The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis.

BACKGROUND: Incidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non-electronic health record (EHR)-specific solutions that can be used across different types of IFs and EHRs. OBJECTIVE: The objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine-based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results. METHODS: A QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation. RESULTS: Of 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention. CONCLUSIONS: Although abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients' subsequent clinical course, potentially increasing patient safety.

Electronic health record-based patient tracking by emergency medicine physicians.

Objectives: Emergency medicine (EM) physicians commonly track the progress of former patients to learn about their clinical outcome. While some studies have described the behavior, little is known about the specific information sought during tracking. The objective of this study was to determine how often EM physicians track patients and the motivations, strategies, and barriers to tracking. Methods: In June 2019 we surveyed EM physicians practicing at six hospitals. We defined patient tracking as viewing the chart of a patient who was no longer under the physician's care or contacting the patient or the patient's subsequent providers to learn about the patient's progress. The survey asked respondents how often they track patients, by what mechanisms, and for what reasons. The survey also asked what information physicians sought when tracking and what barriers to tracking exist. Results: Of the 156 EM physicians invited to respond, 111 completed the survey (72% response rate). Of those, 109 (98%) reported tracking their patients, and residents reported tracking a higher percentage of patients than attendings. Reasons for tracking included an unusual or complex case (98%), uncertain diagnosis (89%), and concern about a potential error (48%). Most respondents (86%) said that knowledge gained from patient tracking changed their subsequent practice patterns, and almost all respondents (98%) strongly agreed or agreed that tracking helps physicians avoid future mistakes. The most commonly sought information types during tracking were the hospital discharge summary or emergency department note from the index visit, test results since the index visit, and new diagnoses added since the index visit. Physicians cited time limitations and difficulty accessing information as the leading barriers to tracking. Conclusions: Patient tracking is nearly ubiquitous among surveyed EM physicians, who find it valuable for learning and patient safety.

Assessing resident and attending error and adverse events in the emergency department.

BACKGROUND: There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula OBJECTIVES: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings. METHODS: Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test. RESULTS: Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups. CONCLUSIONS: Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.

Diagnosis of Patients with Acute Dizziness.

Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.

Errors in Decisionmaking in Emergency Medicine: The Case of the Landscaper's Back and Root Cause Analysis.

Root cause analysis is often suggested as a means of conducting quality assurance, but few physicians are familiar with the actual process. We describe a detailed approach to conducting root cause analysis, with an illustrative case to explain the technique. By studying how root cause analysis is applied to the case of a missed epidural abscess, the reader will see how the process reveals systems improvements that reduce the risk that such a miss will happen again. Following this process will be helpful in using root cause analysis to fix not just individuals' issues but also but systemwide quality assurance issues to improve patient care.

The utility of emergency department physical therapy and case management consultation in reducing hospital admissions.

BACKGROUND: A significant number of patients who present to the emergency department (ED) following a fall or with other injuries require evaluation by a physical therapist. Traditionally, once emergent conditions are excluded in the ED, these patients are admitted to the hospital for evaluation by a physical therapist to determine whether they should be transferred to a sub-acute rehabilitation facility, discharged, require services at home, or require further inpatient care. Case management is typically used in conjunction with a physical therapist to determine eligibility for recommended services and to aid in placement. OBJECTIVE: To evaluate the benefit of using ED-based physical therapist and case management services in lieu of routine hospital admission. METHODS: Retrospective, observational study of consecutive patients presenting to an urban, tertiary care academic medical center ED between December 1, 2017, and November 30, 2018, who had a physical therapist consult placed in the ED. We additionally evaluated which of these patients were placed into ED observation for physical therapist consultation, how many required case management, and ED disposition: discharged home from the ED or ED observation with or without services, placed in a rehabilitation facility, or admitted to the hospital. RESULTS: During the 12-month study period, 1296 patients (2.4% of the total seen in the ED) were assessed by a physical therapist. The mean age was 75.5 ± 15.2 and 832 (64.2%) were female. Case management was involved in 91.8% of these cases. The final patient disposition was as follows: admission 24.3% (95% CI = 22.1-26.7%), home discharge with or without services 47.8% (95% CI = 45.1-50.5%), rehabilitation (rehab) setting 27.9% (95% CI = 25.6%-30.4). The median (interquartile range) time in observation was 13.1 (6.0-20.3), 9.9 (1.8-15.8), and 18.4 (14.1-24.8) hours for patients admitted, discharged home, or sent to rehabilitation (P < 0.001). Among the 979 patients discharged home or sent to rehabilitation, 17 (1.7%) returned to the ED within 72 hours and were ultimately admitted. CONCLUSION: Given that the standard of care would otherwise be an admission to the hospital for 1 day or more for all patients requiring physical therapist consultation, an ED-based physical therapy and case management system serves as a viable method to substantially decrease hospital admissions and potentially reduce resource use, length of hospital stay, and cost both to patients and the health care system.

Using a rule-based system to define error in the emergency department.

INTRODUCTION: The evaluation of peer-reviewed cases for error is key to quality assurance (QA) in emergency medicine, but defining error to ensure reviewer agreement and reproducibility remains elusive. The objective of this study was to create a consensus-based set of rules to systematically identify medical errors. METHODS: This is a prospective, observational study of all cases presented for peer review at an urban, tertiary care, academic medical center emergency department (ED) quality assurance (QA) committee between October 13, 2015, and September 14, 2016. Our hospital uses an electronic system enabling staff to self-identify QA issues for subsequent review. In addition, physician or patient complaints, 72-hour returns with admission, death within 24 hours, floor transfers to ICU < 24 hours, and morbidity and mortality conference cases are automatic triggers for review. Trained reviewers not involved in the patient's care use a structured 8-point Likert scale to assess for error and preventable or non-preventable adverse events. Cases where reviewers perceived a need for additional treatment, or that caused patient harm, are referred to a 20-member committee of emergency department leadership, attendings, residents, and nurses for consensus review. For this study, "rules" were proposed by the reviewers identifying the error and validated by consensus during each meeting. The committee then decided if a rule had been broken (error) or not broken (judgment call). If an error could not be phrased in terms of a rule broken, then it would not be considered an error. The rules were then evaluated by 2 reviewers and organized by theme into categories to determine common errors in emergency medicine. RESULTS: We identified 108 episodes of rules broken in 103 cases within a database of 920 QA reviewed cases. In cases where a rule was broken and therefore an error was scored, the following 5 major themes emerged: (1) not acquiring necessary information (eg, not completing a relevant physical exam), N = 33 (31%); (2) not acting on data that were acquired (eg, abnormal vital signs or labs), N = 25 (23%); (3) knowledge gaps by clinicians (eg, not knowing to reduce a hernia), N = 16 (15%); (4) communication gaps (eg, discharge instructions), N = 17 (16%); and (5) systems issues (eg, improper patient registration), N = 17 (16%). CONCLUSION: The development of consensus-based rules may result in a more standardized and practical definition of error in emergency medicine to be used as a QA tool and a basis for research. The most common type of rule broken was not acquiring necessary information. A rule-based definition of medical error in emergency medicine may identify key areas for risk reduction strategies, help standardize medical QA, and improve patient care and physician education.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events.

OBJECTIVE: Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. METHODS: We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. RESULTS: EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%-7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%-2.9%). CONCLUSION: A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Management pathway for emergency department patients in the setting of the opioid epidemic and emergency department overcrowding.

OBJECTIVE: The United States is currently in the midst of a major opioid addiction epidemic, of which the primary drivers are a sharp increase in prescription opioid pain medications, their misuse, and the inordinate illicit use of opioids. Declared a national health emergency, the opioid crisis puts enormous pressure on various systems, including increasing overcrowding in emergency departments (EDs) and forced changes in prescribing practices. We are piloting a newlydeveloped ED opiate pathway to streamline ED care for patients who frequently present at the ED for chronic pain management or other recurrent pain-causing medical problems. METHODS: Patients at risk of possible opioid addiction are identified and their records are reviewed. If there is no narcotics agreement in place, the ED care team contacts the primary care physician and any other service providers involved in the patient's care to create a comprehensive pain management program. RESULTS: Our pathway is simple and geared toward streamlining and improving care for patients with opioid addiction and misuse. We looked at seven patients in this pilot study with mixed results regarding decreasing future ED visits. CONCLUSION: This strategy may both limit opioid usage and abuse as well as limit ED visits and overcrowding by streamlining ED care for patients who frequently present for chronic pain management or other recurrent medical problems.

The Ethics of Error in Medicine.

The practice of medicine forces medical practitioners to make difficult and challenging choices on a daily basis. On the one hand we are obligated to cure with every resource available, while on the other hand we put the patient at risk because our treatments are flawed. To understand the ethics of error in medicine, its moral value, and the effects, error must first be defined. However, definition of error remains elusive, and its incidence has been extraordinarily difficult to quantify. Yet, a health care system that acknowledges error as a consequence of normative ethical practice must create systems to minimize error. Error reduction, in turn, should attempt to decrease patient harm and improve the entire health care system. We discuss a number of ethical and moral considerations that arise from practicing medicine despite anticipated error.

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review.

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.

Acute Dizziness.

Dizziness is a common chief complaint with an extensive differential diagnosis that includes both benign and serious conditions. Physicians must distinguish the majority of patients who suffer from self-limiting conditions from those with serious illnesses that require acute treatment. The preferred approach to the diagnosis of an acutely dizzy patient emphasizes different aspects of the history to guide a focused physical examination, with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes. Currently, misdiagnoses are frequent and diagnostic testing costs are high. This partly relates to use of an outdated diagnostic paradigm. This commonly used traditional approach relies on dizziness "symptom quality" or "type" (vertigo, presyncope, disequilibrium) to guide inquiry. It does not distinguish benign from dangerous causes and is inconsistent with current best evidence. A better approach categorizes patients into three groups based on timing and triggers. Each category has its own differential diagnosis and targeted bedside approach: (1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; (2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and (3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. The "timing and triggers" diagnostic approach for the acutely dizzy derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreasing diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Comparison of Emergency Medicine Malpractice Cases Involving Residents to Nonresident Cases.

BACKGROUND: Data are lacking on how emergency medicine (EM) malpractice cases with resident involvement differs from cases that do not name a resident. OBJECTIVES: The objective was to compare malpractice case characteristics in cases where a resident is involved (resident case) to cases that do not involve a resident (nonresident case) and to determine factors that contribute to malpractice cases utilizing EM as a model for malpractice claims across other medical specialties. METHODS: We used data from the Controlled Risk Insurance Company (CRICO) Strategies' division Comparative Benchmarking System (CBS) to analyze open and closed EM cases asserted from 2009 to 2013. The CBS database is a national repository that contains professional liability data on > 400 hospitals and > 165,000 physicians, representing over 30% of all malpractice cases in the United States (>350,000 claims). We compared cases naming residents (either alone or in combination with an attending) to those that did not involve a resident (nonresident cohort). We reported the case statistics, allegation categories, severity scores, procedural data, final diagnoses, and contributing factors. Fisher's exact test or t-test was used for comparisons (alpha set at 0.05). RESULTS: A total of 845 EM cases were identified of which 732 (87%) did not name a resident (nonresident cases), while 113 (13%) included a resident (resident cases). There were higher total incurred losses for nonresident cases. The most frequent allegation categories in both cohorts were "failure or delay in diagnosis/misdiagnosis" and "medical treatment" (nonsurgical procedures or treatment regimens, i.e., central line placement). Allegation categories of safety and security, patient monitoring, hospital policy and procedure, and breach of confidentiality were found in the nonresident cases. Resident cases incurred lower payments on average ($51,163 vs. $156,212 per case). Sixty-six percent (75) of resident versus 57% (415) of nonresident cases were high-severity claims (permanent, grave disability or death; p = 0.05). Procedures involved were identified in 32% (36) of resident and 26% (188) of nonresident cases (p = 0.17). The final diagnoses in resident cases were more often cardiac related (19% [21] vs. 10% [71], p < 0.005) whereas nonresident cases had more orthopedic-related final diagnoses (10% [72] vs. 3% [3], p < 0.01). The most common contributing factors in resident and nonresident cases were clinical judgment (71% vs. 76% [p = 0.24]), communication (27% vs. 30% [p = 0.46]), and documentation (20% vs. 21% [p = 0.95]). Technical skills contributed to 20% (22) of resident cases versus 13% (96) of nonresident cases (p = 0.07) but those procedures involving vascular access (2.7% [3] vs 0.1% [1]) and spinal procedures (3.5% [4] vs. 1.1% [8]) were more prevalent in resident cases (p < 0.05 for each). CONCLUSIONS: There are higher total incurred losses in nonresident cases. There are higher severity scores in resident cases. The overall case profiles, including allegation categories, final diagnoses, and contributing factors between resident and nonresident cases are similar. Cases involving residents are more likely to involve certain technical skills, specifically vascular access and spinal procedures, which may have important implications regarding supervision. Clinical judgment, communication, and documentation are the most prevalent contributing factors in all cases and should be targets for risk reduction strategies.

A New Diagnostic Approach to the Adult Patient with Acute Dizziness.

BACKGROUND: Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. OBJECTIVE OF THE REVIEW: This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. DISCUSSION: Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. CONCLUSIONS: The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

Use of Physician Concerns and Patient Complaints as Quality Assurance Markers in Emergency Medicine.

INTRODUCTION: The value of using patient- and physician-identified quality assurance (QA) issues in emergency medicine remains poorly characterized as a marker for emergency department (ED) QA. The objective of this study was to determine whether evaluation of patient and physician concerns is useful for identifying medical errors resulting in either an adverse event or a near-miss event. METHODS: We conducted a retrospective, observational cohort study of consecutive patients presenting between January 2008 and December 2014 to an urban, tertiary care academic medical center ED with an electronic error reporting system that allows physicians to identify QA issues for review. In our system, both patient and physician concerns are reviewed by physician evaluators not involved with the patients' care to determine if a QA issue exists. If a potential QA issue is present, it is referred to a 20-member QA committee of emergency physicians and nurses who make a final determination as to whether or not an error or adverse event occurred. RESULTS: We identified 570 concerns within a database of 383,419 ED presentations, of which 33 were patient-generated and 537 were physician-generated. Out of the 570 reports, a preventable adverse event was detected in 3.0% of cases (95% CI = [1.52-4.28]). Further analysis revealed that 9.1% (95% CI = [2-24]) of patient complaints correlated to preventable errors leading to an adverse event. In contrast, 2.6% (95% CI = [2-4]) of QA concerns reported by a physician alone were found to be due to preventable medical errors leading to an adverse event (p=0.069). Near-miss events (errors without adverse outcome) trended towards more accurate reporting by physicians, with medical error found in 12.1% of reported cases (95% CI = [10-15]) versus 9.1% of those reported by patients (95% CI = [2-24] p=0.079). Adverse events in general that were not deemed to be due to preventable medical error were found in 12.1% of patient complaints (95% CI = [3-28]) and in 5.8% of physician QA concerns (95% CI = [4-8]). CONCLUSION: Screening and systemized evaluation of ED patient and physician complaints may be an underutilized QA tool. Patient complaints demonstrated a trend to identify medical errors that result in preventable adverse events, while physician QA concerns may be more likely to uncover a near miss.

Bedside Ultrasound for Tracheal Tube Verification in Pediatric Emergency Department and ICU Patients: A Systematic Review.

OBJECTIVES: Improper placement of the tracheal tube during intubation can lead to dangerous complications, and bedside ultrasound has been proposed as a method of quickly and accurately identifying tube placement. Recent studies in adults have found it to be accurate, but its applicability in pediatric patients is unclear. This systematic review aims to describe the current available data on the accuracy and feasibility of bedside ultrasound for tracheal tube placement in children. DATA SOURCES: OVID MEDLINE and EMBASE. STUDY SELECTION: Available articles on bedside neck or lung/diaphragm ultrasound for confirmation of tracheal tube placement in children through December 2015. DATA EXTRACTION: Two reviewers screened studies for eligibility and abstracted data independently. The quality of selected articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies statement. DATA SYNTHESIS: A total of nine articles were identified: one study using neck ultrasound, two using lung/diaphragmatic ultrasound, one with both, and five studies looking at direct visualization of the tracheal tube tip met our inclusion criteria. There were 81 intubations evaluated using neck ultrasound, 214 intubations evaluated using diaphragmatic or pleural sliding, and 165 intubations evaluated for feasibility of bedside ultrasound in visualizing tracheal tube tip placement. The sensitivities of transtracheal ultrasound for intubation were overall high ranging from 0.92 to 1.00 with excellent specificities at 1.00. For lung ultrasound, the sensitivities for tracheal placement versus esophageal placement were high at 1.00, but only one study reported esophageal intubations and had a specificity of 1.00. When assessing the appropriate tracheal tube depth for tracheal intubations using lung ultrasound, the sensitivities ranged from 0.91 to 1.00 with specificities ranging from 0.5 to 1.0. Regarding feasibility of direct visualization of tracheal tube tip, visualization ranged from 83% to 100%. CONCLUSION: Bedside ultrasound has been described to be feasible in determining tracheal tube placement in several small single center studies and could be a useful adjunct tool in confirming tracheal tube placement in critically ill pediatric patients, but further studies are needed to assess its accuracy in a randomized multicenter setting.

Use of Handheld Intraoperative Spectral-Domain Optical Coherence Tomography in a Variety of Vitreoretinal Diseases.

BACKGROUND AND OBJECTIVE: The use of intraoperative optical coherence tomography (iOCT) has been described with a variety of imaging devices and techniques. The purpose of this investigation is to examine the role of iVue (Optovue, Fremont, CA), a commercially available, handheld spectral-domain iOCT system, in vitreoretinal surgery. PATIENTS AND METHODS For this retrospective, observational case series, patients who underwent a vitreoretinal surgical procedure and were imaged with the iVue were identified. Images were qualitatively assessed. RESULTS: Five cases were identified, including an examination under anesthesia, epiretinal membrane, macular hole, retinal detachment, and non-clearing vitreous hemorrhage in the setting of proliferative diabetic retinopathy. CONCLUSION: Clinically useful images were obtained in all cases, though it was difficult to center the scan on the area of interest in the retina. Further work is necessary to improve system design and investigate the ways in which iOCT can aid in vitreoretinal surgery.

Multi-purpose extraocular forceps for small-gauge pars plana vitrectomy.

A multi-purpose titanium forceps has been developed for small-gauge pars plana vitrectomy surgery. These forceps were designed to provide the vitreoretinal surgeon with a single tool for the extraocular manipulations that are necessary for the placement and removal of 23- and 25-gauge trochars for small-incision, sutureless pars plana vitrectomy surgery. The forceps has been designed to allow for the atraumatic manipulation of the conjunctiva, measurement of distance from the limbus, and a strong purchase of the trochar for both its fixation and removal.