BACKGROUND: Dashboards and interactive displays are becoming increasingly prevalent in most health care settings and have the potential to streamline access to information, consolidate disparate data sources and deliver new insights. Our research focuses on intensive care units (ICUs) which are heavily instrumented, critical care environments that generate vast amounts of data and frequently require individualized support for each patient. Consequently, clinicians experience a high cognitive load, which can translate to suboptimal performance. The global COVID-19 pandemic exacerbated this problem by generating a large number of additional hospitalizations, which necessitated a new tool that would help manage ICUs' census. In a previous study, we interviewed clinicians at the University Hospitals Bristol and Weston National Health Service Foundation Trust to capture the requirements for bespoke dashboards that would alleviate this problem. OBJECTIVE: This study aims to design, implement, and evaluate an ICU dashboard to allow for monitoring of the high volume of patients in need of critical care, particularly tailored to high-demand situations, such as those seen during the COVID-19 pandemic. METHODS: Building upon the previously gathered requirements, we developed a dashboard, integrated it within the ICU of a National Health Service trust, and allowed all staff to access our tool. For evaluation purposes, participants were recruited and interviewed following a 25-day period during which they were able to use the dashboard clinically. The semistructured interviews followed a topic guide aimed at capturing the usability of the dashboard, supplemented with additional questions asked post hoc to probe themes established during the interview. Interview transcripts were analyzed using a thematic analysis framework that combined inductive and deductive approaches and integrated the Technology Acceptance Model. RESULTS: A total of 10 participants with 4 different roles in the ICU (6 consultants, 2 junior doctors, 1 nurse, and 1 advanced clinical practitioner) participated in the interviews. Our analysis generated 4 key topics that prevailed across the data: our dashboard met the usability requirements of the participants and was found useful and intuitive; participants perceived that it impacted their delivery of patient care by improving the access to the information and better equipping them to do their job; the tool was used in a variety of ways and for different reasons and tasks; and there were barriers to integration of our dashboard into practice, including familiarity with existing systems, which stifled the adoption of our tool. CONCLUSIONS: Our findings show that the perceived utility of the dashboard had a positive impact on the clinicians' workflows in the ICU. Improving access to information translated into more efficient patient care and transformed some of the existing processes. The introduction of our tool was met with positive reception, but its integration during the COVID-19 pandemic limited its adoption into practice.
OBJECTIVES: Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS: This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS: A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS: There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.
Emergency Medicine , Learning Curve , Female , Humans , Pregnancy , Prospective Studies , Ultrasonography , Uterus
INTRODUCTION: There has been a trend toward the use of alternative treatments to opioids for adequate pain management. This has paralleled a growing interest in the utilization of bedside point-of-care ultrasonography to guide placement of regional anesthesia in the emergency department. The purpose of this study was to establish the number of supervised examinations required for an emergency medicine resident to gain proficiency in accurately locating and identifying the nerves of the brachial plexus at the level of the interscalene space. METHODS: Proficiency was defined as the number of attempts a resident required to accurately locate and identify the nerves of the brachial plexus on 10 separate, consecutive examinations. Didactic education was provided prior to the study and residents also participated in two instructional hands-on ultrasound examinations prior to the commencement of initial data collection. Count data are summarized using medians, means, and ranges. Random effects negative binomial regression was used for modeling panel count data where negative coefficients indicate increase in proficiency. RESULTS: A total of 24 emergency medicine residents were enrolled in the study. Fourteen males and ten females participated. There were nine PGY-1 residents (37.5%), nine PGY-2 residents (37.5%), and six PGY-3 residents (25%). The median number of required supervised attempts and range for correctly performing both steps in the identification of the nerves of the brachial plexus was 2 (range 2-12). The median starting confidence level was 2 (range 1-4), and the median ending confidence level was 4 (range 1-5). Increases in confidence from start to finish were found to be statistically significant (P < 0.001). CONCLUSION: Emergency medicine residents are easily adept in the identification of the nerves of the brachial plexus at the level of the interscalene space following two supervised examinations. Residents made steady gains in confidence and proficiency throughout the study; statistical analysis found a significant association between the two.
INTRODUCTION: Poor teamwork leads to preventable medical errors, and thus negatively impacts medical care. One way to improve teamwork is training. A multimodality team training program was designed to impact the attitudes and behavior of first-year residents who will encounter medical situations in the trauma room. The training program included low-fidelity role plays, lectures, and high-fidelity simulation with feedback. MATERIALS AND METHODS: The training program was a one-day workshop that was conducted twice, once for each of the two groups over two days at the beginning of the academic year in July. A total of 41 first-year interns (10 Emergency Medicine and 31 Surgery) were recruited for participation. Participants completed a Situational judgment test (SJT) on trauma teamwork before training. The training began with a low-fidelity simulation that served as an icebreaker to team concepts. Subsequently, a lecture with discussion provided key points regarding teamwork in the trauma room. A high-fidelity simulation then allowed participation in one of four trauma room scenarios with medical expert debriefing. The course concluded with a course summary and an assessment of participant attitudes regarding training along with a second administration of SJT. RESULTS: Participant reactions to the training were positive overall. Results of SJT showed a positive effect for team training in three of the four possible comparisons. CONCLUSION: The program was well received by the residents. Results suggest that a comprehensive training approach using role play, lecture, and simulation can positively affect behavioral choices for teamwork in the trauma room.
Angiotensin converting enzyme inhibitor ACEI-induced angioedema of the intestine is a rare occurrence and often unrecognized complication of ACEI. We present a case of a 45-year-old Hispanic female with angioedema of the small bowel progressing to facial and oral pharyngeal angioedema. Patients are typically middle-aged females on ACEI therapy who present to the emergency department with abdominal pain, nausea, vomiting, and diarrhea. This is a diagnosis of exclusion, and physicians must have a high index of suspicion to make the diagnosis. Symptoms typically resolve within 24-48 hours after ACE inhibitor withdrawal. Recognizing these signs and symptoms, and discontinuing the medication, can save a patient from unnecessary, costly, and invasive procedures.
Cardiopulmonary arrest in pregnancy is rare occurring in 1 in 30,000 pregnancies. When it does occur, it is important for a clinician to be familiar with the features peculiar to the pregnant state. Knowledge of the anatomic and physiologic changes of pregnancy is helpful in the treatment and diagnosis. Although the main focus should be on the mother, it should not be forgotten that there is another potential life at stake. Resuscitation of the mother is performed in the same manner as in any other patient, except for a few minor adjustments because of the changes of pregnancy. The specialties of obstetrics and neonatology should be involved early in the process to ensure appropriate treatment of both mother and the newborn. This article will explore the changes that occur in pregnancy and their impact on treatment. The common causes of maternal cardiac arrest will be discussed briefly.
