED that sees approximately 15,000 patients per year. A convenience sample of participants was enrolled. RESULTS: Three hundred and five of 334 surveys were completed (91% response rate) over a 3-month period. Twenty-four percent of the chief complaints were perceived by those surveyed as emergent or possibly life-threatening, 23% were felt to be very urgent, and 52% were deemed somewhat urgent or minor. Twenty-five percent of those with minor or somewhat urgent complaints arrived by ambulance. Weekend visits and minority race correlated with a lower degree of perceived urgency. Overall, 79% of those surveyed identified a primary care provider (PCP) for themselves or their child. Of those, 54% had attempted to contact the PCP prior to coming to the PED. Six percent of those who attempted to reach their primary care providers were able to contact them and 52% were told to come to the PED. CONCLUSIONS: More than half of patients and parents presenting to the PED believed they had minor or somewhat urgent complaints. While the majority of patients have a regular provider, limited access to timely primary care and convenience may make the PED a more attractive care option than primary care for many parents and patients.