Procedure competence versus number performed: a survey of graduate emergency medicine specialists in a developing nation.

BACKGROUND: Emergency medicine (EM) training programmes are being conducted around the world but no study has assessed the procedural competence of developing nations' EM trainees. OBJECTIVES: To quantify the number of core procedures and resuscitations performed and describe the perceived procedural competency of graduates of Africa's first EM registrarship at the University of Cape Town/Stellenbosch University (UCT/SUN) in Cape Town, South Africa. METHODS: All 30 graduates from the first four classes in the UCT/SUN EM programme (2007-10) were asked to complete a written, self-administered survey on the number of procedures needed for competency, the number of procedures performed during registrarship and the perceived competence in each procedure ranked on a five-point Likert scale. The procedures selected were the 10 core procedures and four types of resuscitations as defined by the US-based Residency Review Committee. Results were compiled and analysed using descriptive statistics. RESULTS: Twenty-seven (90%) completed surveys. For most core procedures and all resuscitations, the number of procedures reported by respondents far exceeded the Residency Review Committee minimum. The three procedures not meeting the minimum were internal cardiac pacing, cricothyrotomy and periocardiocentesis. Respondents reported perceived competence in most procedures and all resuscitations. CONCLUSIONS: EM trainees in a South Africa registrarship report a high number of procedures performed for most procedures and all resuscitations. As medical education moves to the era of direct observation and other methods of assessment, more studies are needed to define and ensure procedural competence in trainees of nascent EM programmes.

The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study.

The utility of aminoterminal pro-brain natriuretic peptide (NT-proBNP) testing in the emergency department to rule out acute congestive heart failure (CHF) and the optimal cutpoints for this use are not established. We conducted a prospective study of 600 patients who presented in the emergency department with dyspnea. The clinical diagnosis of acute CHF was determined by study physicians who were blinded to NT-proBNP results. The primary end point was a comparison of NT-proBNP results with the clinical assessment of the managing physician for identifying acute CHF. The median NT-proBNP level among 209 patients (35%) who had acute CHF was 4,054 versus 131 pg/ml among 390 patients (65%) who did not (p <0.001). NT-proBNP at cutpoints of >450 pg/ml for patients <50 years of age and >900 pg/ml for patients >or=50 years of age were highly sensitive and specific for the diagnosis of acute CHF (p <0.001). An NT-proBNP level <300 pg/ml was optimal for ruling out acute CHF, with a negative predictive value of 99%. Increased NT-proBNP was the strongest independent predictor of a final diagnosis of acute CHF (odds ratio 44, 95% confidence interval 21.0 to 91.0, p <0.0001). NT-proBNP testing alone was superior to clinical judgment alone for diagnosing acute CHF (p = 0.006); NT-proBNP plus clinical judgment was superior to NT-proBNP or clinical judgment alone. NT-proBNP measurement is a valuable addition to standard clinical assessment for the identification and exclusion of acute CHF in the emergency department setting.

The role of abdominal computed tomography scanning in patients with non-traumatic abdominal symptoms.

OBJECTIVES: To describe the non-traumatic clinical settings in which abdominal computed tomography (CT) is used and to determine its diagnostic utility. METHODS: A retrospective descriptive study of consecutive non-traumatic adult patients who underwent abdominal CT in a university hospital emergency department (ED). Radiology reports and patient charts were reviewed. The indication for each CT was determined by two reviewers. Indications were described as specific (e.g. "rule-out" appendicitis) or non-specific (e.g. abdominal pain). CT results were classified as positive, negative (normal or no new information) or indeterminate (technical limitations). For those with specific indications, positive results were further subdivided into supportive (of the clinical suspicion) or non-supportive (abnormal but suggesting an alternative diagnosis). The clinical course and results of subsequent diagnostic procedures were used to confirm CT results for admitted patients. Incidental CT findings were recorded. RESULTS: 177 patients were entered; mean age was 58 years; 48% were men. The most frequent indications ("rule-outs") were aortic disorders (23%), abscess (16%), and diverticulitis (14%). In patients with specific indications (n=160), 44% of the CT results supported the indication, 13% suggested an alternative diagnosis (non-supportive), 41% were negative, and 3% were indeterminate. In admitted patients (n=129), CT findings were contradicted in 6%. CONCLUSIONS: Adult ED patients undergo abdominal CT for a variety of non-traumatic indications. Findings in less than half support the pre-test clinical suspicion and an alternative previously unsuspected diagnosis is suggested in 13%. Follow-up is inconsistent with CT results in a small but significant number of cases.

Use of diagnostic testing in the emergency department for patients presenting with non-traumatic abdominal pain.

The objective of the study was to measure the utilization and diagnostic value of tests used in the Emergency Department (ED) on patients with undifferentiated non-traumatic abdominal or flank pain. Specific goals were to measure how often these tests led to changes in diagnosis or disposition, which tests were most commonly used, and which tests providers considered most helpful. We conducted a pilot single-center, prospective descriptive study, enrolling all eligible adult patients who presented to our ED with non-traumatic abdominal or flank pain during defined hours of our intake period. Based on serial provider interviews pre- and post-testing, we measured the frequency of change of most likely diagnosis and disposition, which tests were performed, and the provider-perceived value of tests. We enrolled 124 subjects with a mean age of 44 years; 27% were admitted. Testing led to a change in most likely diagnosis in 37% of subjects, and in disposition in 41%. Frequency of diagnostic test use varied from a high of 93% for CBC to 6% for a blood or urine culture. Overall, 65% of patients had at least one imaging study performed, and 39% had an abdominal/pelvic computed tomography (CT) scan. Over all subjects, providers identified the most useful tests as the CT scan (31%) and urinalysis (17%). In conclusion, among ED patients who presented with non-traumatic abdominal or flank pain to one academic center, the pre-test most likely diagnosis and disposition were changed based on the ED evaluation in over one-third of subjects. Almost all received blood tests and two-thirds received one or more imaging studies. Based on providers' subjective opinions, the most valuable tests were the abdomino/pelvic CT scan and the urinalysis.

Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned.

Africa's first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the program's first 7 years that may help advise other nascent training programs in developing countries.

The accuracy and completeness of data collected by prospective and retrospective methods.

OBJECTIVES: To describe and test a model that compares the accuracy of data gathered prospectively versus retrospectively among adult emergency department patients admitted with chest pain. METHODS: The authors developed a model of information flow from subject to medical record to the clinical study case report form, based on a literature review. To test this model, a bidirectional (prospective and retrospective) study was conducted, enrolling all eligible adult patients who were admitted with a chief complaint of chest pain. The authors interviewed patients in the emergency department to determine their chest pain history and established a prospective database; this was considered the criterion standard. Then, patient medical records were reviewed to determine the accuracy and completeness of the information available through a retrospective medical record review. RESULTS: The model described applies the concepts of reliability and validity to information passed on by the study subject, the clinician, and the medical record abstractor. This study was comprised of 104 subjects, of which 63% were men and the median age was 63 years. Subjects were uncertain of responses for 0-8% of questions and responded differently upon reinterview for subsets of questions 0-30% of the time. The sensitivity of the medical record for risk factors for coronary artery disease was 0.77 to 0.93. Among the 88 subjects (85%) who indicated that their chest pain was substernal or left chest, the medical record described this location in 44%. Timing of the chest pain was the most difficult item to accurately capture from the medical record. CONCLUSIONS: Information obtained retrospectively from the abstraction of medical records is measurably less accurate than information obtained prospectively from research subjects. For certain items, more than half of the information is not available. This loss of information is related to the data types included in the study and by the assumptions that a researcher performing a retrospective study makes about implied versus explicitly stated responses. A model of information flow that incorporates the concepts of reliability and validity can be used to measure some of the loss of information that occurs at each step along the way from subject to clinician to medical record abstractor.

Duration of symptoms and follow-up patterns of patients discharged from the emergency department after presenting with abdominal or flank pain.

BACKGROUND: Little is known about the duration of symptoms and follow-up patterns of patients seen in emergency departments for abdominal or flank pain. OBJECTIVE: We aimed to measure the duration of symptoms and follow-up rate of patients discharged home from the emergency department after presenting with non-traumatic abdominal or flank pain. METHODS: We conducted a single-centre, prospective descriptive study of adult patients who presented to our emergency department with non-traumatic abdominal or flank pain and were discharged from the emergency department. We gathered clinical data during the index emergency department visit and conducted telephone interviews of subjects 2-5 weeks later. RESULTS: We reached 63 of 90 subjects (70%). The median duration of pain was 3 days after the emergency department visit. During the follow-up period, only 41% had followed-up with their family physician or primary care provider, although an additional 21% had planned to. Persistence of symptoms was common in the 37% of subjects who did not follow-up. CONCLUSION: Of subjects discharged from the emergency department after visits for non-traumatic abdominal or flank pain, most improve within several days. Fewer than half follow-up with a family practitioner or a primary care provider. Emergency department revisits are uncommon and often for unrelated problems.