Cardiopulmonary resuscitation and skill retention in emergency physicians.

STUDY OBJECTIVES: The American Heart Association (AHA) recently established the Resuscitation Quality Improvement (RQI) program, which requires physicians to perform quarterly cardiopulmonary resuscitation (CPR) skill checks. The aim of this study was to determine if timing of last training impacted skill performance of emergency physicians. METHODS: A convenience sample of emergency medicine (EM) physicians was asked to complete a Basic Life Support (BLS) scenario on a manikin. Participants passed the scenario if they successfully performed high-quality CPR. Participants completed a survey to assess clinical experience and timing of prior BLS training. Outcomes were comparisons of skills check pass rates for physicians recently trained in BLS (≤90 days) and those trained >90 days ago and those trained >2 years ago. RESULTS: A total of 113 individuals were included in the study: 87 attending physicians and 26 residents. Overall 92.9% correctly performed CPR with the proper assessment, compression rate, compression depth and rescue breaths. There was no difference between success rates in EM physicians who had BLS training within 90 days (91.7%) and physicians who had not had BLS within 90 days, (93.1%). (p = 1.00) There was no difference in the pass rate of those trained within 90 days (91.7%) to those trained >2 years ago (90.9%) (95CI 0.088, 0.096). CONCLUSION: There was no difference between delivery of high-quality CPR in EM physicians who had recent BLS training and those who did not.

Pilot Study to Evaluate the Adjunct Use of a Povidone-Iodine Topical Antiseptic in Patients with Soft Tissue Abscesses.

BACKGROUND: Povidone-iodine (PVP-I) antiseptic solutions have been shown to be effective against methicillin-resistant Staphylococcal aureus, a common cause of superficial skin abscesses. OBJECTIVES: Our objective was to study the feasibility of using PVP-I as a treatment adjunct in patients with superficial skin abscesses and determine if it confers any benefit over incision and drainage (I&D) alone. METHODS: This was a randomized controlled pilot study of adult patients with an uncomplicated skin abscess. Patients were randomized to PVP-I or standard treatment. All patients had I&D and abscess packing. Patients randomized to PVP-I were instructed on daily application of the agent to hands, wound, and surrounding skin with dressing changes. Subjects returned at 48-72 h and 7-10 days and followed-up by phone at 30 days. The primary outcome was clinical cure 7-10 days after I&D. The secondary outcomes were rate of development of new skin lesions and spread in household contacts within 30 days. RESULTS: Clinical cure occurred in 91.3% of patients in the standard group vs. 88.2% of patients in the PVP-I group (difference, 3.1%; 95% confidence interval [CI] -10.7 to 16.8; p = 0.53). There was a significantly higher adverse event rate in the group who received PVP-I (59.6%) vs. standard care (26.5%) (difference 33.1%, 95% CI 13.2-50.2; p < 0.001). CONCLUSIONS: There was no difference in clinical cure rates among patients using PVP-I (88.2%) vs. standard care (91.3%) after I&D. There were no major adverse events, but the addition of PVP-I was commonly associated with local skin irritation.

Human Trafficking: A Guide to Identification and Approach for the Emergency Physician.

Human trafficking is a significant human rights problem that is often associated with psychological and physical violence. There is no demographic that is spared from human trafficking. Traffickers maintain control of victims through physical, sexual, and emotional violence and manipulation. Because victims of trafficking seek medical attention for the medical and psychological consequences of assault and neglected health conditions, emergency clinicians are in a unique position to recognize victims and intervene. Evaluation of possible trafficking victims is challenging because patients who have been exploited rarely self-identify. This article outlines the clinical approach to the identification and treatment of a potential victim of human trafficking in the emergency department. Emergency practitioners should maintain a high index of suspicion when evaluating patients who appear to be at risk for abuse and violence, and assess for specific indicators of trafficking. Potential victims should be evaluated with a multidisciplinary and patient-centered technique. Furthermore, emergency practitioners should be aware of national and local resources to guide the approach to helping identified victims. Having established protocols for victim identification, care, and referrals can greatly facilitate health care providers' assisting this population.

Geographic Location and Corporate Ownership of Hospitals in Relation to Unfilled Positions in the 2023 Emergency Medicine Match.

Introduction: In the 2023 National Resident Matching Program (NRMP) match, there were 554 unfilled emergency medicine (EM) positions before the Supplemental Offer and Acceptance Program (SOAP). We sought to describe features of EM programs that participated in the match and the association between select program characteristics and unfilled positions. Methods: The primary outcome measures included the proportion of positions filled in relation to state and population density, hospital ownership type, and physician employment model. Secondary outcome measures included comparing program-specific attributes between filled and unfilled programs, including original accreditation type, year of original accreditation, the total number of approved training positions, length of training, urban-rural designation, hospital size by number of beds, resident-to-bed ratio, and the percentage of disproportionate share patients seen. Results: The NRMP Match had 276 unique participating EM programs with 554 unfilled positions. Six states offered 52% of the total NRMP positions available. Five states were associated with two-thirds of the unfilled positions. Public hospitals had a statistically significant higher match rate (88%) when compared to non-profit and for-profit hospitals, which had match rates of 80% and 75%, respectively (P < 0.001). Programs with faculty employed by a health system had the highest match rate of 87%, followed by clinician partnerships at 79% and private equity groups at 68% (P < 0.001 overall and between all subgroups). Conclusion: The 2023 match in EM saw increased rates in the number of residency positions and programs that did not fill before the SOAP. Public hospitals had higher match rates than for-profit or non-profit hospitals. Residency programs that employed academic faculty through the hospital or health system were associated with higher match rates.

What Should Students and Trainees Be Taught About Turfing and Where Patients Belong?

Turfing is a colloquialism that refers to what clinicians do to patients whose needs do not fit neatly and tidily into typical clinical placement protocols, especially during inpatient admissions from a hospital's emergency department. This term and this practice are both clinically and ethically problematic because a patient is rarely, if ever, "turfed" to their advantage. Ethically speaking, turfing constitutes deferral of responsibility for a patient's admission or care to colleagues. This article suggests when and under which circumstances it is clinically and ethically appropriate to defer a patient's care and suggests why turfing happens despite its negative influence on both physicians and patients.

Measles: Contemporary considerations for the emergency physician.

Measles, or rubeola, is a highly contagious acute febrile viral illness. Despite the availability of an effective vaccine since 1963, measles outbreaks continue worldwide. This article seeks to provide emergency physicians with the contemporary knowledge required to rapidly diagnose potential measles cases and bolster public health measures to reduce ongoing transmission.

Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines. OBJECTIVES: The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I & D) technique, and to compare these practices with current evidence. METHODS: Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics. RESULTS: One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I & D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I & D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I & D, even in those with 2 cm or less abscesses (57.5%). CONCLUSIONS: Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.

Clinical and epidemiologic characteristics as predictors of treatment failures in uncomplicated skin abscesses within seven days after incision and drainage.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is now the leading cause of superficial abscesses seen in the Emergency Department. STUDY OBJECTIVES: Our primary aim was to determine if an association exists between three predictor variables (abscess size, cellulitis size, and MRSA culture) and treatment failure within 7 days after incision and drainage in adults. Our secondary aim was to determine if an association exists between two clinical features (abscess size and size of surrounding cellulitis) and eventual MRSA diagnosis by culture. METHODS: Logistic regression models were used to examine clinical variables as predictors of treatment failure within 7 days after incision and drainage and MRSA by wound culture. RESULTS: Of 212 study participants, 190 patients were analyzed and 22 were lost to follow-up. Patients who grew MRSA, compared to those who did not, were more likely to fail treatment (31% to 10%, respectively; 95% confidence interval [CI] 8-31%). The failure rates for abscesses ≥ 5 cm and < 5 cm were 26% and 22%, respectively (95% CI -11-26%). The failure rates for cellulitis ≥ 5 cm and < 5 cm were 27% and 16%, respectively (95% CI -2-22%). Larger abscesses were no more likely to grow MRSA than smaller abscesses (55% vs. 53%, respectively; 95% CI -22-23%). The patients with larger-diameter cellulitis demonstrated a slightly higher rate of MRSA-positive culture results compared to patients with smaller-diameter cellulitis (61% vs. 46%, respectively; 95% CI -0.3-30%), but the difference was not statistically significant. CONCLUSION: Cellulitis and abscess size do not predict treatment failures within 7 days, nor do they predict which patients will have MRSA. MRSA-positive patients are more likely to fail treatment within 7 days of incision and drainage.

Changes in Emergency Department Volumes at the Largest U.S. Military Hospital During the COVID-19 Pandemic.

INTRODUCTION: The coronavirus-2019 (COVID-19) pandemic has significantly impacted global healthcare delivery. Brooke Army Medical Center (BAMC) is the DoD's largest hospital and a critical platform for maintaining a ready medical force. We compare temporal trends in patient volumes and characteristics in the BAMC emergency department (ED) before versus during the pandemic. MATERIALS AND METHODS: We abstracted data on patient visits from the BAMC ED electronic medical record system. Data included patient demographics, visit dates, emergency severity index triage level, and disposition. We visually compared the data from January 1, 2019 to November 30, 2019 versus January 1, 2020 to November 30, 2020 to assess the period with the most apparent differences. We then used descriptive statistics to characterize the pre-pandemic control period (1 March-November 30, 2019) versus the pandemic period (1 March-November 30, 2020). RESULTS: Overall, when comparing the pre-pandemic and pandemic periods, the median number of visits per day was 232 (Interquartile Range (IQR) 214-250, range 145-293) versus 165 (144-193, range 89-308, P < .0001). Specific to pediatric visits, we found the median number of visits per day was 39 (IQR 33-46, range 15-72) versus 18 (IQR 14-22, range 5-61, P < .001). When comparing the median number of visits by month, the volumes were lower during the pandemic for all months, all of which were strongly significant (P < .001 for all). CONCLUSIONS: The BAMC ED experienced a significant decrease in patient volume during the COVID-19 pandemic starting in March 2020. This may have significant implications for the capacity of this facility to maintain a medically ready force.

How do you treat an abscess in the era of increased community-associated methicillin-resistant Staphylococcus aureus (MRSA)?

BACKGROUND: In the era of increased prevalence of community-associated methicillin-resistant Staphylococcus aureus (MRSA), there have been a number of questions and several recent studies that address the clinical management of uncomplicated abscesses in the emergency department (ED). DISCUSSION: We examine the historical and clinical predictors for MRSA in patients with an uncomplicated abscess and review the evidence behind the use of wound cultures, decolonization, antibiotics, irrigation, and packing after incision and drainage. We found that current recommendations and treatment guidelines are often based on limited data, expert opinion, and anecdotal experience. CONCLUSION: In light of the data currently available, antibiotics and decolonization should be used selectively, not routinely, for treatment of most uncomplicated abscesses. Wound cultures are generally not necessary in the ED, and all patients should be given return precautions for worsening symptoms.

Comparison of the Loop Technique With Incision and Drainage for Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis.

BACKGROUND: Cutaneous abscesses are common presentations to the emergency department. While the primary treatment for most abscesses is conventional incision and drainage (CID), this is painful and can lead to multiple return visits. The loop drainage technique (LDT) has been proposed as an alternate, less-invasive approach to abscess management. The primary outcome of this study was to compare LDT with CID for skin and soft tissue abscesses. METHODS: PubMed, Scopus, CINAHL, LILACS, Google Scholar, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective observational, and randomized controlled trials comparing treatment failures between LDT and CID among patients with skin and soft tissue abscesses. Data were dual extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool or the Newcastle-Ottawa scale. Data were summarized and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup analyses were performed for adult and pediatric patients. RESULTS: A total of 1,374 studies were identified with eight studies (n = 910 patients) selected for inclusion. Overall, CID failed in 69 of 487 patients (14.17%), while LDT failed in 35 of 423 patients (8.27%). There was an OR of 2.02 (95% CI = 1.29 to 3.18) in favor of higher failures in the CID group. This finding remained consistent with only randomized controlled trials (OR = 1.75, 95% CI = 1.07 to 2.86), but no difference was identified in the adult or pediatric subgroups. CONCLUSION: The LDT was associated with reduced treatment failures when compared with CID. Future studies should further assess the impact on pain, cosmetic outcomes, and health care costs.

Educating the Leaders and Clinicians of Tomorrow: An Innovative Emergency Medicine Research Curriculum for Resident Physicians.

BACKGROUND: Academic productivity is a requirement by the Accreditation Council for Graduate Medical Education (ACGME). In addition to the requirements by the ACGME, residency training programs are required to provide education on medical research with the end-goal of teaching physicians how to read, interpret, and apply medical evidence in the form of evidence-based medicine. An understanding of research design, evidencebased medicine, and critical appraisal of available literature is central to practicing medicine and applying new research to clinical practice. However, residency programs vary significantly in research curricula provided to residents. We describe an innovative integrated military-civilian emergency medicine research curriculum that provides foundational knowledge in research design and critical appraisal.