Assessment of the Utility of Ordering a Troponin in Low- and Intermediate-Risk Patients Presenting to the Emergency Department with Supraventricular Tachycardia: A Retrospective Chart Review.

BACKGROUND: A troponin assay is commonly sent for patients presenting to emergency departments (EDs) with supraventricular tachycardia (SVT). Multiple studies suggest that elevated troponin levels do not predict coronary artery disease in these patients. Patients with elevated troponins are more likely to have additional cardiac testing, which can lead to increased health care costs and unnecessary invasive procedures. OBJECTIVE: Our objective was to evaluate low- to intermediate-risk patients (HEART [history, electrocardiography, age, risk factors and troponin] Score 1-6) presenting to the ED with SVT. Our hypothesis was that an elevated troponin would not predict major adverse cardiac events (MACE), but would be associated with increased hospital admission rates and lengths of stay. METHODS: This was a retrospective cohort study of adult patients who presented with SVT to a large, urban, academic hospital ED over 4 years who had a troponin result. A total of 46 patients were included in the study. RESULTS: Patients with a positive troponin (>0.05 ng/mL) had a hospital admission rate of 86% versus 21% for patients with negative troponin (p = 0.006); rate of cardiology consult of 86% versus 21% (p < 0.001); and a mean total length of stay of 4157 min versus 1347 min (p = 0.04). At 3 months, none of the patients with a positive troponin had an MACE, death from any cause, or positive results of cardiac testing. CONCLUSIONS: Patients with a positive troponin result had significantly more admissions, cardiology consults, and longer hospital stays. These patients did not have an increased prevalence of MACE.

Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.

A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.

Experiential Learning in Patient Safety: A Multi-Center Study Examining Emergency Medicine Residents' Situational Awareness of Hazards via Simulation.

Introduction The 2016 Clinical Learning Environment Review established that experiential patient safety curricula for residents are uncommon. Moreover, these curricula do not incorporate non-technical skills linked to safety, such as situational awareness (SA). We developed an in-situ patient safety simulation exercise incorporating core SA concepts and subsequently assessed exercise feasibility and acceptability, and measured residents' safety SA. Methods A simulation scenario and mock chart were designed, incorporating 16 patient safety hazards. Residents at two institutions reviewed the chart and had 10 minutes in an emergency department room with the simulated scenario to document identified hazards, followed by a facilitated debriefing. Pre- and post-exercise surveys were completed. We used regression analyses to compare exercise performance and survey responses by training year, and measures of proportional difference and association for survey responses. Results This study included 76 of 104 eligible residents (73.1%). Around 56.5% initially reported being comfortable identifying hazards. During the exercise, hazards requiring higher SA were identified less frequently. Senior residents identified more hazards (OR 2.26; 95%CI 1.56-3.28) (mean 8.28, SD1.45); 93.4% expressed satisfaction with the session, and residents reporting comfort increased significantly (89.5%, p<0.001). Conclusion In-situ simulation incorporating SA concepts feasibly provides experiential safety education and enhances resident comfort with safety issues. Visible hazards were often identified; those requiring information synthesis were usually missed, suggesting a need for developing more robust resident SA. While interns demonstrated the poorest performance, senior residents only identified 50% of errors, indicating that patient safety education enhancing SA should begin early and continue longitudinally.

Global Health Training in U.S. Emergency Medicine Residency Programs.

OBJECTIVES: Formal education in global health (GH) and short-term experiences in GH (STEGH) are offered by many emergency medicine (EM) residency programs in the United States. In an increasingly connected world, training in GH and STEGH can provide essential knowledge and practical skills to trainees, particularly at the graduate medical education level. The current core programmatic components and the essential competencies and curricula that support ethical and effective STEGH, however, still vary widely. The authors conducted a survey of the 228 EM residency programs in the United States to describe the current state of GH training and STEGH. METHODS: An online survey was developed in REDCap by a team of GH faculty. In July 2018, programs were invited to participate via individual invitation of program directors from a directory. The programs received two reminders to participate until January 2019. RESULTS: Of the 84 programs that responded, 75% offer STEGH and 39% have longitudinal GH curricula. Within these programs, only 55% have dedicated GH faculty and only 70% have dedicated sites. Both faculty and residents encounter funding and insurance barriers; most notably, only 20% of programs that offer STEGH provide evacuation insurance for their residents. Most residents (95%) engage in clinical work along with teaching and other activities, but 24% of programs do not allow these activities to fulfill any residency requirements. Finally, only 80 and 85% of programs offer preparatory and debriefing activities for residents, respectively. CONCLUSIONS: While the results of this survey show progress relative to prior surveys, there are still barriers to implementing GH curricula and supporting safe, ethical, and effective STEGH, particularly in the form of continued financial and logistic support for faculty and for residents, in U.S. EM training programs.

Application of the World Health Organization's Basic Emergency Care course in Zambia.

BACKGROUND: In 2013, the Zambian Ministry of Health identified action priorities for strengthening their emergency care system; one of these priorities was emergency care training for healthcare providers. To rapidly train the existing cadre of frontline providers, trainings were implemented in multiple provinces using the World Health Organization's Basic Emergency Care (BEC) course. The BEC course is open-access and emphasizes a practical syndrome-based approach to critical emergency conditions. This paper describes the first reported larger scale educational intervention of the BEC course in 7 provinces of Zambia. METHODS: Course delivery occurred at seven Zambian hospitals selected by the Ministry of Health over a 1 year period. Participant emergency care knowledge was assessed pre- and post-course with a 25-question multiple choice exam. Participant confidence levels related to emergency care provision and emergency care skills were assessed pre- and post-course using a Likert scale survey. RESULTS: Overall, 210 participants were trained at 7 sites. Participants demonstrated significant improvements in their multiple-choice exam scores; the overall pre-course mean was 61.47, and the post-course mean was 79.87 (p < 0.0001). Self-reported confidence in the care of ill and injured adults and children increased after taking the course, and participants generally agreed that the BEC course was highly valuable and applicable to local needs. CONCLUSION: Implementation of the WHO's BEC course at seven hospitals throughout Zambia led to improvement in the participants' emergency care knowledge and confidence levels at all sites. The BEC course has the potential to be implemented in a nationwide initiative but would require allocation of significant human and physical resources. Additional work evaluating patient outcomes and long-term participant educational outcomes is needed.

Six years of epinephrine digital injections: absence of significant local or systemic effects.

STUDY OBJECTIVE: Epinephrine autoinjectors are known to result in accidental digital injections. Treatment recommendations and adverse outcomes are based on case reports. The objective of our study is to determine the frequency of digit ischemia after epinephrine autoinjector digital injections. In addition, we describe the frequency of epinephrine digital injections, treatments used, adverse local effects, and systemic effects. METHODS: We performed a retrospective cohort study on cases reported to 6 poison centers during 6 years, using a search of the Texas Poison Center Network database. Patients who had an epinephrine injection of the hand were reviewed, and digital injections were included. Variables collected included demographics, local and systemic effects, symptom duration, treatments used, comorbidities, and whether admission, surgery, or hand surgery consultation was used. One trained abstractor used a standard electronic data collection form. RESULTS: There were 365 epinephrine injections to the hand identified for the 6-year period. Of these, 213 were digital injections, and 127 had follow-up. All patients had complete resolution of symptoms. None of the patients were hospitalized or received hand surgery consultation or surgical care. Significant systemic effects were not reported. Pharmacologic vasodilatory treatment was used in 23% (29/127) of patients. Ischemic effects were documented for 4 patients, and 2 of these had symptom resolution within 2 hours. All 4 patients received vasodilatory therapy and were discharged home, with complete resolution of symptoms. CONCLUSION: In our series of patients using poison center calls about digital epinephrine autoinjections, there were no cases in which clinically apparent systemic effects were recorded and few patients had ischemia. No patient was admitted or had surgery. Most clinicians did not use vasodilation medications or techniques.

Asynchronous Curriculum "Socially Synchronized": Learning Via Competition.

INTRODUCTION: Now widespread in emergency medicine (EM) residency programs, asynchronous curriculum (AC) moves education outside of classic classrooms. Our program's prior AC had residents learning in isolation, achieving completion via quizzes before advancing without the benefit of deliberate knowledge reinforcement. We sought to increase engagement and spaced repetition by creating a social AC using gamification. METHODS: We created a website featuring monthly options from textbooks and open-access medical education. Residents selected four hours of material, and then submitted learning points. Using these learning points, trivia competitions were created. Residents competed in teams as "houses" during didactic conference, allowing for spaced repetition. Residents who were late in completing AC assignments caused their "house" to lose points, thus encouraging timely completion. RESULTS: Completion rates prior to deadline are now >95% compared to ~30% before intervention. Surveys show increased AC enjoyment with residents deeming it more valuable clinically and for EM board preparation. CONCLUSION: Socially synchronized AC offers a previously undescribed method of increasing resident engagement via gamification.

San Antonio refugees: Their demographics, healthcare profiles, and how to better serve them.

OBJECTIVE: The recent refugee crisis has resulted in the largest burden of displacement in history, with the US being the top resettlement country since 1975. Texas welcomed the second most US-bound refugees in 2016, with a large percentage arriving in San Antonio. Yet, the composition of the San Antonio refugees has not been described and their healthcare needs remain ill-defined. Through this study, we aim at elucidating their demographics and healthcare profiles, with the goal of devising recommendations to help guide refugee program development and guide other refugee resettlement programs. METHODS: Data from 731 charts belonging to 448 patients at the San Antonio Refugee Health Clinic (SARHC) were extracted and analyzed. Data included age, gender, country of origin, first language, interpretation need, health insurance status, medical history, vital signs, diagnoses, and prescribed medications. RESULTS: Women constituted the majority of patients (n = 267; 56.4%), and the median age of all patients was 39 (Q1:26, Q3:52). Nepali-speaking Bhutanese patients were the most represented group (n = 107, 43.1%), followed by Iraqi (n = 35, 14.1%), Burmese (n = 30, 12.1%), and Iranian (n = 19, 7.7%) refugees. Of those who responded, 200 (86.6%) did not have any form of health insurance. Additionally, 262 (50.9%) had a body-mass index (BMI) in the overweight or obese range. Further, 61.4% (n = 337) had blood pressures in the hypertensive range, while 9.3% (n = 51) had an elevated blood pressure. On average, each patient had 1.9 complaints, with abdominal pain, headaches, and cough being the predominant complaints. Allergic rhinitis, viral upper respiratory infections, and elevated blood pressure were the most common diagnoses. However, the list of common diagnoses differed per country of origin. CONCLUSION: The SARHC demographics were different from those of other Texas refugees. The rate of the uninsured and the burden of non-communicable diseases were high. Furthermore, each refugee subgroup had a different set of common problems. These findings reveal important considerations for refugee healthcare providers and the unique approach that may be required for different communities.

Registry of emergency airways arriving at combat hospitals.

BACKGROUND: Prehospital Emergency Medical Services have demonstrated variable success with regards to prehospital airway management in U.S. civilian settings. We attempted to identify the incidence of successful prehospital endotracheal intubations in the modern combat environment. METHODS: This was a prospective, observational study. Data collection occurred at Combat Support Hospitals (CSH) within Operation Iraqi Freedom locations between January 2005 and March 2007. Military trauma physicians systematically examined casualties presenting to the CSH that received advanced prehospital airway management. Correct endotracheal tube (ETT) positioning was verified using an explicit combination of clinical findings and colorimetric end-tidal carbon dioxide detection. The primary outcome was correct placement of the ETTs by combat prehospital providers. RESULTS: A total of 6,875 combat casualties presented to participating CSHs during the study period, of which there were 293 (4.2%) advanced prehospital airways, of which 282 (97.3%) were trauma patients. Prehospital airway management included: 253 endotracheal intubations (86.6%); 23 supraglottic airways (7.5%), and 17 cricothyrotomies (5.8%). Of the ETTs, upon arrival to the CSH, 242 (95.7%) were determined to be correctly placed. There were 11 incorrectly placed ETTs: 10 were in the right mainstem bronchus, and 1 was found to be dislodged in the hypopharynx. There were no unrecognized battlefield esophageal intubations. CONCLUSIONS: Under combat conditions, the overall rate of correctly placed ETTs performed by military prehospital providers was comparable with that of published U.S. civilian paramedic data.

Using Interprofessional Education to Promote Oral Health Literacy in a Faculty-Student Collaborative Practice.

The aim of this study was to assess the oral health literacy knowledge gained by patients who are refugees, community members, and medical and nursing students after participating in an interprofessional education collaborative of students and faculty from the University of Texas Health San Antonio Schools of Dentistry, Medicine, and Nursing. In this faculty-student collaborative practice, all patients were triaged (including oral hygiene status and alcohol/tobacco use), and tailored treatment options were offered following assessment of their dental, medical, and social histories. The study was designed as a pre-post assessment of an educational intervention on oral health literacy. In the pretest, all groups were invited to respond to questionnaires assessing their knowledge of oral health. After participants engaged in oral hygiene instruction demonstrations and received information about an oral health literacy campaign, a posttest was conducted to assess knowledge gained. A total of 151 patients who were refugees, 38 medical students, 34 nursing students, and 17 community/parish members voluntarily participated in this initiative. Each group had a significant increase in mean oral health literacy score from pre- to posttest: patients 33.5%, community/parish members 22.3%, nursing students 20.8%, and medical students 13% (all p<0.0001). These results showed that the oral health literacy initiative helped increase all participants' oral health literacy and knowledge of preventive care.

Emergency Physicians at War.

Operation Enduring Freedom (OEF-A) in Afghanistan and Operation Iraqi Freedom (OIF) represent the first major, sustained wars in which emergency physicians (EPs) fully participated as an integrated part of the military's health system. EPs proved invaluable in the deployments, and they frequently used the full spectrum of trauma and medical care skills. The roles EPs served expanded over the years of the conflicts and demonstrated the unique skill set of emergency medicine (EM) training. EPs supported elite special operations units, served in medical command positions, and developed and staffed flying intensive care units. EPs have brought their combat experience home to civilian practice. This narrative review summarizes the history, contributions, and lessons learned by EPs during OEF-A/OIF and describes changes to daily clinical practice of EM derived from the combat environment.

Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a US Tertiary Combat Hospital.

Introduction Analysis of injuries during military operations has focused on those related to combat. Non-combat complaints have received less attention, despite the need for many troops to be evacuated for non-battle illnesses in Iraq. This study aims to further characterize the disease and non-battle injuries (DNBIs) seen at a tertiary combat hospital and to describe the types of procedures and medications used in the management of these cases. METHODS: In this observational study, patients were enrolled from a convenience sample with non-combat-related diseases and injuries who were evaluated in the emergency department (ED) of a US military tertiary hospital in Iraq from 2007-2008. The treating emergency physician (EP) used a data collection form to enroll patients that arrived to the ED whose injury or illness was unrelated to combat. RESULTS: Data were gathered on 1,745 patients with a median age of 30 years; 84% of patients were male and 85% were US military personnel. The most common diagnoses evaluated in the ED were abdominal disorders, orthopedic injuries, and headache. Many cases involved intravenous access, laboratory testing, and radiographic testing. Procedures performed included electrocardiogram, lumbar puncture, and intubation. CONCLUSION: Disease and non-battle traumatic injuries are common in a tertiary combat hospital. Emergency providers working in austere settings should have the diagnostic and procedural skills to evaluate and treat DNBIs. Bebarta VS , Mora AG , Ng PC , Mason PE , Muck A , Maddry JK . Disease and non-battle traumatic injuries evaluated by emergency physicians in a US tertiary combat hospital. Prehosp Disaster Med. 2018;33(1):53-57.

Confusion recurs 2 weeks after fall.

A 77-year-old woman presented to the emergency department complaining of a headache following a syncopal episode (while standing) earlier that day. She said that she'd lost consciousness for several minutes, and then experienced several minutes of mild confusion that resolved spontaneously. On physical exam, she was oriented to person and place, but not time. She had a contusion in her left occipitoparietal region without extensive bruising or deformity. The patient had normal cardiopulmonary, abdominal, and neurologic exams. Her past medical history included hypertension and normal pressure hydrocephalus, and her vital signs were within normal limits. She was taking aspirin once daily. The patient's initial head and neck computerized tomography (CT) scans were normal, but she was hospitalized because of her confusion. During her hospitalization, the patient had mild episodic headaches that resolved with acetaminophen. The next day, her confusion resolved, and repeat CT scans were unchanged. She was discharged within 24 hours. Two weeks later, the patient returned to the hospital after her daughter found her on the toilet, unable to stand up from the sitting position. She was confused and experienced a worsening of headache during transport to the hospital. No recurrent falls or additional episodes of trauma were reported. A CT scan was performed. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project.

OBJECTIVES: In medical education and training, increasing numbers of institutions and learners are participating in global health experiences. Within the context of competency-based education and assessment methodologies, a standardized assessment tool may prove valuable to all of the aforementioned stakeholders. Milestones are now used as the standard for trainee assessment in graduate medical education. Thus, the development of a similar, milestone-based tool was undertaken, with learners in emergency medicine (EM) and global health in mind. METHODS: The Global Emergency Medicine Think Tank Education Working Group convened at the 2016 Society for Academic Medicine Annual Meeting in New Orleans, Louisiana. Using the Interprofessional Global Health Competencies published by the Consortium of Universities for Global Health's Education Committee as a foundation, the working group developed individual milestones based on the 11 stated domains. An iterative review process was implemented by teams focused on each domain to develop a final product. RESULTS: Milestones were developed in each of the 11 domains, with five competency levels for each domain. Specific learning resources were identified for each competency level and assessment methodologies were aligned with the milestones framework. The Global Health Milestones Tool for learners in EM is designed for continuous usage by learners and mentors across a career. CONCLUSIONS: This Global Health Milestones Tool for learners in EM may prove valuable to numerous stakeholders. The next steps include a formalized pilot program for testing the tool's validity and usability across training programs, as well as an assessment of perceived utility and applicability by collaborating colleagues working in training sites abroad.

Bedside rounds versus board rounds in an emergency department.

BACKGROUND: Our objective was to gain insight into whether bedside rounding at shift turnover in the emergency department improved education quality, as compared with board rounds. Board rounds are commonly used in the emergency department, where the teams review the patient and transfer care near a computer screen or written board, rather than at the patient's bedside. The impact on teaching or patient care has not been extensively compared between the two approaches. METHODS: We conducted a prospective study in an academic emergency department to compare bedside rounds versus board rounds. A convenience sample of 408-hour clinical shifts were randomised to either bedside or board rounds. Data collected included frequency of discussion of differential diagnosis, questions asked per patient, total time for which alternative therapies were discussed, total time for which alternative tests were discussed, total time for which exam findings were discussed and demonstrated, and resident impression of education quality. RESULTS: The randomisation of 20 shifts in each cohort provided a total of 274 patient cases. Our primary outcome was an increased frequency of discussion of the differential diagnosis, which occurred more often in the bedside group (72 versus 53%). We also detected that with bedside rounding more questions per patient were asked, and alternative therapies and tests, exam findings and results were discussed more often. CONCLUSIONS: Bedside rounding in the emergency department, as compared with board rounding, appears to increase the frequency of learner education measures. Emergency medicine residents reported the quality of education was better with bedside rounding. Bedside rounds took on average 4 minutes longer, without achieving statistical significance.