Utility of initial prehospital end-tidal carbon dioxide measurements to predict poor outcomes in adult asthmatic patients.

STUDY OBJECTIVE: To determine if an initial (before treatment) prehospital end-tidal carbon dioxide (EtCO2) measurement in adult, non-chronic obstructive pulmonary disease (COPD), asthmatic patients predicts patient outcomes. METHODS: This is a retrospective chart review of EtCO2 assessment data in a convenience sample of adult, asthmatic patients transported via advanced life support (ALS) units to a large, urban, academic hospital. Initial EtCO2 measurements were obtained routinely on all respiratory distress patients in the field, and emergency department physicians were unaware of the results. Data were analyzed using descriptive statistics, including percentages, means, and 95% confidence intervals (CI). RESULTS: We reviewed data for prehospital initial EtCO2 measurements on 299 unique asthma patients (repeat visits by same patient were not included). Mean (SD) age was 43.1 years (12.5) and 142 (47.5%) were male. The mean EtCO2 measurement was 38.8 mmHg (SD ± 9.5; CI: 37.7-39.9; range: 14-82). Examination of initial EtCO2 measurements by deciles revealed that extreme values, in the lowest (14-28 mmHg) and highest (50-82 mmHg) deciles, experienced more markers of poor outcome than less extreme measurements. Patients were thus dichotomized by extreme (n = 59) or nonextreme (n = 240) EtCO2 measurements. More extreme patients were ultimately intubated (30.5 vs. 5.8%; p < 0.001; positive predictive value (ppv) = 30.5% ), and/or admitted to the intensive care unit (ICU) (28.8 vs. 6.7%; p <0.001; ppv = 28.8%), and/or died (5.1 vs. 0%; p = 0.007 [Fisher's exact test]; ppv = 5.1%), than nonextreme patients, respectively. CONCLUSION: Extreme (both low and high) prehospital initial EtCO2 measurements may be associated with markers of poor patient outcomes. Future work will prospectively determine whether the addition of this information improves early recognition of severe asthma episodes beyond clinical assessment.

Self-reported non-adherence to immune-suppressant therapy in liver transplant recipients: demographic, interpersonal, and intrapersonal factors.

Adherence to immune suppressants and follow-up care regimen is important in achieving optimal long-term outcomes after organ transplantation. To identify patients most at risk for non-adherence, this cross-sectional, descriptive study explores the prevalence and correlates of non-adherence to immune-suppressant therapy among liver recipients. Anonymous questionnaires mailed consisted of the domains: (i) adherence barriers to immune suppressants, (ii) immune suppressants knowledge, (iii) demographics, (iv) social support, (v) medical co-morbidities, and (vi) healthcare locus of control and other beliefs. Overall response was 49% (281/572). Data analyzed for those transplanted within 10 yr of study reveal 50% (119/237) recipients or 9.2/100 person years reporting non-adherence. Non-adherence was reported highest in the 2-5 yr post-transplant phase (69/123, 56%). The highest immune-suppressant non-adherence rates were in recipients who are: divorced (26/34, 76%, p=0.0093), have a history of substance or alcohol use (42/69, 61%, p=0.0354), have mental health needs (50/84, 60%, p=0.0336), those who missed clinic appointments (25/30, 83%, p<0.0001), and did not maintain medication logs (71/122, 58%, p=0.0168). Respondents who were non-adherent with physician appointments were more than four and a half times as likely (OR 4.7, 95% CI 1.5-14.7, p=0.008) to be non-adherent with immune suppressants. In conclusion, half of our respondents report non-adherence to immune suppressants. Factors identified may assist clinicians to gauge patients' non-adherence risk and target resources.

Effectiveness of stroke education in the emergency department waiting room.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of stroke education provided to patients and their significant others in the emergency department (ED) waiting area. Our focus was on the 4 main aspects of stroke: signs and symptoms, risk factors, behavior modification, and the urgency to seek medical attention. We hypothesized that showing educational videos, providing one-on-one counseling, and distributing literature would result in greater stroke knowledge and positive behavioral modification. METHODS: In this pilot, randomized controlled trial, our research team enrolled patients and visitors in the fast-track waiting area of the ED. After obtaining informed written consent, participants were randomly assigned to the control group or to the intervention group. The intervention group received an educational video program, one-on-one counseling, and stroke education materials, and completed a 13-question test after receiving the education. The control group completed the same test without receiving any education. Both groups completed the same test again at 1 and 3 months to assess stroke knowledge retention. RESULTS: There were a total of 329 participants: 151 in the control group and 178 in the intervention group. Gender, age, and educational level of participants did not differ between groups. At all time points of the study, participants receiving stroke education demonstrated better test scores than those in the control group. However, knowledge retention in the intervention group gradually declined during the follow-up. Individuals enrolled in the intervention group appeared to be more motivated to reduce their smoking habits, compared with control subjects; however, the number of cigarettes they smoked per day did not dramatically decrease in comparison with their own baseline. Receiving the education session did not result in positive diet or physical activity changes. CONCLUSIONS: ED stroke education, which includes video program, one-on-one counseling, and written educational materials, is able to significantly increase stroke knowledge. Modification and reinforcement of education is needed to achieve better knowledge retention and favorable lifestyle modifications.

Is Youth Football Safe? An Analysis of Youth Football Head Impact Data.

BACKGROUND: The issue of whether sports-related head trauma at the youth level can result in long-term sequelae that may negatively impact the participant has been widely debated. OBJECTIVE: To investigate head impacts in the Summit Youth Football League equipped with helmets using the Riddell InSite impact monitoring system. The monitoring system allowed for analysis of the number of impacts and severity of impacts by player. METHODS: Data were obtained for all 20 members of the youth football team. Impacts were recorded as "low," "medium," and "high" intensity. RESULTS: All 20 players participated in all practices and games throughout the season. No player suffered a concussion throughout the entire season. There were 817 recorded impacts throughout the season. This was an average of 41 impacts per player over the course of the season and fewer than 4 impacts per player per week. Only one impact registered as "high." CONCLUSION: We demonstrate that there are few head impacts over the course of an entire season at the middle school level. Guardian Caps, safe tackling techniques, and the age of participants may have contributed to the very low number of impacts recorded and the complete lack of injuries. This study only provides data demonstrating that youth football, when Guardian Caps and safe tackling techniques are enforced, does not appear to result in significant head impacts causing immediate head injuries. This study cannot comment on the safety of playing football at the collegiate or professional level.

Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review.

BACKGROUND: Trainees and practicing physicians alike find breaking bad, sad, or difficult news to a patient or family member as one of the most challenging communication tasks they perform. Interpersonal and communication skills are a core competency for resident training. However, in disciplines where technical skills have a major emphasis, such as surgery, the teaching of communication skills may not be a priority. OBJECTIVE: The objective of our study is to review literature in order to identify best practices and learning modalities used to teach surgery trainees the communication skills regarding delivery of difficult news to patients and family members. METHODS: The criteria for inclusion in this literature review were that the study (1) addresses surgeons' training (nontechnical skills) in breaking difficult news to patient and/or families, (2) describes a teaching modality or intervention targeted to teach surgery residents how to deliver difficult news to patient/family, and (3) is published in English. RESULTS: Articles (n = 225) were screened for final eligibility. After discarding duplicates and noneligible studies, and after abstract/full-text review, 18 articles were included in the final analysis. Most studies are single site; address general surgery residents at varying training levels; and include case-specific, outpatient, and intensive care unit (ICU) settings. There is a paucity of studies in the trauma and unexpected death setting. There is a recent trend to use Objective Structured Clinical Examination (OSCE) both to teach and assess communication skills. Variable tools are used to assess this competency as described. CONCLUSION: Simulation and OSCE format have emerged as modalities of choice both to teach surgery residents how to deliver difficult news and to assess achievement of this competency. There is a gap in the literature regarding teaching and assessing surgery resident communication skills in delivering difficult news after unexpected events in the trauma and operating room settings.

Antibiotic prophylaxis for oral lacerations: our emergency department's experience.

BACKGROUND: The purpose of this study was to examine the emergency physician (EP) practice of prescribing prophylactic antibiotics for patients with oral lacerations. A secondary outcome measure was the infection rate of those who were or were not prescribed antibiotics. METHODS: The study was a retrospective chart review of 323 patients who presented to a large urban emergency department (ED) between January 1, 2012 and December 31, 2012 with an oral laceration. RESULTS: Of the 323 charts reviewed, topical and/or systemic antibiotics were prescribed in the ED to 62 % (199/323) of patients. Of those patients, 38 % (75/199) received only topical antibiotics, 34 % (68/199) received only systemic antibiotics, and 28 % (56/199) were prescribed topical and systemic antibiotics. Thirty-eight percent (124/323) of patients received no antibiotics. Eighteen percent (58/323) of patients returned for follow-up with an infection rate of 10 % (6/58). There was a statistical difference in rates of infection between patients who received antibiotics and who did not receive antibiotics and a statistical difference in rates of infection between patients with complex lacerations who received and did not receive antibiotic. CONCLUSIONS: This study shows that there is a considerable amount of practice variance in prescribing prophylactic antibiotics for oral lacerations among EPs in our ED. Due to the poor follow-up rate, an accurate infection rate could not be determined. In the future, adequately powered randomized controlled studies may provide compelling data for or against the necessity for prophylactic antibiotic use for oral lacerations.

A suggested emergency medicine boot camp curriculum for medical students based on the mapping of Core Entrustable Professional Activities to Emergency Medicine Level 1 milestones.

BACKGROUND: An increasing number of students rank Emergency Medicine (EM) as a top specialty choice, requiring medical schools to provide adequate exposure to EM. The Core Entrustable Professional Activities (EPAs) for Entering Residency by the Association of American Medical Colleges combined with the Milestone Project for EM residency training has attempted to standardize the undergraduate and graduate medical education goals. However, it remains unclear as to how the EPAs correlate to the milestones, and who owns the process of ensuring that an entering EM resident has competency at a certain minimum level. Recent trends establishing specialty-specific boot camps prepare students for residency and address the variability of skills of students coming from different medical schools. OBJECTIVE: Our project's goal was therefore to perform a needs assessment to inform the design of an EM boot camp curriculum. Toward this goal, we 1) mapped the core EPAs for graduating medical students to the EM residency Level 1 milestones in order to identify the possible gaps/needs and 2) conducted a pilot procedure workshop that was designed to address some of the identified gaps/needs in procedural skills. METHODS: In order to inform the curriculum of an EM boot camp, we used a systematic approach to 1) identify gaps between the EPAs and EM milestones (Level 1) and 2) determine what essential and supplemental competencies/skills an incoming EM resident should ideally possess. We then piloted a 1-day, three-station advanced ABCs procedure workshop based on the identified needs. A pre-workshop test and survey assessed knowledge, preparedness, confidence, and perceived competence. A post-workshop survey evaluated the program, and a posttest combined with psychomotor skills test using three simulation cases assessed students' skills. RESULTS: Students (n=9) reported increased confidence in the following procedures: intubation (1.5-2.1), thoracostomy (1.1-1.9), and central venous catheterization (1.3-2) (a three-point Likert-type scale, with 1= not yet confident/able to perform with supervision to 3= confident/able to perform without supervision). Psychomotor skills testing showed on average, 26% of students required verbal prompting with performance errors, 48% with minor performance errors, and 26% worked independently without performance errors. All participants reported: 1) increased knowledge and confidence in covered topics and 2) overall satisfaction with simulation experience. CONCLUSION: Mapping the Core EPAs for Entering Residency to the EM milestones at Level 1 identifies educational gaps for graduating medical students seeking a career in EM. Educators designing EM boot camps for medical students should consider these identified gaps, procedures, and clinical conditions during the development of a core standardized curriculum.

Community health workers recruitment from within: an inner-city neighborhood-driven framework.

BACKGROUND: Community health workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served (APHA 2009). Among other roles, they are effective in closing critical communication gap between healthcare providers and patients as they possess key abilities to overcome cultural barriers, minimize disparities, and maximize adherence to clinical directions. In previous descriptions of the selection of CHWs, the role of community is clearly emphasized, but residence in the community is not indicated. OBJECTIVE: We present an effective model of CHW selection by the community of members that reside in the community to be served. METHODS: We outlined and implemented necessary steps for recruiting CHWs from within their target neighborhood between years 2011 and 2013. The identified community was an "isolated" part of Newark, New Jersey comprised of approximately 3000 people residing in three publicly-funded housing developments. We utilized a community empowerment model and established a structure of self-governance in the community of interest. In all phases of identification and selection of CHWs, the Community Advisory Board (CAB) played a leading role. RESULTS: The process for the successful development of a CHW initiative in an urban setting begins with community/resident engagement and ends with employment of trained CHWs. The steps needed are: (1) community site identification; (2) resident engagement; (3) health needs assessment; (4) CHW identification and recruitment; and (5) training and employment of CHWs. Using an empowered community model, we successfully initiated CHW selection, training, and recruitment. Thirteen CHW candidates were selected and approved by the community. They entered a 10-week training program and ten CHWs completed the training. We employed these ten CHWs. CONCLUSIONS: These five steps emerged from a retrospective review of our CHW initiative. Residing in the community served has significant advantages and disadvantages. Community empowerment is critical in changing the health indices of marginalized communities.

Impact of an emergency medicine clerkship on students' perceptions of emergency medicine.

PURPOSE: To determine the impact of an emergency medicine (EM) clerkship on senior (4th year) medical students' perceptions of the EM specialty. SUBJECTS AND METHODS: This was a pre/posttest observational study in a mandatory 4-week EM clerkship. Students were anonymously surveyed pre- and postclerkship regarding perceptions of EM. The survey used 24 statements grouped across four domains: 1) student EM clerkship expectations/experiences, 2) perceptions regarding EM physicians, 3) perceptions regarding patients in the emergency department (ED), and 4) EM as a desirable career. Data were analyzed using paired-sample t-tests, and comparisons made using McNemar's χ (2) test. RESULTS: A total of 385 of 407 students (94.6%) completed the pre- and postclerkship survey. There was no significant difference between mean ratings before and after related to perceptions regarding EM physicians (3.71 versus 3.71), ED patients (3.80 versus 3.76), or EM as a desirable career (3.88 versus 3.84). However, ratings regarding clerkship expectations/experiences decreased (3.88 versus 3.56, P=0.001). Of the 292 students that ranked their top three specialties in both pre- and postclerkship surveys, 46 (16%) included EM as a top choice preclerkship, with 31 of these maintaining this interest postclerkship. Conversely, 12 students (5%) became interested in EM postclerkship. Some survey-statement ratings were influenced and varied by urban versus community clerkship-rotation site. CONCLUSION: A mandatory senior EM clerkship did not significantly change overall students' perceptions regarding EM. Students with an interest in EM rated domains higher than those not interested, though there may have been an overall decline in perceptions related to clerkship expectations and experiences. Larger, multisite studies may help identify aspects of the field or EM clerkship that influence a student's ultimate career choice.

Structured communication: teaching delivery of difficult news with simulated resuscitations in an emergency medicine clerkship.

INTRODUCTION: The objective is to describe the implementation and outcomes of a structured communication module used to supplement case-based simulated resuscitation training in an emergency medicine (EM) clerkship. METHODS: We supplemented two case-based simulated resuscitation scenarios (cardiac arrest and blunt trauma) with role-play in order to teach medical students how to deliver news of death and poor prognosis to family of the critically ill or injured simulated patient. Quantitative outcomes were assessed with pre and post-clerkship surveys. Secondarily, students completed a written self-reflection (things that went well and why; things that did not go well and why) to further explore learner experiences with communication around resuscitation. Qualitative analysis identified themes from written self-reflections. RESULTS: A total of 120 medical students completed the pre and post-clerkship surveys. Majority of respondents reported that they had witnessed or role-played the delivery of difficult news, but only few had real-life experience of delivering news of death (20/120, 17%) and poor prognosis (34/120, 29%). This communication module led to statistically significant increased scores for comfort, confidence, and knowledge with communicating difficult news of death and poor prognosis. Pre-post scores increased for those agreeing with statements (somewhat/very much) for delivery of news of poor prognosis: comfort 69% to 81%, confidence 66% to 81% and knowledge 76% to 90% as well as for statements regarding delivery of news of death: comfort 52% to 68%, confidence 57% to 76% and knowledge 76% to 90%. Respondents report that patient resuscitations (simulated and/or real) generated a variety of strong emotional responses such as anxiety, stress, grief and feelings of loss and failure. CONCLUSION: A structured communication module supplements simulated resuscitation training in an EM clerkship and leads to a self-reported increase in knowledge, comfort, and competence in communicating difficult news of death and poor prognosis to family. Educators may need to seek ways to address the strong emotions generated in learners with real and simulated patient resuscitations.

Stroke education in an emergency department waiting room: a comparison of methods.

BACKGROUND: Since the emergency department (ED) waiting room hosts a large, captive audience of patients and visitors, it may be an ideal location for conducting focused stroke education. The aim of this study was to assess the effectiveness of various stroke education methods. METHODS: Patients and visitors of an urban ED waiting room were randomized into one of the following groups: video, brochure, one-to-one teaching, combination of these three methods, or control group. We administered a 13-question multiple-choice test to assess stroke knowledge prior to, immediately after, and at 1 month post-education to patients and visitors in the ED waiting room. RESULTS: Of 4 groups receiving education, all significantly improved their test scores immediately post intervention (test scores 9.4±2.5-10.3±2.0, P<0.01). At 1 month, the combination group retained the most knowledge (9.4±2.4) exceeding pre-intervention and control scores (both 6.7±2.6, P<0.01). CONCLUSION: Among the various stroke education methods delivered in the ED waiting room, the combination method resulted in the highest knowledge retention at 1-month post intervention.

Medical utilization of kiosks in the delivery of patient education: a systematic review.

BACKGROUND: The utilization of kiosks has previously been shown to be effective for collecting information, delivering educational modules, and providing access to health information. We discuss a review of current literature for the utilization of kiosks for the delivery of patient education. METHODS: The criteria for inclusion in this literature review were: (1) study discusses the utilization of kiosks for patient health education; (2) study discusses the use of touch screens for patient health information; (3) published in English. Our review includes searches via MEDLINE databases and Google Scholar for the years 1996-2014. RESULTS: Overall, 167 articles were screened for final eligibility, and after discarding duplicates and non-eligible studies with abstract. Full-text review of 28 articles was included in the final analysis. CONCLUSION: The review of available literature demonstrates the effectiveness of touch screen kiosks to educate patients and to improve healthcare, both at a performance and cost advantage over other modes of patient education.

Palliative care provision in the emergency department: barriers reported by emergency physicians.

BACKGROUND: There is increasing interest in moving palliative care (PC) upstream to the emergency department (ED). However, barriers to PC provision in ED exist and are not yet clearly delineated. OBJECTIVE: To elicit the ED physicians' perceived barriers to provision of PC in the ED. METHODS: ED physicians at an urban, level-1 trauma center completed an anonymous survey. Participants ranked 23 statements on a five-point Likert-like scale (1=strongly disagree to 5=strongly agree). Statements covered four main domains of PC barriers: (1) education and training, (2) communication, (3) ED environment, and (4) personal beliefs. Respondents were also asked if they would initiate a PC consultation for ED-specific clinical scenarios (based on established triggers). RESULTS: Sixty-seven percent (30/45) of eligible participants completed the survey, average age 31 years. Respondents listed two major barriers to ED PC provision: lack of 24 hour availability of PC team (mean 4.4) and lack of access to complete medical records (mean 4.2). Almost all respondents agreed they would initiate a PC consultation for a hospice patient in respiratory distress, and the majority would consult for massive intracranial hemorrhage, traumatic arrest, or metastatic cancer. However inpatient triggers like frequent readmits for organ failure issues, e.g., dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), were rarely chosen for an ED PC consultation. CONCLUSION: We identify two main ED physician-perceived barriers to PC provision: lack of access to medical records and lack of 24/7 availability of PC team. ED physicians may not use the same criteria to initiate PC consultation as used in traditional inpatient PC trigger models. Outlining ED-specific triggers may help streamline the palliative consultation process.

When a patient declines curative care: management of a ruptured aortic aneurysm.

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case. We present the case of a 72-year-old patient who presented to the ED with a ruptured abdominal aortic aneurysm, but refused surgery. We discuss the transition of the patient from a curative to a comfort care approach with appropriate direct referral to hospice from the ED. Using principles of autonomy, decision-making capacity, informed consent, prognostication, and goals-of-care, ED clinicians are best able to align their approach with patients' goals and values.

Emergency-department-initiated palliative care consults: a descriptive analysis.

BACKGROUND: To provide optimal palliative care (PC) services in the acute setting of the emergency department (ED), it may be beneficial for the consult team to delineate the most commonly requested ED-PC services and understand why ED clinicians currently request palliative care consults (PCC). METHODS: Using a retrospective review of data gathered by the PC team on services and consults we studied patterns of ED-initiated PCC (EDI-PCC) and describe here the use of PC services in an urban tertiary-care-center ED. We then compare these with PC services provided in the traditional in-patient consult setting. RESULTS AND CONCLUSIONS: EDI-PCC patients are young, likely secondary to traumatic and critical, sudden events. In-hospital mortality rate for EDI-PCC patients is very high (most die early and in the ED setting), signifying a trend for ED clinicians to request PC consults in those who are imminently dying. PC consult teams called to the ED should expect to provide high-priority, time-sensitive services and anticipate a high level of bereavement/emotional support for distraught and unprepared families, with major discussions around end-of-life care.