Experience with a Clinical Audit Requirement for Interns in the Emergency Department.

BACKGROUND: The clinical audit is an important evaluation tool to ensure quality assurance. A clinical audit requirement for interns during their emergency department (ED) term may be a valuable educational activity. METHODS: The Emergency Audit Initiative (EAI) Program was initiated at Redcliffe Hospital in January 2018. Interns, who were paired with a staff specialist audit mentor, chose a topic of interest and carried out a clinical audit during their 10-week ED term. At the end of term, interns formally presented audit findings in a grand round setting. Interns and staff specialists were surveyed at the end of the intern year regarding aspects of the program. Surveys aimed to assess: (1) value of the program as an educational activity, (2) availability of time and resources to conduct the audit, and (3) perceived impact on practice. RESULTS: During the first year of the program, 27 clinical audits were carried out. 16 interns (59%) and 8 staff specialists (57%) responded to the surveys. Interns and staff specialists reported that the audit was a valuable educational experience (88% and 100%). Interns also reported that they had adequate time (94%) and resources (81%) to conduct the audit. Interns and staff specialists however reported only a modest impact on clinical practice because of the audit program. CONCLUSIONS: Our experience with the EAI program suggests that incorporating a clinical audit requirement into the ED term is possible. Interns and staff specialists reported it to be a beneficial educational and professional development activity.

Review article: Postoperative bariatric patients in the emergency department: Review of surgical complications for the emergency physician.

With the rise of obesity in adult populations in the western world there has been a concurrent rise in bariatric procedures to address this problem. Although the safety of bariatric procedures has improved significantly over the past 20 years, there are still a number of serious surgical complications that can occur in the postoperative period that emergency physicians need to be familiar with. These complications can have subtle presentations that if unrecognised can go on to cause morbidity and mortality. This review will cover the more common bariatric procedures that are being performed today. It will discuss the complications, clinical presentations and management of these patients that emergency physicians should be familiar with.

Enhancing intern emergency medicine education using a combined didactic and web-based learning curriculum: The EDGE programme.

OBJECTIVE: To assess the effectiveness of an education programme that integrates web-based learning into classroom sessions. METHODS: This prospective study involved a convenience sample of ED interns rotating at two study site hospitals between April 2015 and January 2017. Interns undertook weekly ED classroom-based education and were given access to a web-based learning resource with completion being voluntary. To assess change in medical knowledge multiple choice examinations were administered during week 1 and week 10 of the term. The study's primary end-point was the effect of the web-based resource on participants' knowledge. The median % of online modules completed by participants (75%) was used as a cut-off to create two groups. The % improvement between the test scores at week 1 and week 10 of each group were then compared. Intern satisfaction with the programme was also assessed using a satisfaction survey. RESULTS: The average examination score for all participants was significantly higher at week 10 than week 1 (80% vs 68%; P < 0.001). The primary end-point, % improvement between the week 1 and week 10 scores of those that completed ≤75% of web-based modules (mean 16%; 95% CI 12-20%) and those that completed >75% of web-based modules (mean 27%; 95% CI 20-34%), showed a statistically significant difference (P = 0.03). Interns surveyed were also highly satisfied with programme. CONCLUSIONS: This blended curriculum that integrates a web-based resource into classroom learning shows promise in enhancing intern emergency medicine education.

Use of sterile saline as a conduction agent for ultrasound visualization of central venous structures.

OBJECTIVE: To determine whether sterile saline as a conduction agent provides adequate visualization of anatomic structures to attempt ultrasound-guided vascular access. METHODS: This prospective study involved a convenience sample of adult patients (18 years and older) who presented to an urban academic ED during a 3-month study period. Each patient had three six-second ultrasound video clips obtained of the right internal jugular vein and surrounding structures utilizing three different conduction agents, water-based gel (the control), sterile saline or no conduction agent. Video clips were randomized and assigned a numeric code to blind reviewers to the conduction agent. They were then independently reviewed by two experts who determined whether anatomic structures were visualized with enough detail to perform ultrasound-guided vascular access. The reviewers also rated the overall image quality of each video clip using a 100 mm visual analogue scale (VAS). RESULTS: Forty-seven patients were included in the final analysis. The raw agreement was 100% (95% confidence intervals [CI]: 93-100%) with a kappa of 1.0 between the two reviewers in assessing whether they would be able to perform vascular access using the images obtained using saline as a conduction agent. The median VAS for gel across both reviewers was 92 (95% CI: 90-93) and the median VAS differences for saline and no medium were -3 (95% CI: -1 to -3) and -46 (95% CI: -22 to -61), respectively. CONCLUSIONS: The use of sterile saline as a conduction agent allows adequate visualization of anatomic structures to attempt ultrasound-guided vascular access.

MHC class I-like genes in cattle, MHCLA, with similarity to genes encoding NK cell stimulatory ligands.

A comparative genomics approach for mining databases of expressed sequence tags (ESTs) was used to identify two members of a novel MHC class I gene family in cattle. These paralogous genes, named MHC class I-like gene family A1 ( MHCLA1) and MHCLA2, were shown by phylogenetic analysis to be related to human and mouse genes encoding NK cell stimulatory ligands, ULBP, RAET, H60 and Raet-1. Radiation hybrid mapping placed cattle MHCLA1 on BTA9, which, on the basis of existing comparative mapping data, identified the ULBP, RAET1, H60 and Raet1 genes as homologues of the cattle MHCLA genes. However, the human and mouse orthologues of MHCLA1 and MHCLA2 could not be defined due to extensive sequence divergence from all known members of the ULBP1/ RAET1/H60/Raet1 gene family. The cattle MHCLA1 molecule is predicted to be missing an alpha(3) domain, similar to the human and mouse homologues. Like the human ULBP genes, MHCLA1 was found to be transcribed constitutively in a variety of fetal and adult tissues by RT-PCR. The patterns of hybridization obtained by Southern blotting using MHCLA1 as a probe and DNA from 14 species representing five mammalian orders suggests that the MHCLA genes evolved rapidly in the Cetartiodactyla. Previous findings demonstrating that ULBPs serve as ligands for the NK cell NKG2D stimulatory receptor, and that this interaction can be blocked by a human cytomegalovirus glycoprotein that binds to ULBPs, suggests that the extensive divergence found among the cattle, human and mouse MHCLA homologues is due to selection exerted by viral pathogens.