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1.
Br J Radiol ; 93(1106): 20190781, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31868522

RESUMO

OBJECTIVE: Sedation for pediatric patients undergoing interventional procedures in radiology is in increasing demand. Once only anesthesiology-performed, there is a demand for sedation services to perform sedations for these procedures. However, the safety of performing long sedations by non-anesthesiologists in interventional radiology has not been reported. This pilot study aimed at describing a single center's experience and outcome with sedation. METHODS: This study reviews the sedations performed at a single center by a pediatric emergency physician who performed the sedation. The results regarding safety and satisfaction were reviewed. RESULTS: A total of 52 sedations were documented. Four cases of significant adverse events and three adverse events occurred. In all cases, the procedures were completed. None of the patients required intubation or admission following the sedation. There was high satisfaction by the interventional radiologists. CONCLUSION: This small pilot study shows that sedations for procedures in interventional radiology can be performed safely and successfully by dedicated non-anesthesiology sedation services. This may be considered as an alternative when anesthesiology service is not available. ADVANCES IN KNOWLEDGE: This small, single center pilot study examines the safety of sedation by a non-anesthesiologist for interventional radiology procedures. This may offer an additional method of performing procedures in the pediatric population while anesthesia is not readily available.


Assuntos
Sedação Consciente/métodos , Medicina de Emergência/estatística & dados numéricos , Malformações Vasculares/cirurgia , Adolescente , Anestesiologistas , Criança , Pré-Escolar , Sedação Consciente/efeitos adversos , Medicina de Emergência/normas , Métodos Epidemiológicos , Feminino , Humanos , Lactente , Masculino , Segurança do Paciente
2.
Am Surg ; 85(9): 961-964, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638507

RESUMO

Enmeshment of emergency trauma providers (ETPs) into the United States health-care fabric resulted in the establishment of a formalized surgical critical care fellowship and certification for emergency medicine trainees. The aim of this study was to compare trauma outcomes for surgery-trained providers (STPs) and ETPs at our institution, hypothesizing patient outcome equivalency. We performed an institutional review board-exempt institutional registry review (January 1, 2004 to August 1, 2018), comparing 74 STPs and 6 ETPs. Comparator variables included all-cause mortality, all-cause morbidity, CT imaging studies per provider, time in ED (min), hospital/ICU lengths of stay, ICU admissions, and functional outcomes on discharge. Statistical comparisons included chi-square test for categorical data and analysis of covariance for continuous data (adjustments made for patient age, Injury Severity Score, and trauma mechanism; all P < 0.20). Statistical significance was set at P < 0.05, with an equivalence study design. A total of 33,577 trauma resuscitations were reviewed (32,299 STP-led and 1,278 ETP-led). Except for patient age (STP 50.2 ± 25.9 vs ETP 54.9 ± 25.3 years), Injury Severity Score (8.47 ± 8.14 vs 9.22 ± 8.40), and ICU admissions (16.1% vs 18.8%), we noted no significant intergroup differences. ETPs' performance was equivalent to that of STPs for all primary comparator variables (mortality, morbidity, CT utilization, time in the ED, lengths of stay, and functional outcomes). Incorporation of ETPs into our trauma center resulted in outcome parity between ETPs and STPs, while simultaneously expanding the expertise and experiential diversity within our multidisciplinary team. This study provides support for further incorporation of ETPs as equal partners across the growing network of United States regional trauma centers.


Assuntos
Competência Clínica , Medicina de Emergência/normas , Cirurgia Geral/normas , Ferimentos e Lesões/cirurgia , Cuidados Críticos , Medicina de Emergência/educação , Cirurgia Geral/educação , Mortalidade Hospitalar , Humanos , Tempo de Internação , Duração da Cirurgia , Avaliação de Resultados da Assistência ao Paciente , Pennsylvania , Complicações Pós-Operatórias , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Estados Unidos
3.
Clinics (Sao Paulo) ; 74: e663, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31644664

RESUMO

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.


Assuntos
Avaliação Educacional , Medicina de Emergência/educação , Respiração Artificial , Estudantes de Medicina , Inquéritos e Questionários/normas , Adulto , Brasil , Estudos Transversais , Medicina de Emergência/normas , Análise Fatorial , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internato e Residência , Masculino , Reprodutibilidade dos Testes
4.
J Urol ; 202(3): 475-483, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31412438

RESUMO

PURPOSE: Renal colic is common and CT (computerized tomography) is frequently utilized when the diagnosis of kidney stone is suspected. CT is accurate, but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. MATERIALS AND METHODS: In conjunction with the ACEP (American College of Emergency Physicians®) E-QUAL (Emergency Quality Network) we formed a nine-member panel with three physician representatives each from the ACEP, the ACR® (American College of Radiology) and the AUA (American Urological Association). A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%) and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%) with ultrasound in 9 (31%) and no further imaging needed in 13 (45%). CONCLUSIONS: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.


Assuntos
Consenso , Cólica Renal/diagnóstico por imagem , Sociedades Médicas/normas , Tomografia Computadorizada por Raios X/normas , Ultrassonografia/normas , Técnica Delfos , Medicina de Emergência/normas , Humanos , Comunicação Interdisciplinar , Radiologia/normas , Tomografia Computadorizada por Raios X/efeitos adversos , Estados Unidos , Urologia/normas
6.
Emerg Med J ; 36(6): 346-354, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31097464

RESUMO

OBJECTIVES: Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED. METHODS: We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory. RESULTS: Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives. CONCLUSIONS: EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.


Assuntos
Relações Médico-Paciente , Médicos/psicologia , Adulto , Idoso , Atitude do Pessoal de Saúde , Medicina de Emergência/métodos , Medicina de Emergência/normas , Serviço Hospitalar de Emergência/organização & administração , Feminino , Grupos Focais/métodos , Humanos , Masculino , Pessoa de Meia-Idade , New England , Participação do Paciente/psicologia , Pesquisa Qualitativa
7.
BMC Med Educ ; 19(1): 100, 2019 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-30953546

RESUMO

BACKGROUND: Simulation-based medical education (SBME) is a cornerstone for procedural skill training in residency education. Multiple studies have concluded that SBME is highly effective, superior to traditional clinical education, and translates to improved patient outcomes. Additionally it is widely accepted that mastery learning, which comprises deliberate practice, is essential for expert level performance for routine skills; however, given that highly structured practice is more time and resource-intensive, it is important to assess its value for the acquisition of rarely performed technical skills. The bougie-assisted cricothyroidotomy (BAC), a rarely performed, lifesaving procedure, is an ideal skill for evaluating the utility of highly structured practice as it is relevant across many acute care specialties and rare - making it unlikely for learners to have had significant previous training or clinical experience. The purpose of this study is to compare a modified mastery learning approach with deliberate practice versus self-guided practice on technical skill performance using a bougie-assisted cricothyroidotomy model. METHODS: A multi-centre, randomized study will be conducted at four Canadian and one American residency programs with 160 residents assigned to either mastery learning and deliberate practice (ML + DP), or self-guided practice for BAC. Skill performance, using a global rating scale, will be assessed before, immediately after practice, and 6 months later. The two groups will be compared to assess whether the type of practice impacts performance and skill retention. DISCUSSION: Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource-intensive and its efficacy is not fully defined. This multi-centre study will provide generalizable data about the utility of highly structured practice for technical skill acquisition of a rare, lifesaving procedure within postgraduate medical education. Study findings will guide educators in the selection of an optimal training strategy, addressing both short and long term performance.


Assuntos
Competência Clínica/normas , Cartilagem Cricoide/cirurgia , Medicina de Emergência/educação , Internato e Residência , Intubação Intratraqueal/métodos , Cartilagem Tireóidea/cirurgia , Traqueostomia/educação , Canadá , Educação Baseada em Competências , Simulação por Computador , Avaliação Educacional , Medicina de Emergência/normas , Humanos , Internato e Residência/normas , Intubação Intratraqueal/normas , Traqueostomia/normas , Estados Unidos
8.
Medicine (Baltimore) ; 98(14): e14948, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30946318

RESUMO

Despite the widespread awareness of concussion across all levels of sport, the management of concussion from youth to college is inconsistent and fragmented. A fundamental gap contributing to inconsistent care is the lack of a scalable, systematic approach to document initial injury characteristics following concussion. The purpose of this study was to determine differences in injury profiles and management of youth, high school, and college athletes using a mobile application for incident report documentation.A cohort study was conducted in which concussion electronic incident report data from 46 high schools and colleges, and Cleveland Clinic ambulatory concussion clinics were gathered and analyzed.In sum, 1421 (N = 88 youth, N = 1171 high school and N = 162 college) athletes with sport-related concussions were included.Despite the relative absence of red flags, youth athletes had a greater probability of being sent to the emergency department than high school and collegiate athletes. Over 60% of athletes were removed from play immediately post-injury. Injury recognition was delayed in 25% of athletes due to delayed symptom reporting (20% of males, 16% of females) or delayed symptom onset (5% of males, 9% of females). A significantly greater incidence of red flags was evident in males, and in high school and collegiate athletes compared to youth athletes.The high frequency of youth athletes sent to the emergency department, despite the absence of red flags, may be a reflection of inadequate medical coverage at youth events, ultimately resulting in unnecessary utilization of emergency medicine services. The relatively high incidence of delayed injury reporting implies that additional educational efforts targeting student-athletes and the utilization of resources to improve injury detection are warranted. The systematic collection of injury-related demographics through the electronic mobile application facilitated interdisciplinary communication and improved the efficiency of managing athletes with concussion.


Assuntos
Traumatismos em Atletas/epidemiologia , Concussão Encefálica/epidemiologia , Gestão de Riscos/métodos , Medicina Esportiva/estatística & dados numéricos , Adolescente , Atletas/estatística & dados numéricos , Traumatismos em Atletas/terapia , Concussão Encefálica/diagnóstico , Concussão Encefálica/terapia , Medicina de Emergência/normas , Feminino , Humanos , Incidência , Comunicação Interdisciplinar , Masculino , Aplicativos Móveis/normas , Administração dos Cuidados ao Paciente/normas , Estudos Retrospectivos , Instituições Acadêmicas , Medicina Esportiva/normas , Estudantes , Universidades , Adulto Jovem
10.
Int J Clin Pharm ; 41(3): 667-671, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30953272

RESUMO

Background Emergency medicine (EM) pharmacists are increasingly recognized as integral team members in the care of emergency department (ED) patients but there is variability in the scope of direct patient care services. Objectives The primary objective was to categorize direct patient care activities and drug therapy recommendations. The secondary objectives were to categorize recommendations based on drug class and to determine the proportion of recommendations associated with Institute for Safe Medication Practices (ISMP) high-alert medications. Methods This retrospective, single-center, chart review was conducted in an academic ED with 65,000 annual visits. EM pharmacists documented direct patient care activities in the electronic health record. Documented activities from 1/1/2015 through 3/31/2015 were abstracted electronically for analysis by a trained reviewer. Results There were 3567 interventions and direct patient care activities documented. The most common activities were facilitation of medication histories (n = 1300) and drug therapy recommendations (n = 1165). Of 1165 drug therapy recommendations, 986 were linked to a drug class such as antimicrobial agents (31.9%), cardiovascular agents (16.6%), and analgesic agents (13.2%) and 20% of these interventions were associated with ISMP high-alert medications. Conclusion EM pharmacists documented several types of direct patient care activities with the majority being drug therapy recommendations and medication histories.


Assuntos
Medicina de Emergência/métodos , Erros de Medicação/prevenção & controle , Assistência ao Paciente/métodos , Farmacêuticos , Serviço de Farmácia Hospitalar/métodos , Papel Profissional , Medicina de Emergência/normas , Humanos , Assistência ao Paciente/normas , Farmacêuticos/normas , Serviço de Farmácia Hospitalar/normas , Estudos Retrospectivos
13.
West J Emerg Med ; 20(2): 357-362, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30881557

RESUMO

Introduction: The use of competency-based milestones for emergency medicine (EM) was mandated by the Accreditation Council for Graduate Medical Education in 2013. However, clinical competency committees (CCC) may lack diverse, objective data to assess these new competencies. To remedy the lack of objective data when assessing the pharmacotherapy sub-competency (PC5) we introduced a unique approach that actively involves departmental clinical pharmacists in determining the milestone level achieved by the resident. Methods: Our pharmacists assess the pharmacotherapy knowledge of the residents through multiple methods: direct observation of orders, communication with the residents while performing patient care within the emergency department (ED), and real-time chart review. This observation occurs informally on a daily basis in the ED and is incorporated into the routine work of the pharmacist. The pharmacists use the PC5 sub-competency as their standard evaluation tool in this setting to keep all assessments consistent. Results: Since our residency program introduced pharmacist assessment of resident pharmacotherapy knowledge, the CCC has conducted seven biannual meetings. Of the 120 separate PC5 sub-competency assessments made during those meetings there was 100% agreement between the pharmacist's assessment and the CCC's final assessment of the trainee. A survey of the CCC members concluded that the pharmacists' assessments were useful and aided in accurate resident evaluation. Conclusion: The use of ED pharmacists in assessing the pharmacotherapy sub-competency provides important information used in resident assessment of the PC5 milestone.


Assuntos
Competência Clínica/normas , Avaliação Educacional/métodos , Medicina de Emergência/educação , Internato e Residência , Acreditação/normas , Avaliação Educacional/estatística & dados numéricos , Medicina de Emergência/normas , Humanos , Farmacêuticos , Avaliação de Programas e Projetos de Saúde
14.
Artigo em Inglês | MEDLINE | ID: mdl-30832448

RESUMO

In October 2018, at Asia Pacific Conference for Disaster Medicine (APCDM), an expert meeting to identify key research needs was organized by the World Health Organization (WHO) Centre for Health Development (WHO Kobe Centre (WKC)), convening the leading experts from Asia Pacific region, WHO, WHO Thematic Platform for Health Emergency and Disaster Risk Management (Health-EDRM) Research Network (TPRN), World Association for Disaster and Emergency Medicine (WADEM), in collaboration with Asia Pacific Conference for Disaster Medicine (APCDM) and Japan International Cooperation Agency (JICA). International experts, who were pre-informed about the meeting, contributed experience-based priority issues in Health-EDRM research, ethics, and scientific publication. Two moderators, experienced in multi-disciplinary research interacted with discussants to transcribe practical issues into related methodological and ethical issues. Each issue was addressed in order to progress research and scientific evidence in Health-EDRM. Further analysis of interactive dialogues revealed priorities for action, proposed mechanism to address these and identified recommendations. Thematic discussion uncovered five priority areas: (1) the need to harmonize Health-EDRM research with universal terms and, definitions via a glossary; (2) mechanisms to facilitate and speed up ethical review process; (3) increased community participation and stakeholder involvement in generating research ideas and in assessing impact evaluation; (4) development of reference materials such as possible consensus statements; and (5) the urgent need for a research methods resource textbook for Health-EDRM addressing these issues.


Assuntos
Medicina de Desastres/normas , Planejamento em Desastres/normas , Medicina de Emergência/normas , Projetos de Pesquisa/normas , Medicina de Desastres/ética , Medicina de Desastres/organização & administração , Planejamento em Desastres/organização & administração , Medicina de Emergência/ética , Medicina de Emergência/organização & administração , Guias como Assunto , Humanos , Agências Internacionais/organização & administração , Cooperação Internacional , Japão , Organização Mundial da Saúde/organização & administração
15.
Emerg Med J ; 36(3): 148-153, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30728189

RESUMO

BACKGROUND: Serious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and lack of clinical practice guidelines for this population. The primary objective was to investigate practice patterns in performance of LPs in the ED management of febrile infants aged ≤30 days with bronchiolitis. METHODS: A cross-sectional survey of two national paediatric emergency research networks (PediatricEmergency Research Canada (PERC) and the PediatricEmergency Research UK/Ireland (PERUKI)) was conducted January to November 2017 using a modified Dillman technique. The survey was preceded by a clinical vignette describing a well appearing, 21-day-old infant with low-grade fever, respiratory findings typical of bronchiolitis and no perinatal serious bacterial infection (SBI) risk features. RESULTS: The response rate from PERC was 169/250 (68%) and 172/201 (86%) from PERUKI. Nine physicians in training were excluded, leaving 332 eligible participants. Although most physicians believe that neonates with bronchiolitis rarely have meningitis (PERC 141/161 (87.6%); PERUKI 154/171 (90%)) and feel comfortable diagnosing bronchiolitis in this group (PERC 136/161 (84.5%); PERUKI 143/171 (83.6%)), there was significant variation in the proportion who would be likely/very likely to perform an LP (PERC 100/161 (62.1%); PERUKI 15/171 (8.8%)) (p<0.0001). Practice in Canada, <10 years in practice and lack of comfort with diagnosing bronchiolitis represent multivariable predictors of LP; OR 23.7 (95% CI 11.7 to 47.9), 2.3 (95% CI 1.2 to 4.2) and 2.5 (95% CI 1.1 to 5.0), respectively. Rapid knowledge of respiratory syncytial virus positivity would decrease LP probability from 35.4% to 20.2%. CONCLUSION: Estimated probability of performing LPs and other interventions in otherwise healthy febrile neonates with bronchiolitis is highly variable between emergency physicians in Canada and the UK/Ireland. Network, <10 years in ED practice and comfort level with diagnosing bronchiolitis in newborns constitute independent predictors of the likelihood of LP performance.


Assuntos
Padrões de Prática Médica/tendências , Punção Espinal/métodos , Punção Espinal/normas , Bronquiolite/complicações , Bronquiolite/etiologia , Canadá , Estudos Transversais , Medicina de Emergência/métodos , Medicina de Emergência/normas , Feminino , Febre/complicações , Febre/etiologia , Humanos , Recém-Nascido , Masculino , Fatores de Risco , Inquéritos e Questionários , Reino Unido
17.
J Emerg Med ; 56(3): 308-318, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30711368

RESUMO

BACKGROUND: Recent-onset atrial fibrillation (RAF) is the most frequent supraventricular dysrhythmia in emergency medicine. Severely compromised patients require acute treatment with injectable drugs OBJECTIVE: The main purpose of this external validity study was to compare the short-term efficacy of esmolol with that of amiodarone to treat severe RAF in an emergency setting. METHODS: This retrospective survey was conducted in mobile intensive care units by analyzing patient records between 2002 and 2013. We included RAF with (one or more) severity factors including: clinical shock, angina pectoris, ST shift, and very rapid ventricular rate. A blind matching procedure was used to constitute esmolol group (n = 100) and amiodarone group (n = 200), with similar profiles for age, gender, initial blood pressure, heart rate, severity factors, and treatment delay. The main outcome measure was the percentage of patients with a ventricular rate control defined as heart frequency ≤ 100 beats/min. More stringent (rhythm control) and more humble indicators (20% heart rate reduction) were analyzed at from 10 to 120 min after treatment initiation. RESULTS: Patient characteristics were comparable for both groups: age 66 ± 16 years, male 71%, treatment delay < 1 h 36%, 1-2 h 29%, > 2 h 35%, chest pain 61%, ST shift 62%, ventricular rate 154 ± 26 beats/min, and blood pressure 126/73 mm Hg. The superiority of esmolol was significant at 40 min (64% rate control with esmolol vs. 25% with amiodarone) and for all indicators from 10 to 120 min after treatment onset. CONCLUSION: In "real life emergency medicine," esmolol is better than amiodarone in the treatment of RAF.


Assuntos
Amiodarona/normas , Fibrilação Atrial/tratamento farmacológico , Frequência Cardíaca/efeitos dos fármacos , Propanolaminas/normas , Antagonistas de Receptores Adrenérgicos beta 1/normas , Antagonistas de Receptores Adrenérgicos beta 1/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Amiodarona/uso terapêutico , Antiarrítmicos/normas , Antiarrítmicos/uso terapêutico , Medicina de Emergência/métodos , Medicina de Emergência/normas , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Propanolaminas/uso terapêutico , Estudos Retrospectivos , Inquéritos e Questionários , Fatores de Tempo
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