Pulmonary contusion in the pan-scan era

BACKGROUND

Although pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC.

OBJECTIVES

We sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury).

METHODS

Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes.

RESULTS

Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1-32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6-4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores>10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC.

CONCLUSIONS

PC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.

Clinical Decision Rules for Diagnostic Imaging in the Emergency Department: A Research Agenda

BACKGROUND

Major gaps persist in the development, validation, and implementation of clinical decision rules (CDRs) for diagnostic imaging.

OBJECTIVES

The objective of this working group and article was to generate a consensus-based research agenda for the development and implementation of CDRs for diagnostic imaging in the emergency department (ED).

METHODS

The authors followed consensus methodology, as outlined by the journal Academic Emergency Medicine (AEM), combining literature review, electronic surveys, telephonic communications, and a modified nominal group technique. Final discussions occurred in person at the 2015 AEM consensus conference.

RESULTS

A research agenda was developed, prioritizing the following questions: 1) what are the optimal methods to justify the derivation and validation of diagnostic imaging CDRs, 2) what level of evidence is required before disseminating CDRs for widespread implementation, 3) what defines a successful CDR, 4) how should investigators best compare CDRs to clinical judgment, and 5) what disease states are amenable (and highest priority) to development of CDRs for diagnostic imaging in the ED?

CONCLUSIONS

The concepts discussed herein demonstrate the need for further research on CDR development and implementation regarding diagnostic imaging in the ED. Addressing this research agenda should have direct applicability to patients, clinicians, and health care systems.

Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use

STUDY OBJECTIVE

The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present.

METHODS

We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging.

RESULTS

We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%.

CONCLUSION

Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians.

External Validation of the STONE Score, a Clinical Prediction Rule for Ureteral Stone: An Observational Multi-institutional Study

Study objective

The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis.

Methods

We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013. In accordance with STONE predictors, we categorized participants into low-, moderate-, or high-score groups. We determined the performance of the STONE score and physician gestalt for ureteral stone.

Results

Eight hundred forty-five participants were included for analysis; 331 (39%) had a ureteral stone. The global performance of the STONE score was superior to physician gestalt (area under the receiver operating characteristic curve=0.78 [95% confidence interval {CI} 0.74 to 0.81] versus 0.68 [95% CI 0.64 to 0.71]). The prevalence of ureteral stone on CT scan ranged from 14% (95% CI 9% to 19%) to 73% (95% CI 67% to 78%) in the low-, moderate-, and high-score groups. The sensitivity and specificity of a high score were 53% (95% CI 48% to 59%) and 87% (95% CI 84% to 90%), respectively.

Conclusion

The STONE score can successfully aggregate patients into low-, medium-, and high-risk groups and predicts ureteral stone with a higher specificity than physician gestalt. However, in its present form, the STONE score lacks sufficient accuracy to allow clinicians to defer CT scan for suspected ureteral stone.

Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT)

BACKGROUND

Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.

METHODS AND FINDINGS

From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.

CONCLUSIONS

We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.

Barriers to Homeless Persons Acquiring Health Insurance Through the Affordable Care Act

BACKGROUND

Medicaid expansion under the Affordable Care Act (ACA) is intended to provide a framework for increasing health care access for vulnerable populations, including the 1.2 million who experience homelessness each year in the United States.

OBJECTIVE

We sought to characterize homeless persons' knowledge of the ACA, identify barriers to their ACA enrollment, and determine access to various forms of communication that could be used to facilitate enrollment.

METHODS

At an urban county Level I trauma center, we interviewed all noncritically ill adults who presented to the emergency department (ED) during daytime hours and were able to provide consent. We assessed access to communication, awareness of the ACA, insurance status, and barriers preventing subjects from enrolling in health insurance and compared homeless persons' responses with concomitantly enrolled housed individuals.

RESULTS

Of the 650 enrolled subjects, 134 (20.2%) were homeless. Homeless subjects were more likely to have never heard of the ACA (26% vs. 10%). "Not being aware if they qualify for Medicaid" was the most common (70%) and most significant (30%) barrier to enrollment reported by uninsured homeless persons. Of homeless subjects who were unsure if they qualified for Medicaid, 91% reported an income < 138% of the federal poverty level, likely qualifying them for enrollment. Although 99% of housed subjects reported access to either phone or internet, only 74% of homeless subjects reported access.

CONCLUSIONS

Homeless persons report having less knowledge of the ACA than their housed counterparts, poor understanding of ACA qualification criteria, and limited access to phone and internet. ED-based outreach and education regarding ACA eligibility may increase their enrollment.

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study

STUDY OBJECTIVE

Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention.

METHODS

Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury.

RESULTS

Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury).

CONCLUSION

In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.

Sternal fracture in the age of pan-scan

STUDY OBJECTIVE

Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients.

METHODS

We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation.

RESULTS

Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0).

CONCLUSIONS

Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.

Interruptions of Trauma Resuscitations for Radiographic Procedures

BACKGROUND

Although x-ray studies provide important diagnostic information during trauma resuscitations, they may also lead to significant interruptions in care.

OBJECTIVES

We sought to determine the frequency and duration of interruptions for chest x-ray studies (CXR) and pelvic x-ray studies (PXR) and the frequency of lead apron use among providers who exited trauma rooms during resuscitation.

METHODS

Using a convenience sampling method, we conducted a prospective, observational study from August 2013 to March 2014, enrolling adult trauma patients at a Level I trauma center who received CXR and PXR in the first 30 min of evaluation. An observer stood outside resuscitation rooms and recorded the time elapsed from the first provider exiting the room to the last provider returning. We recorded how many exiting providers wore lead aprons and whether unused aprons were available.

RESULTS

Of the 156 trauma cases observed, 67.3% were of male patients with a mean age of 52 years (interquartile range [IQR] 34-67 years); 97.4% (184/189) of radiographs resulted in interruptions of trauma evaluation. Mean and median interruption times were 67 s and 50 s, respectively (IQR 25-95) for CXR; 37 s and 27 s, respectively (IQR 16-43) for PXR; and 160 s and 180 s, respectively (IQR 120-180) for combined CXR/PXR. A mean of 3.5 providers (IQR 3-5) left the immediate bedside and exited the room during x-ray studies. Most (91%) providers leaving the room were not wearing lead aprons, and extra aprons were available in the room 91% (167/184) of the time.

CONCLUSIONS

Radiographic procedures often result in interruptions of trauma resuscitations despite the availability of lead aprons.

Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations

BACKGROUND

Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization.

OBJECTIVES

The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect.

METHODS

From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury.

RESULTS

Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv.

CONCLUSIONS

Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.

Validation of a prediction rule for endocarditis in febrile injection drug users

BACKGROUND

Infectious endocarditis (IE) in febrile injection drug users (IDUs) is a critical diagnosis to identify in the emergency department (ED). A decision tool that identifies patients at very low risk for endocarditis using readily available clinical data could reduce admissions and cost.

OBJECTIVE

To evaluate the diagnostic performance of a previously derived decision instrument to rule out endocarditis in febrile IDUs (Prediction Rule for Endocarditis in Injection Drug Users [PRE-IDU]) and to develop a prediction model for likelihood of endocarditis for those who are not ruled out by PRE-IDU.

METHODS

Febrile IDUs admitted to rule out endocarditis were prospectively enrolled from 2 urban EDs in June 2007 to March 2011. Clinical data from ED presentation (first 6 hours) and outcome data from inpatient records were recorded and reviewed by 2 independent investigators. Diagnosis of IE was based on modified Duke criteria and discharge summaries. The diagnostic performance of PRE-IDU, which combines tachycardia, cardiac murmur, and absence of skin infection, was determined using recursive partitioning and logistic regression modeling.

RESULTS

Of the 249 subjects, 18 (7%) had IE. Recursive partitioning yielded an instrument with 100% sensitivity (95% confidence interval [CI], 84%-100%) and 100% negative predictive value (95% CI, 91%-100%), but low specificity (13%; 95% CI, 12%-13%). Multiple logistic regression modeling with the 3 clinical predictors allowed risk stratification with posttest probabilities ranging from 3% to 20%.

CONCLUSION

The PRE-IDU instrument predicted IE with high sensitivity and ruled out IE with high negative predictive value. Our logistic regression model provided posttest probabilities ranging from 3% to 20%. The PRE-IDU instrument and the associated model may help guide hospital admission and diagnostic testing in evaluation of febrile IDUs in the ED.

NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma

IMPORTANCE

Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. OBJECTIVE To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance.

DESIGN, SETTING, AND PARTICIPANTS

From December 2009 to January 2012, we enrolled blunt trauma patients older than 14 years who received chest radiography in this prospective, observational, diagnostic decision instrument study at 9 US level I trauma centers. Prior to viewing radiographic results, physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria (age >60 years, rapid deceleration mechanism, chest pain, intoxication, abnormal alertness/mental status, distracting painful injury, and tenderness to chest wall palpation).

MAIN OUTCOMES AND MEASURES

Thoracic injury seen on chest imaging was defined as pneumothorax, hemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion or laceration seen on radiographs. An expert panel generated an a priori classification of clinically major, minor, and insignificant TICIs according to associated management changes.

RESULTS

Of 9905 enrolled patients, 43.1% had a single CXR, 42.0% had CXR and chest CT, 6.7% had CXR and abdominal CT (without chest CT), 5.5% had multiple CXRs without CT, and 2.6% had chest CT alone in the emergency department. The most common trauma mechanisms were motorized vehicle crash (43.9%), fall (27.5%), pedestrian struck by motorized vehicle (10.7%), bicycle crash (6.3%), and struck by blunt object, fists, or kicked (5.8%). Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major clinical significance, 1079 (73.0%) minor clinical significance, and 36 (2.4%) no clinical significance. NEXUS Chest had a sensitivity of 98.8% (95% CI, 98.1%-99.3%), a negative predictive value of 98.5% (95% CI, 97.6%.6-99.1%), and a specificity of 13.3% (95% CI, 12.6%-14.1%) for TICI. The sensitivity and negative predictive value for TICI with clinically major injury were 99.7% (95% CI, 98.2%-100.0%) and 99.9% (95% CI, 99.4%-100.0%), respectively.

CONCLUSIONS AND RELEVANCE

We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.

Study of medical students' malpractice fear and defensive medicine: a "hidden curriculum?"

Introduction: Defensive medicine is a medical practice in which health care providers' primary intent is to avoid criticism and lawsuits, rather than providing for patients' medical needs. The purpose of this study was to characterize medical students' exposure to defensive medicine during medical school rotations.

Methods: We performed a cross-sectional survey study of medical students at the beginning of their third year. We gave students Likert scale questionnaires, and their responses were tabulated as a percent with 95% confidence interval (CI).

Results: Of the 124 eligible third-year students, 102 (82%) responded. Most stated they rarely worried about being sued (85.3% [95% CI=77.1% to 90.9%]). A majority felt that faculty were concerned about malpractice (55.9% [95% CI=46.2% to 65.1%]), and a smaller percentage stated that faculty taught defensive medicine (32.4% [95% CI=24.1% to 41.9%]). Many students believed their satisfaction would be decreased by MC and lawsuits (51.0% [95% CI=41.4% to 60.5%]). Some believed their choice of medical specialty would be influenced by MC (21.6% [95% CI=14.7% to 30.5%]), and a modest number felt their enjoyment of learning medicine was lessened by MC (23.5% [95% CI=16.4% to 32.6%]). Finally, a minority of students worried about practicing and learning procedures because of MC (16.7% [95% CI=10.7% to 25.1%]).

Conclusion: Although third-year medical students have little concern about being sued, they are exposed to malpractice concerns and taught considerable defensive medicine from faculty. Most students believe that fear of lawsuits will decrease their future enjoyment of medicine. However, less than a quarter of students felt their specialty choice would be influenced by malpractice worries and that malpractice concerns lessened their enjoyment of learning medicine. [West J Emerg Med. 2014;15(3):293–298.]

English-based Pediatric Emergency Medicine Software Improves Physician Test Performance on Common Pediatric Emergencies: A Multicenter Study in Vietnam

INTRODUCTION

Global health agencies and the Vietnam Ministry of Health have identified pediatric emergency care and health information technology as high priority goals. Clinical decision support (CDS) software provides physicians with access to current literature to answer clinical queries, but there is limited impact data in developing countries. We hypothesized that Vietnamese physicians will demonstrate improved test performance on common pediatric emergencies using CDS technologies despite being in English.

METHODS

This multicenter, prospective, pretest-posttest study was conducted in 11 Vietnamese hospitals enrolled a convenience sample of physicians who attended an 80-minute software training on a pediatric CDS software (PEMSoft). Two multiple-choice exams (A, B) were administered before and after the session. Participants, who received Test A as a pretest, received Test B as a posttest, and vice versa. Participants used the CDS software for the posttest. The primary outcome measure was the mean percentage difference in physician scores between the pretest and posttest, as calculated by a paired, two-tailed t-test.

RESULTS

For the 203 participants, the mean pretest, posttest, and improvement scores were 37% (95% CI: 35-38%), 70% (95% CI: 68-72%), and 33% (95% CI: 30-36%), respectively, with p<0.0001. This represents an 89% improvement over baseline. Subgroup analysis of practice setting, clinical experience, and comfort level with written English and computers showed that all subgroups equivalently improved their test scores.

CONCLUSION

After brief training, Vietnamese physicians can effectively use an English-based CDS software based on improved performance on a written clinical exam. Given this rapid improvement, CDS technologies may serve as a transformative tool in resource-poor environments.

Role of sirtuins in stem cell differentiation

Sirtuins play an essential role in the cellular response to environmental stress, promoting DNA repair, telomere stability, cell cycle arrest, cellular senescence, and apoptosis. Much attention has been given to the role of sirtuins in aging and cancer development; however, less is known about their role in stem cell regulation. This review focuses in this topic and discusses the possible implications in adult stem cell aging.

Fear of discovery among Latino immigrants presenting to the emergency department

OBJECTIVES

Recent legislation mandating reporting of undocumented immigrants may instill fear of discovery when they access emergency department (ED) services. The objectives of this study were to: 1) characterize the knowledge and beliefs of undocumented Latino immigrants (UDLI) about health care workers' reporting (or nonreporting) of illegal immigrants in the ED, 2) determine whether UDLI fear discovery when presenting to the ED, and 3) determine the nature and sources of this fear.

METHODS

This was a cross-sectional study of UDLI and two comparison groups conducted in two California county EDs, from November 2009 to August 2010. The authors interviewed a convenience sample of adult UDLI, Latino legal residents (LLR), and non-Latino legal residents (NLLR) using a structured instrument in their native language. The main outcome was fear of discovery among UDLI and the sources of that fear.

RESULTS

Of 1,224 patients approached, 1,007 (82.3%) were interviewed: 314 UDLI, 373 LLR, and 320 NLLR. The median age was 43 years (interquartile range [IQR] = 31 to 55 years), and 51% were male. UDLIs were less likely to speak English (14%, 95% confidence interval [CI] = 10% to 18%), have health insurance (39%, 95% CI 32% to 44%), or have a regular primary care provider (PCP; 39%, 95% CI = 34% to 45%), compared to LLR (English 56%, 95% CI = 51% to 61%; health insurance 50%, 95% CI = 45% to 55%; regular PCP 51%, 95% = CI 46% to 57%) and NLLR (English 95%, 95% CI = 92% to 97%; health insurance 49%, 95% CI = 43% to 54%; regular PCP 51%, 95% CI = 45% to 56%). Of the 16% of UDLI who stated that nurses and doctors treat undocumented immigrant patients differently than citizens, 41% (95% CI = 29% to 54%) reported less respect given to UDLI by staff. Thirty-two percent of UDLI had heard of Proposition 187, 13% believed hospital staff reported UDLI to immigration authorities, and 9% said they were asked about their citizenship status. Fear of coming to the hospital because of discovery was expressed by 12% (95% CI = 9% to 16%) of UDLI, with 42% (95% CI = 28% to 58%) citing discussions with friends/family, 32% (95% CI = 19% to 47%) citing media and 16% (95% CI = 7% to 30%) citing both as sources of this fear.

CONCLUSIONS

One in eight of UDLI presenting to the ED express fear of discovery and consequent deportation. Belief that medical staff report UDLI and recent immigration are risk factors for this fear. Family, friends, and media are the primary sources of these concerns.

Accuracy of the initial diagnosis among patients with an acutely altered mental status

OBJECTIVES

The objectives of this prospective observational study were to: (1) determine the accuracy of physician diagnosis in patients with an acutely altered mental status (AMS) within the first 20 min of emergency department (ED) presentation; and (2) access if physician confidence in early diagnosis correlates with accuracy of diagnosis.

METHODS

A prospective observational convenience study was conducted of 112 adult patients who presented to an urban county ED with AMS (Glasgow Coma Scale (GCS) score ≤14) between August 2008 and July 2009. Within the first 20 min of patient presentation to the ED, treating physicians were asked to record their best diagnostic guess of the cause of the patient's AMS and their confidence in this diagnosis. Serial hourly GCS was performed and the results of all diagnostic testing were recorded. Blinded investigators determined the final consensus diagnostic cause of the patient's AMS.

RESULTS

The final consensus diagnoses for AMS aetiologies were as follows: isolated alcohol intoxication 31%, other (psychotic episodes, underlying dementia) 21%, combination alcohol/other drug intoxications 18%, isolated other drug intoxications 10%, other metabolic derangements 6%, cerebrovascular accident/transient ischaemic attack 4%, seizures/post-ictal states 4%, traumatic brain injuries 3%, isolated opiate intoxications 2%, isolated benzodiazepine intoxication 1% and septic episode 1%. The emergency physician's initial diagnosis of the AMS patient correlated with the accuracy of the final diagnosis (r(2)=0.807). The quintiles of confidence of diagnosis were: 0-20% degree of confidence had a 33% diagnostic accuracy, 21-40% had 25% accuracy, 41-60% had 43% accuracy, 61-80% had 52% accuracy and those with 81-100% confidence of initial diagnosis had 78% accuracy. Of the 106 patients with an initial diagnosis, 52 (51%) had a head CT performed, with eight (8%) having an acute abnormality.

DISCUSSION

Early diagnoses of AMS patients are moderately accurate. Few early misdiagnoses of AMS patients were clinically relevant. Physicians' greater degree of confidence in their diagnosis correlated with greater accuracy.

Aberrant epigenetic regulation of bromodomain BRD4 in human colon cancer

The bromodomain protein BRD4 is involved in cell proliferation and cell cycle progression, primarily through its role in acetylated chromatin-dependent regulation of transcription at targeted loci. Here, we show that BRD4 is frequently downregulated by aberrant promoter hypermethylation in human colon cancer cell lines and primary tumors. Ectopic re-expression of BRD4 in these colon cancer cell lines markedly reduced in vivo tumor growth, suggesting a role of BRD4 in human colon cancer.

Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments

BACKGROUND

Although they infrequently lead to management changing diagnoses, chest x-rays (CXRs) are the most commonly ordered imaging study in blunt trauma evaluation.

OBJECTIVES

To determine: 1) the reasons physicians order chest X-ray studies (CXRs) in blunt trauma assessments; 2) what injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low likelihood of injury on CXR.

METHODS

At a Level I Trauma Center, we asked resident and attending physicians treating adult blunt trauma patients: 1) the primary reason(s) for getting CXRs; 2) what, if any, significant intrathoracic injuries (SITI) they expected CXRs to reveal; and 3) the likelihood of these injuries. An expert panel defined SITI as two or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings.

RESULTS

There were 484 patient encounters analyzed--65% of participating physicians were residents and 35% were attendings; 16 (3.3%) patients had SITI. The most common reasons for ordering CXRs were: "enough concern for significant injury" (62.9%) and belief that CXR is a "standard part of trauma work-up" (24.8%). Residents were more likely than attendings to cite "standard trauma work-up" (mean difference = 13.5%, p = 0.003). When physicians estimated a < 10% likelihood of SITI on CXR, 2.1% (95% confidence interval [CI] 1.0-4.1%) of patients had SITI; when they predicted a 10-25% likelihood, 5.7% (95% CI 1.2-15.7%) had SITI; and when they predicted a > 25% likelihood, 9.1% (95% CI 3.0-20.0%) had SITI.

CONCLUSIONS

Physicians order CXRs in blunt trauma patients because they expect to find injuries and believe that CXRs are part of a "standard" work-up. Providers commonly do not expect CXRs to reveal SITI. When providers estimated low likelihood of SITI, the rate of SITI was very low.

Cost-effectiveness of targeted human immunodeficiency virus screening in an urban emergency department

OBJECTIVES

Although targeted screening of patients at high risk for human immunodeficiency virus (HIV) infection in the emergency department (ED) improves patient outcomes and may prevent HIV transmission, ED-based screening programs incur additional costs and have thus not been widely scaled up. The objective of this study was to evaluate the cost-effectiveness of ED-based targeted HIV screening as implemented in actual practice.

METHODS

This was a cost-utility analysis of a rapid HIV screening program in an urban ED. Physicians were encouraged to screen patients undergoing inpatient admission or who had HIV risk factors. The authors measured costs directly and estimated quality-adjusted life expectancy using chart review, literature assumptions, and mathematical modeling. Incremental cost utility was evaluated from a societal perspective using a lifetime time horizon.

RESULTS

From June 2008 through September 2009, a total of 3,766 HIV tests were ordered (235 tests per month), of which an estimated 2,406 (64%) represented screening in patients without HIV-related signs or symptoms. Nineteen (0.8%) patients were newly diagnosed through screening during the study period, of whom nine (47%) were eligible for antiretroviral therapy (ART) and maintained consistent outpatient follow-up. Estimated screening costs were $82,300 per year, or $45.53 per screening test, of which $28.01 (62%) was for program management. Targeted screening prevented an estimated 2.1 HIV transmission events over 16 months. Per patient screened, targeted screening saved $112 (95% uncertainty range [UR] = $20 to $225) and resulted in 2.71 quality-adjusted life-days gained (95% UR = 1.71 to 4.01). Cost-utility was most sensitive to the prevalence of undiagnosed HIV in the screened population.

CONCLUSIONS

Targeted HIV screening, as implemented in an urban ED, is cost saving and increases quality-adjusted life expectancy.

Hand-off education and evaluation: piloting the observed simulated hand-off experience (OSHE)

AIM

The Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students' sign-out skills using a real-time assessment tool, the Hand-off CEX.

SETTING

Thirty-two 4th year medical students participated as part of an elective course.

PROGRAM DESCRIPTION

One week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video.

PROGRAM EVALUATION

Internal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the "Mini-CEX," which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre- and post-student self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4-9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post- vs. 27% pre-reporting 'well-prepared,' p<0.009).

DISCUSSION

This brief, standardized hand-off training exercise improved students' confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s11606-009-1170-y) contains supplementary material, which is available to authorized users.