Virtual interviewing for graduate medical education recruitment and selection: A BEME systematic review: BEME Guide No. 80.

BACKGROUND: The COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses. METHODS: PubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance. RESULTS: One hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel. CONCLUSIONS: The use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Impact of Electronic Health Record Implementation on Ophthalmology Trainee Time Expenditures.

OBJECTIVE: Electronic health records (EHRs) are widely adopted, but the time demands of EHR use on ophthalmology trainees are not well understood. This study evaluated ophthalmology trainee time spent on clinical activities in an outpatient clinic undergoing EHR implementation. DESIGN: Prospective, manual time-motion observations of ophthalmology trainees in 2018. PARTICIPANTS: Eleven ophthalmology residents and fellows observed during 156 patient encounters. METHODS: Prospective time-motion study of ophthalmology trainees 2 weeks before and 6 weeks after EHR implementation in an academic ophthalmology department. Manual time-motion observations were conducted for 11 ophthalmology trainees in 6 subspecialty clinics during 156 patient encounters. Time spent documenting, examining, and talking with patients were recorded. Factors influencing time requirements were evaluated using linear mixed effects models. MAIN OUTCOME MEASURES: Total time spent by ophthalmology residents and fellows per patient, time spent on documentation, examination, and talking with patients. RESULTS: Seven ophthalmology residents and four ophthalmology fellows with mean (standard deviation) postgraduate year of 3.7 (1.2) were observed during 156 patient encounters. Using paper charts, mean total time spent on each patient was 11.6 (6.5) minutes, with 5.4 (3.5) minutes spent documenting (48%). After EHR implementation, mean total time spent on each patient was 11.8 (6.9) minutes, with 6.8 (4.7) minutes spent documenting (57%). Total time expenditure per patient did not significantly change after EHR implementation (+0.17 minutes, 95% confidence interval [CI] for difference in means: -2.78, 2.45; p = 0.90). Documentation time did not change significantly after EHR implementation in absolute terms (+1.42 minutes, 95% CI: -3.13, 0.29; p = 0.10), but was significantly greater as a proportion of total time (48% on paper to 57% on EHR; +9%, 95% CI: 2.17, 15.83; p = 0.011). CONCLUSION: Total time spent per patient and absolute time spent on documentation was not significantly different whether ophthalmology trainees used paper charts or the recently implemented EHR. Percentage of total time spent on documentation increased significantly with early EHR use. Evaluating EHR impact on ophthalmology trainees may improve understanding of how trainees learn to use the EHR and may shed light on strategies to address trainee burnout.

Rural-Urban Differences in Costs of End-of-Life Care for Elderly Cancer Patients in the United States.

PURPOSE: The objective of this study was to examine the rural-urban differences in Medicare expenditures on end-of-life care for elderly cancer patients in the United States. METHODS: We analyzed Medicare claims data for 175,181 elderly adults with lung, colorectal, female breast, or prostate cancer diagnosis who died in 2008. The end-of-life costs were quantified as total Medicare expenditures for the last 12 months of care including inpatient, outpatient, physician services, hospice, home health, skilled nursing facilities (SNF), and durable medical expenditure. Linear regression models were used to estimate rural-urban differences in log-transformed end-of-life costs and logistic regressions were used to estimate probability of service use, adjusting for demographics, socioeconomic status, and comorbidities. FINDINGS: On average, elderly cancer patients cost Medicare $51,273, $50,274, $62,815, and $50,941 in the last year for breast, prostate, colorectal, and lung cancer, respectively. Rural patients cost Medicare about 10%, 6%, 8%, and 4% less on end-of-life care than their urban counterparts for breast, prostate, colorectal, and lung cancer, respectively. Rural cancer patients were less likely to use hospice and home health, more likely to use outpatient and SNF, and they cost Medicare less on inpatient and physician services and more on outpatient care conditional on service use. CONCLUSIONS: The lower Medicare spending on end-of-life care for the rural cancer patients suggests disparities based on place of residence. A future study that delineates the source of the rural-urban difference can help us understand whether it indicates inappropriate level of palliative care and find effective policies to reduce the urban-rural disparities.

Health care provider perceptions of a query-based health information exchange: barriers and benefits.

BACKGROUND: Health information exchange (HIE) systems are implemented nationwide to integrate health information and facilitate communication among providers. The Nebraska Health Information Initiative is a state-wide HIE launched in 2009. OBJECTIVE: The purpose of this study was to conduct a comprehensive assessment of health care providers' perspectives on a query-based HIE, including barriers to adoption and important functionality for continued utilization. METHODS: We surveyed 5618 Nebraska health care providers in 2013. Reminder letters were sent 30 days after the initial mailing. RESULTS: A total of 615 questionnaires (11%) were completed. Of the 100 current users, 63 (63%) indicated satisfaction with HIE. The most common reasons for adoption among current or previous users of an HIE (N = 198) were improvement in patient care (N = 111, 56%) as well as receiving (N = 95, 48%) and sending information (N = 80, 40%) in the referral network. Cost (N = 233, 38%) and loss of productivity (N = 220, 36%) were indicated as the 'major barriers' to adoption by all respondents. Accessing a comprehensive patient medication list was identified as the most important feature of the HIE (N = 422, 69%). CONCLUSIONS: The cost of HIE access and workflow integration are significant concerns of health care providers. Additional resources to assist practices plan the integration of the HIE into a sustainable workflow may be required before widespread adoption occurs. The clinical information sought by providers must also be readily available for continued utilization. Query-based HIEs must ensure that medication history, laboratory results and other desired clinical information be present, or long-term utilization of the HIE is unlikely.

Stress Factors Contributing to Depression Among Latino Migrant Farmworkers in Nebraska.

Migrant farmworkers represent a structurally vulnerable population coming to rural communities to work, but often are economically disadvantaged and socially isolated. Based on survey data from 200 migrant farmworkers in rural Nebraska in 2013, this study seeks to identify and categorize major stressors that have contributed to depression among farmworkers. Over 30% of respondents were identified to have high stress levels as indicated by the Migrant Farmworker Stress Inventory (MFWSI). The MFWSI was categorized into eight domains: economics and logistics; acculturation and social isolation; relationship with partner; health; entertainment; concerns for children; and substance use by others. Nearly half (45.8%) of respondents were depressed. Correlations between the principal component scores of the eight stressor domains and the cumulative depression score were significant for the domains: (1) economics and logistics and (2) health (r = 0.22, p < 0.01). Findings highlight the importance of improving economic and living conditions as well as addressing social and cultural needs by creating more welcoming receiving communities.

Resource utilization and national demographics of laryngotracheal trauma in children.

IMPORTANCE: Pediatric laryngotracheal trauma is rare but can carry considerable morbidity and health care resource expenditure. However, the true cost of these injuries has not been thoroughly investigated. OBJECTIVE: To use a national administrative pediatric database to identify normative data on pediatric laryngotracheal trauma, specifically with regard to cost and resource utilization. DESIGN AND PARTICIPANTS: Retrospective medical record review using the Kids' Inpatient Database (KID) 2009. Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for fractures or open wounds of the larynx and trachea. MAIN OUTCOMES AND MEASURES: Among many data analyzed were demographic information and admission characteristics, including length of stay, diagnoses, procedures performed, and total charges. RESULTS: There were 106 admissions that met inclusion criteria. Patient mean (SE) age was 15.9 (0.45) years, and 79% were males. The mean (SE) length of stay (LOS) was 8.4 (1.1) days; more than 50% of patients had a LOS longer than 4 days. The mean number of diagnoses per patient was 6.9 (0.6); other traumatic injuries included pneumothorax (n = 18). More than 75% of patients underwent more than 2 procedures during their admission; 60.2% underwent a major operative procedure. The most common procedures performed were laryngoscopy (n = 54) and operative repair of the larynx and/or trachea (n = 32). Tracheostomy was performed in only 30 patients. The mean (SE) total charge was $90,879 ($11,419), and one-third of patients had total charges more than $100,000. CONCLUSIONS AND RELEVANCE: Pediatric laryngotracheal trauma remains a relatively rare clinical entity. These injuries primarily affect older children and are associated with long hospitalizations, multiple procedures, and high resource utilization.

Quality of end-of-life care among rural Medicare beneficiaries with colorectal cancer.

BACKGROUND: Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors. METHODS: Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death. RESULTS: About 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU. CONCLUSIONS: Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.

Disparities in end of life care for elderly lung cancer patients.

The objective of this study was to examine geographic and race/ethnic disparities in access to end of life care among elderly patients with lung cancer. The study sample consisted of 91,039 Medicare beneficiaries with lung cancer who died in 2008. The key outcome measures included the number of emergency room visits, the number of inpatient admissions and the number of intensive care unit (ICU) days in the last 90 days of life, hospice care ever used and hospice enrollment within the last 3 days of life. Medicare beneficiaries with lung cancer residing in rural, remote rural, and micropolitan areas had more ER visits in the last 90 days of life as compared to urban residents. Urban residents however, had more ICU days in the last 90 days of life and were more likely to have ever used hospice as compared to residents of rural, remote rural and micropolitan counties. Racial minority lung cancer patients had more ICU days, ER visits and inpatient days than non-Hispanic White patients, and also were less likely to have ever used hospice care or be enrolled in hospice in the last 3 days of life. Lung cancer patients with very low socioeconomic status (SES) were less likely to ever use hospice or be enrolled in hospice care in the last 3 days of life, as compared to those who had very high SES. Geographic, racial and socioeconomic disparities in end of life care call for targeted efforts to address access barriers for these groups of patients.

Barriers to electronic prescribing: Nebraska pharmacists' perspective.

PURPOSE: Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria. METHODS: We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants' responses. FINDINGS: Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing. CONCLUSIONS: The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted.

Socioeconomic implications of pediatric cervical methicillin-resistant Staphylococcus aureus infections.

OBJECTIVE: To study cervical methicillin-resistant Staphylococcus aureus (MRSA) infections using a national database with the goal of providing normative data and identifying variations in resource utilization. DESIGN: Retrospective review using a pediatric national data set (Kids' Inpatient Database 2009). SUBJECTS: Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for both MRSA and specific neck and pharyngeal infections. RESULTS: There were 26,829 admissions with MRSA; 3571 included a head and neck infection. The mean (SE) age at admission was 7.72 (0.20) years. Most patients (65.0%) were in the lower 2 socioeconomic quartiles; the most common payer was Medicaid (53.3%). The mean total charge per admission was $20,442. The mean (SE) length of stay (LOS) was 4.39 (0.15) days; there were significant differences among age (P < .001) and racial (P < .001) groups. A total of 1671 children underwent at least 1 surgical drainage procedure; there were statistically significant differences among racial (P < .001), age (P < .001), and socioeconomic (P = .048) groups. There were no regional variations in resource utilization when LOS, number of procedures, and total hospital charges were compared. CONCLUSIONS: Cervical MRSA infections have a large socioeconomic impact across the nation. There are differences among the various races in resource utilization. Younger children have longer hospitalizations, are more likely to need surgery, and require more intubations. Children from the lowest socioeconomic group require surgery more frequently, but their LOS is not statistically different when compared with the other 3 groups. Knowledge of such characteristics for cervical MRSA infections in children can facilitate targeted clinical interventions to improve care of affected populations.

Healthcare cost usage for hospitalised injuries sustained in industrial settings in the USA.

OBJECTIVE: To describe characteristics and outcomes of patients hospitalised for injuries occurring in industrial settings during a 1-year period. METHODS: A retrospective analysis of hospital admissions in the USA in 2006 using the Nationwide Inpatient Sample was performed. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) code E849.3 (industrial place and premises) was used to identify work-related injury admissions. RESULTS: A total of 5826 patients were hospitalised with injuries sustained in industrial settings (weighted, 28,354 patients). The mean age was 42.9 years (82% were men). They were 48% Caucasian, 19% Hispanic and 6% African-American. The majority were admitted from the Emergency Department (72%). Further the majority of admissions were discharged home (79%; 9% with home healthcare) and 10.7% were transferred to another facility. The mean length of stay was 4.5 days (range 0-109 days). Mean total charges per admission was US$32,254 (median US$18,364, 90th percentile US$66,607). Common diagnoses included: orthopaedic injuries (including amputations) to: finger/hand (20.9%), foot/ankle (8.2%), leg (10.2%) and spine (8.4%); infection (10.8%), pulmonary diagnosis (6.6%), soft tissue injuries (3.6%) and burns to <10% of the body (3.6%). Comorbidities included hypertension (17.0%) and diabetes mellitus (6.3%). Most common procedures performed included fracture reduction (17.6%), blood transfusions (3.1%) and spinal surgery (3%). A total of 194 (0.7%) patients died in the hospital. CONCLUSIONS: Injuries in industrial settings result in significant healthcare usage, morbidity and mortality on an annual basis in the USA. These admission levels facilitate development of targeted strategies to optimise the quality and economics of care for injuries in industrial settings.

Thyroidectomy outcomes: a national perspective.

OBJECTIVES: Describe trends and outcomes of patients undergoing thyroidectomy. STUDY DESIGN AND SETTING: Retrospective search of national inpatient database. SUBJECTS AND METHODS: The Nationwide Inpatient Sample 2009 was searched using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for thyroidectomy. Data extraction included patient demographics, hospital characteristics, and associated diagnoses. Subgroup analysis was performed on mortalities; bivariate and multivariate analysis was used to examine predictors of complications. RESULTS: In the United States, 59,478 patients were admitted and underwent thyroidectomy in 2009. Their mean (SD) age was 53.0 (16.4) years. Mean (SD) length of stay was 3.0 (6.9) days, and mean (SD) total charges was $39,236 ($73,679). Total thyroidectomy was performed in 53.6% of patients; 33.2% underwent unilateral lobectomy. Most common thyroid disorders included nontoxic nodular goiter (36.0%) and malignant neoplasm (30.3%). There were 363 (0.61%) mortalities, with a mean (SD) age of 65.5 (15.2) years, length of stay of 13.9 (15.2) days, and total charges of $218,855 ($191,977). Of all patients, 6.18% had hypocalcemia and 0.77% had hypoparathyroidism; the incidence of vocal cord paresis was 0.85% unilaterally and 0.34% bilaterally. Multivariate analysis revealed predictors of complications following thyroid surgery were female sex (P = .0001), total thyroidectomy procedure (P < .0001), hospital location and teaching status (P = .0060), hospital bed size (P = .0054), type of thyroid disorder, and underlying patient comorbidities. CONCLUSION: Reporting of normative data for thyroidectomy facilitates comparison. Hospitalizations for patients undergoing thyroidectomy require significant resource utilization. Predictors of complications include female sex, type of thyroid disorder and procedure, hospital location and teaching status, hospital bed size, and patient comorbidities.

Orbital and periorbital infections: a national perspective.

OBJECTIVES: To describe the epidemiologic features of pediatric orbital and periorbital infections from a national perspective and to identify predictors of surgery. DESIGN: Analysis of the Kids' Inpatient Database. SETTING: Administrative data set. PATIENTS: Pediatric inpatient admissions with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of orbital cellulitis. MAIN OUTCOME MEASURES: Hospital admission, socioeconomic, and clinical variables were examined and predictors of surgical intervention were evaluated using logistic regression. RESULTS: A total 5440 hospital admissions was noted for pediatric orbital cellulitis; of these, 672 patients (12.4%) underwent surgical intervention. Mean length of stay for all patients was 3.8 days; 90.4% were routinely discharged. Patients who had surgery were older, with a mean (SE) age of 10.1 (0.29) years compared with 6.1 (0.10) years for nonsurgical patients (P < .001). Surgical patients had a significantly longer mean hospital stay (7.1 vs 3.4 days, P < .001) and a higher mean cost of care ($41 009 vs $13 008, P < .001) compared with nonsurgical patients. Demographic predictors of surgical intervention included male sex, admitting characteristics, and hospital location. Except for sex, these variables remained significant in a multivariate model. Clinically, diplopia is a predictor of surgical intervention (odds ratio, 6.3; 95% confidence interval, 3.4-11.7). CONCLUSIONS: This study describes the medical and surgical management of pediatric orbital and periorbital infections from a national perspective. Predictors of surgical intervention include older age, presentation with diplopia, and hospital admission via the emergency department. Knowledge of these variables facilitates analysis of resource utilization for pediatric orbital cellulitis and can be used to optimally triage patients, ultimately reducing costs and lengths of stay while preserving quality of care.

Pediatric acute sinusitis: predictors of increased resource utilization.

OBJECTIVE: To determine variations in resource utilization in the management of pediatric acute sinusitis. STUDY DESIGN: Retrospective analysis of a publicly available national dataset. METHODS: The Kids' Inpatient Database 2006 was analyzed using ICD-9 codes for acute sinusitis. RESULTS: A total of 8,381 patients (55% male, mean age 8.5 years [SE = 0.2]) were admitted with acute sinusitis. Mean total charges was $20,062 (SE = 1,159.1). Mean length of stay was 4.2 days (SE = 0.12), with 4.8 diagnoses (SE = 0.06) and 0.85 procedures (SE = 0.06). Thirty-six percent had concomitant respiratory diseases, 11% otitis media, and 8% orbital symptoms. A total of 703 patients underwent operations on the upper aerodigestive tract (534 were nasal sinusectomies); 582 patients underwent lumbar puncture and 162 underwent orbital surgery. The primary payer was private insurance in 50% and Medicaid in 41%. Predictors of increased total charges were male gender (P =.028), being a teaching hospital (P < .0001), metropolitan patient location (P < .0001), hospitals in the western region (P < .0001), admission source from another hospital (P < .0001), and discharge status to another inpatient hospital or home healthcare (P < .0001). There is a large geographic variation in resource utilization (range = $5,837 [Arkansas] to $48,327 [California]). Race, primary payer, admission type, and urgency were not significant predictors of increased resource utilization. CONCLUSIONS: Despite being a common diagnosis, there exists a large national variation in management of acute pediatric sinusitis. Predictors of increased resource utilization included male gender, teaching hospital status, metropolitan patient location, western hospital region, admission source, and discharge status. Knowledge of these variables may allow interventions and potentially facilitate benchmarking to reduce the economic burden of this entity while ensuring optimal outcomes.

Management of foreign bodies obstructing the airway in children.

OBJECTIVE: To review national trends in the management of pediatric airway foreign bodies (A-FBs) and esophageal foreign bodies (E-FBs) that obstruct the airway. DESIGN: Retrospective review using a national pediatric data set (Kids' Inpatient Database). SETTING: Pediatric patients admitted across the United States during 2003. PATIENTS: The Kids' Inpatient Database 2003 samples 2 984 129 pediatric discharges from 3438 hospitals in 36 states. MAIN OUTCOME MEASURES: The Kids' Inpatient Database 2003 was analyzed for A-FBs and E-FBs (International Classification of Diseases, Ninth Revision, Clinical Modification codes E911 and E912) in patients 20 years or younger, and weighted data are presented to facilitate national estimates. RESULTS: A total of 2771 patients (59% male) were admitted for an A-FB or an E-FB that was obstructing the airway. The mean (SE) age of the patients was 3.5 (0.17) years; 55% were younger than 2 years. The foreign bodies were classified as food (42%; mean age, 2.5 years) or other (58%; mean age, 4.3 years). The average length of stay was 6.4 days (median [SE], 1.5 [0.6] days), and the average number of procedures was 2.4 (median [SE], 1.3 [0.1] procedures). Seventy-one percent of the patients were treated at teaching hospitals. The mean (SD) total charges were $34 652 ($3543), with regional variation (P < .001). Children's hospitals (28%) had higher mean total charges than nonchildren's hospitals (P = .03); 3.4% of admissions died in the hospital (mean [SE] age, 4.6 [0.9] years), with an average length of stay of 11.7 (SE, 2.7) days and an average of 6.2 (SE, 0.7) procedures. Bronchoscopy (52%), esophagoscopy (28%), and tracheotomy (1.7%) were the primary procedures performed. The rates of positive FB findings for bronchoscopy and esophagoscopy were 37% and 46%, respectively. CONCLUSIONS: Pediatric A-FBs and E-FBs that obstruct the airway occur infrequently. Most of the patients are referred to teaching institutions. Among patients who were admitted with a diagnosis of airway obstruction from an A-FB or an E-FB, the rates of positive findings at surgery were 37% and 46%, respectively. A surprisingly high mortality rate was noted. Alternative education measures should be considered to train physicians in the management of this infrequent, potentially lethal condition.

Assessment of a new model for femoral ultrasound-guided central venous access procedural training: a pilot study.

OBJECTIVES: Repetitive practice with feedback in residency training is essential in the development of procedural competency. Lightly embalmed cadaver laboratories provide excellent simulation models for a variety of procedures, but to the best of our knowledge, none describe a central venous access model that includes the key psychomotor feedback elements for the procedure, namely intravascular contents that allow for determination of correct needle position by either ultrasonographic imaging and/or aspiration or vascular contents. METHODS: A cadaver was lightly embalmed using a technique that preserves tissue texture and elasticity. We then performed popliteal fossa dissections exposing the popliteal artery and vein. Vessels were ligated distally, and 14-gauge catheters were introduced into the lumen of each artery and vein. The popliteal artery and vein were then infused with 200 mL of icterine/gel and 200 mL of methylene blue/gel, respectively. Physician evaluators then performed ultrasound (US)-guided femoral central venous line placements and rated the key psychomotor elements on a five-point Likert scale. RESULTS: The physician evaluators reported a median of 10.5 years of clinical emergency medicine (EM) experience with an interquartile range (IQR) of 16 and a median of 10 central lines placed annually (IQR = 10). Physician evaluators rated the key psychomotor elements of the simulated procedure as follows: ultrasonographic image of vascular elements, 4 (IQR = 0); needle penetration of skin, 4.5 (IQR = 1); needle penetration of vein, 5 (IQR = 1); US image of needle penetrating vein, 4 (IQR = 2); aspiration of vein contents, 3 (IQR = 2); passage of dilator into vein, 4 (IQR = 2); insertion of central venous catheter, 5 (IQR = 1); US image of catheter insertion into vein, 5 (IQR = 1); and overall psychomotor feedback of the simulated procedure compared to the evaluators' actual patient experience, 4 (IQR = 1). CONCLUSIONS: For the key psychomotor elements of central venous access, the lightly embalmed cadaver with intravascular water-soluble gel infusion provided a procedural model that closely simulated clinicians' experience with patients.

Validation of self-reported occupational exposures in meatpacking workers.

OBJECTIVE: The ability of workers to accurately recall exposures that occur on the day of their injury is considered a potential limitation of case-crossover studies. This study assessed validity of occupational exposures reported by uninjured workers at a Midwestern meatpacking plant. METHODS: One hundred thirty-six workers were observed for 60 min while working and then interviewed within 8 days (median 3 days) about exposures during the observation period. The level of agreement between self-reports and direct observations was assessed using kappas and intraclass correlation coefficients. RESULTS: Excellent agreement was found between observed and reported work location (kappa = 0.97, 95% CI: 0.92-1.0), task (kappa = 0.83, 95% CI: 0.76-0.91) and tools used (kappa = 0.88, 95% CI: 0.81-0.95). Personal protective equipment varied by work type and location, and agreement between observed and reported usage varied from excellent to poor for various items. Excellent agreement was found for tool sharpening (kappa = 0.89, 95% CI: 0.82-0.97); good agreement for occurrence of break during the observation period (kappa = 0.60, 95% CI: 0.45-0.74); and poor agreement for equipment malfunction, line stoppages, being tired, unusual task, unusual work method, being distracted, rushing, slipping, or falling. CONCLUSIONS: Agreement between observed and reported occupational exposures varied widely. Self-reported exposures are utilized in many occupational studies, and future exposure validity assessment studies should continue to improve retrospective study methods. Valid exposures will allow researchers to better understand injury etiology and ultimately prevent injuries from occurring.

Retained foreign bodies during surgery in pediatric patients: a national perspective.

BACKGROUND: Attention has been placed on surgical and medical errors, though there is a lack of data on the frequency of some complications. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification, code 998.4 and E code 871.0 were used to search a database from the United States. RESULTS: In the Kids' Inpatient Database 2003, there were 103 reports of retained foreign bodies after surgery (incidence, 0.0031%) with a mean age of 11.5 years. There was a wide range between the 36 states sampled. Total charges for a patient with this complication are $56,683 (95% confidence interval, $41,327-$72,039); mean length of stay is 10.5 days. There is an increased charge of $42,077 in patients who have this complication (P < .0001). Of the cases, 74% occurred at teaching institutions. CONCLUSIONS: On a national perspective in the United States, the rate of a retained foreign body is 0.0031% or approximately 1 in 32,672 cases and is associated with an increased charge of $42,077 for this complication. Comparative data demonstrate that pediatric surgery in the United States is exceptionally safe with regard to retained foreign bodies.

Airway management in pediatric epiglottitis: a national perspective.

OBJECTIVES: The purpose of this study was to describe current demographics and resource utilization in the treatment of pediatric epiglottitis. STUDY DESIGN: Case series from a national database. SUBJECTS AND METHODS: The Kids' Inpatient Database was systematically searched to extract patients under 19 years old admitted with a diagnosis of epiglottitis and undergoing an airway intervention. RESULTS: Three hundred forty-two sampled admissions were for epiglottitis; 40 of these patients were under the age of 19 and had an airway intervention (intubation or tracheotomy). On average, patients were 4.3 years old (SD = 6.0 years). The average length of stay was 15.6 days (SD = 33.9 and range = 0-199) with average total charges of $74,931 (SD = $163,387, range = $3342-$938,512). Multivariate analysis revealed that admission to a children's facility, admission other than via the emergency room, and nonemergent admission were associated with increased total charges. Twenty-two states reported an admission for pediatric epiglottitis that required airway intervention. CONCLUSIONS: In our sample, only 40 patients were identified who were under the age of 19 years and required an airway intervention for the treatment of epiglottitis. Epiglottitis is a rare, expensive, and protracted disease to treat in the postvaccine era. The unique nature of this disease has implications for training future surgeons on proper management of this potentially fatal disease.