Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall

STUDY OBJECTIVE

Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies.

METHODS

This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up.

RESULTS

Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension.

CONCLUSION

Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma

BACKGROUND

Although clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging.

OBJECTIVE

This study evaluated risk factors and outcomes of geriatric patients with uncertain head injury.

METHODS

This prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15.

RESULTS

We enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67-13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67-13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15-12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24-1.99), alcohol use (OR 1.62; 95% CI 1.25-2.09), antiplatelet use (OR 1.84; 95% CI 1.46-2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54-4.13). Patients with uncertain trauma had no characteristics associated with increased ICH.

CONCLUSIONS

Although ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

The Laboratory Characterization of Fugitive Aerosol Emissions From a Standard Jet Nebulizer With and Without a Filtered Mouthpiece

Background and objective The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission from patients with coronavirus disease 2019 (COVID-19) during nebulization is unclear. In this study, we aimed to address this issue. Methods Fugitive emissions of aerosolized saline during nebulization were observed using a standard jet nebulizer fitted with unfiltered and filtered mouthpieces connected via a mannequin to a breathing simulator. Fugitive emissions were observed by using a laser sheet and captured on high-definition video, and they were measured by using optical particle counters positioned where a potential caregiver may be administering nebulization and three other locations in the sagittal plane at various distances downstream of the mannequin. Results The use of a standard unfiltered mouthpiece resulted in significant emission of fugitive aerosols ahead of and above the mannequin (spread over 2 m in front). A mouthpiece with a filter-adaptor effectively suppressed the emissions, with only minor leakage from the nebulizer cup. Particle count measurements supported the visual observations, providing total particle count levels and aerosol concentration levels at the measurement locations. The levels decayed slowly with downstream distance. Conclusions The visualization described above captured the dispersion of emitted aerosols in the plane of the laser sheet, aligned with the sagittal plane. The particle count measurements provided temporal and spatial distributions of the aerosol concentration levels over the time and locations considered. However, the exhaled air and aerosolized droplets spread three-dimensionally in front of and above the mannequin. The results visually highlight the effectiveness of using a filtered mouthpiece in suppressing the fugitive aerosols and identify an approach for limiting the occupational exposure of healthcare workers to these emissions while administering nebulized therapies.

Repeat Fall Risk in Geriatric Patients After Fall-Induced Head Trauma

Introduction There are many known risk factors for falls, with poor health and physiologic decreases in function as the major contributors to fall risk in older adults. However, risk factors for repeat falls after initial ED discharge are not well-described. This study seeks to prospectively investigate risk factors for short-term repeat falls in geriatric ED patients with fall-related head trauma who do not require hospital admission. Methods This is a prospective study of patients aged 65 years and older with fall-related head trauma who presented to the EDs of two community level I trauma centers. Patients were excluded for intracerebral hemorrhage, admission during initial ED visit, or death in the hospital. Patients were followed for 14 days. Patient characteristics, repeat ED visits, and reason for returns were noted. Results About 2,143 patients were identified as meeting the inclusion criteria. Within 14 days of the initial presentation, 14.1% of patients returned to the ED, with 8.3% presenting with a complaint related to the initial trauma and 2.6% with a new injury. Patients with comorbidities of dementia (OR 3.02, 95% CI, 1.72-5.33, p<0.001), stroke (OR 2.12, 95% CI, 1.05-4.27, p=0.031), and smoking (OR 4.27, 95% CI,1.76-10.37, p<0.001) were significantly more likely to sustain a new injury leading to a repeat ED visit within 14 days. Conclusions After an ED visit due to a fall, over one in 10 patients will re-present to the ED due to a new injury or sequelae from the initial fall. In the immediate period after a fall, enhanced outpatient follow-up or risk mitigation strategies should be considered to lessen return visits and decrease morbidity.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness

Objective

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients.

Methods

This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention.

Results

Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation.

Conclusion

Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Sudden Decompensation of Patients Admitted to Non-ICU Settings Within 24 h of Emergency Department Admission

BACKGROUND

Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics.

METHODS

This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not.

RESULTS

Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p  =  0.023) and dyspnea (70.6% vs 29.4%, p  =  0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p  =  0.010) or hypertension (9.1% vs 0%, p  =  0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p  =  0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p  =  0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found.

CONCLUSIONS

Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.

Launching a Teaching Academy (Virtually) During a Pandemic: Silver Linings to a Challenge

The pandemic disrupted our plans to launch a Teaching Academy to formally support medical educators. Moving forward virtually provided a collaborative and supportive network to plan and deliver professional development activities to navigate pandemic challenges. Through sharing and practicing new teaching technologies together, the social connection and engagement with colleagues helped navigate pandemic challenges.

A Simulation-based PPE orientation training curriculum for novice physicians

Background

Personal protective equipment (PPE) is effective in preventing coronavirus disease (COVID-19) infection. Resident knowledge of proper use and effective training methods is unknown. We hypothesise that contamination decreases and knowledge increases after a formalised PPE educational session.

Methods

Participants included first year interns during their residency orientation in June 2020. Before training, participants took a knowledge test, donned PPE, performed a simulated resuscitation, and doffed. A standardised simulation-based PPE training of the donning and doffing protocol was conducted, and the process repeated. Topical non-toxic highlighter tracing fluid was applied to manikins prior to each simulation. After doffing, areas of contamination, defined as discrete fluorescent areas on participants' body, was evaluated by ultraviolet light. Donning and doffing were video recorded and asynchronously rated by two emergency medicine (EM) physicians using a modified Centers for Disease Control and Prevention (CDC) protocol. The primary outcome was PPE training effectiveness defined by contamination and adherence to CDC sequence.

Results

Forty-eight residents participated: 24 internal medicine, 12 general surgery, 6 EM, 3 neurology, and 3 psychiatry. Before training, 81% of residents were contaminated after doffing; 17% were contaminated after training (P<0.001). The most common contamination area was the wrist (50% pre-training vs. 10% post-training, P<0.001). Donning sequence adherence improved (52% vs. 98%, P<0.001), as did doffing (46% vs. 85%, P<0.001). Participant knowledge improved (62%-87%, P <0.001). Participant confidence (P<0.001) and preparedness (P<0.001) regarding using PPE increased with training.

Conclusion

A simulation-based training improved resident knowledge and performance using PPE.

Comparing rates of skull fractures in female versus male geriatric patients who sustain head injuries

BACKGROUND

Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. This study aims to evaluate the role of sex in the risk of skull fracture in patients over the age of 65.

METHODS

A prospective cohort study was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents. Over a year-long period, consecutive patients aged 65 years and older who presented with blunt head injury were included. Patients who did not receive head CT imaging were excluded. The primary outcome was rate of skull fracture due to the acute trauma, compared by sex. Additional factors examined included patient race/ethnicity and mechanism of injury.

RESULTS

Among 5402 patients enrolled, 3010 (56%) were female and 2392 (44%) were male. 4612 (85%) of the head injuries sustained were due to falls, and 4536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2-2.1, p = 0.002). This trend was also seen across race/ethnicity and mechanism of injury.

CONCLUSIONS

Older males were found to have a higher rate of skull fractures compared to females after sustaining blunt head trauma, mostly due to falls.

Pelvic Exam Laws in the United States: A Systematic Review

Laws regulating patient care are an essential component of protecting patients and doctors alike. No studies have previously examined what laws exist regarding pelvic examinations in the United States (US). This study systematically reviews and compares regulation and legislation of pelvic examinations in the U.S. and provides a comprehensive resource to educate clinicians, patients, and lawmakers. Each of the fifty States in the U.S. was included. The primary outcome was existence of any pelvic or rectal exam laws. Data was obtained for the type of examination defined within the law, exceptions to the law, to whom the law applied to, the type of consent required, and to whom the consent applied to. Laws were identified from each of the individual state legislative websites. All sections of each law pertaining to pelvic examination were reviewed and organized by state. Descriptive statistics were performed for each of the variables, including frequencies of each amongst the fifty states. State regulation for pelvic examinations varied from no law or regulation to laws pertaining to pelvic, rectal, prostate, and breast examination performed in any context. As of November 22, 2022, there are twenty states (40%) with pelvic examination laws applying to anesthetized or unconscious patients. Thirteen additional states (26%) have proposed pelvic exam laws. Seventeen states (34%) do not have any laws regarding pelvic examinations. Regulation of pelvic examinations has become an increasingly important issue over the past few years in response to growing concerns of patient autonomy and the ethical issues raised by such sensitive examinations. While pelvic examination laws that balance protection for patient autonomy and the needs of caregivers and educators exist in much of the U.S., more work needs to continue in consultation with physicians and health care providers to ensure that all states have reasonable laws protecting the autonomy of patients while also maintaining quality of care.

Impact of COVID-19 on emergency medicine resident procedure performance

BACKGROUND

As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic.

METHODS

This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February.

RESULTS

A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001).

CONCLUSIONS

The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.

The Role of Thromboelastography in Identifying Coagulopathy Among Geriatric Traumatic Brain Injury Patients

Background The geriatric population has the highest incidence of head injury, and those who are anticoagulated have an increased risk of traumatic intracranial hemorrhage (ICH). The availability of viscoelastic coagulation studies has coincided with the development of many anticoagulation reversal agents. In this study, our objective was to assess whether the thromboelastography (TEG) assay affected clinical decision-making regarding reversal agent administration among geriatric patients with ICH caused by blunt head trauma. Methodology We prospectively screened adults aged 65 and older with head trauma presenting to the emergency departments of two level-one trauma centers. International Classification of Diseases, Tenth Revision codes S00-09 were used to identify the diagnosis of head injury. Patients with CT head imaging positive for acute ICH were included. Each patient was assessed for home use of antiplatelet or anticoagulant medications, as well as in-hospital use of any reversal agents. Reversal agent administration and mortality were compared between patients who received TEG and those who did not. Results A total of 680 patients had acute ICH on head CT, and 324 (48%) patients received TEG. More patients screened with TEG were transfused platelets (30.2% vs. 10.7%, p < 0.001). This remained significant for patients taking anticoagulants, antiplatelets, or neither. There were no differences in the administration of other reversal agents (prothrombin complex concentrate or fresh frozen plasma) or mortality whether or not TEG was performed. Conclusions Patients who had TEG performed were more likely to receive platelet reversal agents, regardless of antiplatelet medication usage. Among elderly adults with ICH, TEG is a rapid screening test that may help identify patients with platelet function abnormalities requiring reversal.

The Treatment of COVID-19 With Monoclonal Antibody Therapy: Patient-Reported Outcomes

Objective

There have been many efforts to research and produce treatment modalities for COVID-19. Monoclonal antibodies have been one of the effective treatments since their approval by the US Food and Drug Administration (FDA) under emergency use authorization (EUA) in 2020. This study surveyed COVID-19 patients about their disease course and experience with monoclonal antibody treatment.

Methods

Patients who received monoclonal antibody treatment between February 12, 2021, and June 2, 2021, at a South Florida community hospital were enrolled in the study. This included patients over 18 years of age with a confirmed positive COVID-19 test result, with mild to moderate symptoms within 10 days of onset and identified as high risk for progression to severe disease. There were no exclusion criteria. After 30 days, patients were followed up via a structured telephone survey regarding subsequent emergency department (ED) visits for worsening COVID-19 symptoms, need for oxygenation, intubation, and death. Secondary outcomes were adverse effects and patient perceptions.

Results

Among the 119 patients who received monoclonal antibodies during the established time frame, 93 (78.1%) consented to participate in the telephone survey. Of these, 11.8% had a subsequent visit to the ED for worsening COVID-19 symptoms, 6.5% required oxygen, and 2.2% were admitted to the intensive care unit (ICU). There were no reported intubations or deaths. The vast majority (91.4%) would recommend monoclonal antibody treatment to others.

Conclusion

Patients who received monoclonal antibody therapy had low rates of subsequent ED visits and rarely required oxygen or ICU admission. The majority of patients would recommend treatment with monoclonal antibodies to others.

Fear Not: Utilizing Simulation for Medical Malpractice Education

INTRODUCTION

Medical malpractice payouts across specialties totaled over $4.03 billion USD in 2019. It is estimated that over 72% of Emergency Medicine (EM) physicians will be involved in a medical malpractice lawsuit by age 55. The majority of EM residencies do not include adequate education on medicolegal risk mitigation and litigation. The purpose of the study is implementation of an innovative interprofessional simulation to target this education gap.

METHODS

An anonymous pre- and post-survey was distributed to participating EM providers electronically. The surveys evaluated baseline medicolegal knowledge, self-rated deposition comfort and concern regarding malpractice litigation. The simulation event involved an interactive lecture on basic tenets of medical malpractice and state legal statutes from medicolegal experts. Resident physician volunteers acted as defendant physicians during simulated depositions using a redacted, closed malpractice case.

RESULTS

Eighty EM providers attended the event over two days. All attendees completed the pre-survey (80/80), and 66.3% (53/80) completed the post-survey. The majority incorrectly answered 4 of 5 medicolegal questions. The mean comfort level regarding being deposed is 1.53 ± 0.94 on a 1-5 Likert scale (extremely uncomfortable to extremely comfortable); the mean level of concern/fear of malpractice litigation is 3.38 ± 0.95 on a 1-5 Likert scale (not at all to extremely concerned). There was a statistically significant increase in deposition comfort level post-event (1.83, P < .01).

CONCLUSION

The majority of EM physicians are inexperienced and concerned regarding litigation. After participating in an educational event and observing a simulated deposition, physicians reported an increased comfort level regarding being deposed in the future.

Age adjusted D-dimer cutoffs for pulmonary embolism in a geriatric population utilizing a D-dimer unit assay

BACKGROUND

Age adjusted serum d-dimer (AADD) with clinical decision rules have been utilized to rule out pulmonary embolism (PE) in low-risk patients; however, its use in the geriatric population has been questioned and the use of d-dimer unit (DDU) assay is uncommon.

OBJECTIVE

The present study aims to compare the test characteristics of the AADD (age × 5) measured in DDU with the standard cutoff (DDU < 250) and study hospital laboratory's d-dimer cutoff (DDU < 600) in geriatric patients presenting with suspected PE.

METHODS

This retrospective study enrolled patients ≥65 years old with suspected PE and d-dimer performed between January 1, 2019 and December 31, 2019 who presented to the emergency department (ED). Charts were reviewed for CTA chest and ventilation perfusion imaging results for PE. Diagnostic parameters for each cutoff were calculated for the primary outcome.

RESULTS

510 patients were included, 20 with PE. There was no significant difference between the sensitivities of AADD (100%, 95% CI: 80-100), standard cutoff (100%, 95% CI: 80-100), and hospital cutoff (90%, 95% CI: 66.9-98.2). The hospital cutoff specificity (22.7%, 95% CI: 17.1-29.3) was significantly greater than the AADD (13.4%, 95% CI: 9.1-19.2) and standard cutoff (10.8%, 95% CI: 7.0-16.3) specificities.

CONCLUSIONS

In geriatric patients presenting to the ED with suspected PE, the AADD measured in DDUs maintained sensitivity with improved specificity compared to standard cutoff. In this population, the AADD would have safely reduced imaging by 19% without missing any PEs. AADD remains a valid tool with high sensitivity and negative predictive value in ruling out PE in geriatric patients.

Mortality in Pulmonary Embolism According to Risk Category at Presentation in Emergency Department: Impact of Cardiac Arrest

In this investigation we explore whether assessment of the risk of mortality can be refined by stratifying high-risk patients with pulmonary embolism (PE) according to whether they had cardiac arrest. We stratified high-risk patients according to whether they had shock but no cardiac arrest, or cardiac arrest diagnosed in the emergency department (ED). This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample (NEDS), 2016. Included patients were 274,227 who were admitted to the same hospital as the ED or died in the ED. This was 77% of 354,616 patients with pulmonary embolism seen in the ED in 2016. Patients were identified based on International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) Codes. High-risk with no cardiac arrest were 4,317 of 274,227 (1.6%) and high-risk with cardiac arrest were 1,027 of 274,227 (0.4%). Mortality of high-risk patients who did not have cardiac arrest was 1,753 of 4,317 (41%). Mortality of high-risk patients who had cardiac arrest was 754 of 1027 (74%). Mortality increased with age in high-risk patients who did not have cardiac arrest, but mortality was not age-related in high-risk patients with cardiac arrest. In conclusion, high-risk patients with PE are a heterogeneous group and stratification according to whether they had cardiac arrest refines risk assessment.

Acute and Delayed Intracranial Hemorrhage in Head-Injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy

INTRODUCTION

Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies.

METHODS

A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH.

RESULTS

Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56-1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84-5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10-2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27-3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention.

CONCLUSION

Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.

Supporting the Quadruple Aim Using Simulation and Human Factors During COVID-19 Care

The health care sector has made radical changes to hospital operations and care delivery in response to the coronavirus disease (COVID-19) pandemic. This article examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the COVID-19 era. First, patient safety is enhanced through development and testing of new technologies, equipment, and protocols using laboratory-based and in situ simulation. Second, population health is strengthened through virtual platforms that deliver telehealth and remote simulation that ensure readiness for personnel to deploy to new clinical units. Third, prevention of lost revenue occurs through usability testing of equipment and computer-based simulations to predict system performance and resilience. Finally, simulation supports health worker wellness and satisfaction by identifying optimal work conditions that maximize productivity while protecting staff through preparedness training. Leveraging simulation and human factors will support a resilient and sustainable response to the pandemic in a transformed health care landscape.

Disaster Day: A Simulation-Based Disaster Medicine Curriculum for Novice Learners

BACKGROUND

Mass casualty and multi-victim incidents have increased in recent years due to a number of factors including natural disasters and terrorism. The Association of American Medical Colleges (AAMC) recommends that medical students be trained in disaster preparedness and response. However, a majority of United States medical students are not provided such education.

OBJECTIVE

The goal of this study was to evaluate the effectiveness of a 1 day, immersive, simulation-based Disaster Day curriculum.

SETTINGS AND DESIGN

Learners were first and second year medical students from a single institution.

MATERIALS AND METHODS

Our education provided learners with information on disaster management, allowed for application of this knowledge with hands-on skill stations, and culminated in near full-scale simulation where learners could evaluate the knowledge and skills they had acquired.

STATISTICAL ANALYSIS USED

To study the effectiveness of our Disaster Day curriculum, we conducted a single-group pretest-posttest and paired analysis of self-reported confidence data.

RESULTS

A total of 40 first and second year medical students participated in Disaster Day as learners. Learners strongly agreed that this course provided new information or provided clarity on previous training, and they intended to use what they learned, 97.6% and 88.4%, respectively.

CONCLUSIONS

Medical students' self-reported confidence of key disaster management concepts including victim triage, tourniquet application, and incident command improved after a simulation-based disaster curriculum. This Disaster Day curriculum provides students the ability to apply concepts learned in the classroom and better understand the real-life difficulties experienced in a resource limited environment.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness

OBJECTIVE

We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States.

METHODS

We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network.

RESULTS

We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%).

CONCLUSIONS

This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic

BACKGROUND

The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections.

AIM

To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.

METHODS

A cross-sectional multi-center national survey of PICU medical director(s) from children’s hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation.

RESULTS

We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children’s hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives.

CONCLUSIONS

A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.

Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

Background

Antiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.

Methods

A retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.

Results

Of 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.

Conclusions

Patients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.

Level of evidence

Level III, prognostic.

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners' confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the "right way." The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

Adjunctive Therapy and Mortality in Patients With Unstable Pulmonary Embolism

Mortality with adjunctive therapy in patients with unstable pulmonary embolism, defined as those in shock or on ventilator support, is sparsely studied and requires further investigation. This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016. In-hospital all-cause mortality in unstable patients with acute pulmonary embolism was assessed according to treatment. Patients were identified by International Classification of Diseases-10-Clinical Modification Codes. Most unstable patients, 85%, received only anticoagulants. Their mortality was 3,080 of 6,635 (46%) without an inferior vena cava (IVC) filter, and mortality was much less with an IVC filter, 285 of 1,185 (24%) (p <0.0001). Mortality with catheter-directed thrombolysis alone, 70 of 235 (30%), did not differ significantly from mortality with anticoagulants plus an IVC filter, p = 0.07, although a trend favored the latter. Intravenous thrombolytic therapy without an IVC filter showed a mortality of 295 of 695 (42%) which tended to be lower than mortality with anticoagulants alone (p = 0.06). The addition of an IVC filter to intravenous thrombolytic therapy resulted in a mortality of 20 of 165 (12%), which was the lowest mortality with any combination of adjunctive treatments. Intravenous thrombolytic therapy, however, was associated with more adverse effects of therapy than catheter-directed thrombolysis or anticoagulants.

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine

OBJECTIVES

Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.

METHODS

The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.

RESULTS AND ANALYSIS

Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.

CONCLUSIONS/IMPLICATIONS FOR EDUCATORS

We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.

Ancillary Findings on CT Pulmonary Angiograms that are Negative for Pulmonary Embolism

CONTEXT

One advantage of computed tomographic pulmonary angiograms (CTPA) is that they often show pathology in patients in whom pulmonary embolism (PE) has been excluded. In this investigation, we identified the ancillary findings on CTPAs that were negative for PE to obtain an impression of the type of findings shown.

METHODS

This was a retrospective analysis of findings on CTPAs that were negative for PE obtained in nine emergency departments between January 2016 - February 2018. Ancillary findings were assessed by review of the radiographic reports.

RESULTS

Ancillary findings were identified in N=338 (40.9%) of 825 patients with CTPAs that were negative for PE. Most ancillary findings, 254 (75.1%) of 338 were pulmonary or pleural abnormalities. Liver, gall bladder, kidney, or pancreatic abnormalities were shown in 26 (7.7%) cases, and abnormalities of the heart or great vessels were shown in 23 (6.8%) of cases. Abnormalities of the esophagus or intestine were shown in 12 (3.6%), abnormalities of the thyroid in 10 (3.0%) and abnormalities of bone or soft tissue lesions were shown in three (0.9%) cases. Inferential statistical procedures demonstrated that the occurrence of ancillary findings in patients with negative CTPAs was proportionately greater in patients who were 50 years and older (p < 0.001), although not between genders (p = 0.145).

CONCLUSIONS

Ancillary findings on CTPAs that were negative for PE were frequently reported. Future studies might focus of the extent to which ancillary findings on CTPA assisted physicians in management of the patient.

Advanced closed-loop communication training: the blindfolded resuscitation

Closed-loop communication (CLC) improves task efficiency and decreases medical errors; however, limited literature on strategies to improve real-time use exist. The primary objective was whether blindfolding a resuscitation leader was effective to improve crisis resource management (CRM) skills, as measured by increased frequency of CLC. Secondary objectives included whether blindfolding affected overall CRM performance or perceived task load. Participants included emergency medicine (EM) or EM/paediatric dual resident physicians. Participants completed presurveys, were block randomised into intervention (blindfolded) or control groups, lead both adult and paediatric resuscitations and completed postsurveys before debriefing. Video recordings of the simulations were reviewed by simulation fellowship-trained EM physicians and rated using the Ottawa CRM Global Rating Scale (GRS). Frequency of CLC was assessed by one rater via video review. Summary statistics were performed. Intraclass correlation coefficient was calculated. Data were analysed using R program for analysis of variance and regression analysis. There were no significant differences between intervention and control groups in any Ottawa CRM GRS category. Postgraduate year (PGY) significantly impacts all Ottawa GRS categories. Frequency of CLC use significantly increased in the blindfolded group (31.7, 95% CI 29.34 to 34.1) vs the non-blindfolded group (24.6, 95% CI 21.5 to 27.7). Participant’s self-rated perceived NASA Task Load Index scores demonstrated no difference between intervention and control groups via a Wilcoxon rank sum test. Blindfolding the resuscitation leader significantly increases frequency of CLC. The blindfold code training exercise is an advanced technique that may increase the use of CLC.

Iatrogenic Critical Care Procedure Complication Boot Camp: A Simulation-based Pilot Study

BACKGROUND

Traditional medical education strategies teach learners how to correctly perform procedures while neglecting to provide formal training on iatrogenic error management. Error management training (EMT) requires active exploration as well as explicit encouragement for learners to make and learn from errors during training. Simulation provides an excellent methodology to execute a curriculum on iatrogenic procedural complication management. We hypothesize that a standardized simulation-based EMT curriculum will improve learner's confidence, cognitive knowledge, and performance in iatrogenic injury management.

METHODS

This was a pilot, prospective, observational study performed in a simulation center using a curriculum developed to educate resident physicians on iatrogenic procedural complication management. Pre- and postintervention assessments included confidence surveys, cognitive questionnaires, and critical action checklists for six simulated procedure complications. Assessment data were analyzed using medians and interquartile ranges (IQRs), and the paired change scores were tested for median equality to zero via Wilcoxon signed rank tests with p < 0.05 considered statistically significant.

RESULTS

Eighteen residents participated in the study curriculum. The median (IQR) confidence increased significantly by a summed score of 12.5 (8.75-17.25; p < 0.001). Similarly, the median (IQR) knowledge significantly increased by 6 (3-8) points from the pre- to postintervention assessment (p < 0.001). For each of the simulation cases, the number of critical actions performed increased significantly (p < 0.001 to p = 0.002).

CONCLUSION

We demonstrated significant improvement in the confidence, clinical knowledge, and performance of critical actions after the completion of this curriculum. This pilot study provides evidence that a structured EMT curriculum is an effective method to teach management of iatrogenic injuries.

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies

PURPOSE

The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED).

DESIGN/METHODOLOGY/APPROACH

A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications.

FINDINGS

This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries.

ORIGINALITY/VALUE

Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

Evaluation of Technical Competency in Healthcare Simulation (E-TeCHS) tool: a modified Delphi study

Background

Graduates of simulation fellowship programmes are expected to have the ability to perform a variety of simulation specific skills at the time of graduation. Currently, simulation fellowship directors have access to tools to assess the ability of a fellow to debrief learners. However, there is no tool to assess a simulation fellow’s competency in technical skills. The purpose of our manuscript was to develop and obtain content validation of a novel instrument designed to assess a simulation fellow’s ability to perform the five core simulation technical skills.

Methods

The study protocol was based on a methodology for content validation of curriculum consensus guidelines. This approach involves a three-step process, which includes the initial delineation of the curricular content. This was then followed by the validation of the curricular content using survey methodology and lastly obtaining consensus on modifications using Delphi methodology.

Results

Two rounds of modified Delphi methodology were performed. Seventy-four respondents provided feedback on the round 1 survey and 45 respondents provided feedback on round 2. The final assessment tool has five elements and 16 subitems with four optional subitems.

Conclusion

The Evaluation of Technical Competency in Healthcare Simulation tool provides an instrument developed from a national consensus of content experts. This tool provides simulation fellowship directors a method to evaluate fellows’ competency in technical skills.

Pacemaker-associated Phlegmasia Cerulea Dolens Treated with Catheter-directed Thrombolysis

Phlegmasia cerulea dolens (PCD) is a rare and severe form of deep venous thrombosis that is classically associated with the lower extremities. We report a case of upper extremity PCD developing abruptly in a 37-year-old female with an indwelling cardiac pacemaker who presented to the emergency department complaining of pain and paresthesias in her left arm, adjoining left chest wall, and inferior neck. Her condition was promptly diagnosed and successfully treated with intravenous unfractionated heparin and balloon venoplasty with catheter-directed thrombolysis without any known residual signs or symptoms at hospital discharge.

Sleep and Lifestyle Habits of Osteopathic Emergency Medicine Residents During Training

Context

Duty hours were enacted in 2003 with the intent to improve patient safety and resident well-being. However, limited data exist regarding improvements in residents’ well-being since the implementation of these restrictions.

Objective

To examine osteopathic emergency medicine (EM) resident characteristics regarding sleep and lifestyle habits and duty hour reporting.

Method

A convenience sample of osteopathic EM residents was surveyed at a statewide conference in May 2014. The conference included 177 residents from 15 osteopathic EM residencies. Data regarding demographics, sleep and lifestyle habits (including work-related motor vehicle incidents [MVIs] and chemical aid use for sleep/wakefulness), and duty hour reporting were collected. The Epworth Sleepiness Scale (ESS) score was calculated, with a score greater than 10 indicating sleep disturbance.

Results

Of the 128 residents (72%) who returned the survey, approximately two-thirds were female, were currently on an EM rotation, and were training in suburban emergency departments with more than 60,000 annual visits. Only 35% of respondents slept 8 or more hours per night during an EM rotation, and 63% admitted to weight change during residency. Forty-two percent of respondents had a work-related MVI, which was more likely to occur if their ESS score was greater than 11 (P<.03). Mean (SD) ESS score was 9.9 (4.8; range, 0-24). Respondents reported using chemical aids for staying awake or going to sleep on a mean (SD) of 6.9 (9.3) days per month (range, 0-30). The majority of respondents (84%) reported strict duty hour enforcement policies, few (17%) had ever been asked to falsify reports, and more than half (56%) had ever voluntarily reported false hours.

Conclusion

Most residents surveyed slept fewer than 8 hours per night and had a weight change during EM residency training. The majority of residents used a chemical aid for sleep or wakefulness. Nearly half of residents surveyed met criteria for disordered sleep, which was associated with a higher occurrence of MVIs.

Development, Validation, and Implementation of a Medical Judgment Metric

Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss’s Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen’s Kappa 0.851 to 0.880). Discussion: The MJM demonstrated preliminary evidence of reliability and validity.

Training the trainers: a survey of simulation fellowship graduates

BACKGROUND

Coupled with the expansion of simulation has been the development and growth of medical simulation fellowships. These non-accredited fellowships do not have a standardized curriculum and there are currently no studies investigating the simulation fellowship experience. The purpose of this study was to explore the simulation fellowship experience of graduates throughout North America and how it prepared them for their post-fellowship career.

METHODS

A web-based survey was developed by Emergency Medicine attending physicians both of whom completed one-year fellowships in medical simulation. Prior to distribution, the survey was reviewed and tested by three simulation fellowship graduates and a PhD researcher. Feedback was integrated into the survey prior to distribution. The survey consisted of a maximum of 29 multiple choice questions including two step-logic questions and two open response questions. The survey was distributed to simulation fellowship directors in multiple disciplines and the directors were asked to forward the survey to graduates. Additionally, the Society for Academic Emergency Medicine Simulation Academy list-serve was utilized for distribution of the survey.

RESULTS

The survey had 35 responses. The majority of respondents completed fellowship within the last two years (66%, 23/35). Fellowship graduates strongly agreed or agreed that their fellowship adequately prepared them for their post-fellowship simulation career (88%). Graduates report that research design/reporting (53%) and administration (18%) were areas of their fellowship curriculum that needed the most improvement.

CONCLUSION

The majority of simulation fellowship graduates agreed that their fellowship experience adequately prepared them for their post-fellowship simulation career. Graduates also felt that training in research and administration are areas that could be improved.

SIMULATION DIRECTORS AS IMPROVEMENT LEADERS

Physician leaders who oversee simulation labs play vital roles in the advancement of efficiency and effectiveness of their organizations.

Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants

BACKGROUND

Outpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants.

METHODS

This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014.

RESULTS

Pulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known.

CONCLUSION

Even in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.

Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study

Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: 58.9 ± 8.9 versus post: 72.8 ± 6.1, p = 0.01) and CS total scores (pre: 22.2 ± 6.4 versus post: 29.9 ± 3.4, p = 0.007). Significant differences were noted in airway management, p = 0.008; appropriate cycles of drug/shock-CPR, p = 0.008; left uterine displacement, p = 0.008; and identifying causes of cardiac arrest, p = 0.008. Nonsignificant differences were noted for administration of appropriate drugs/doses, p = 0.074; chest compressions, p = 0.074; bag-mask ventilation before intubation, p = 0.074; and return of spontaneous circulation identification, p = 0.074. Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.

Follow-up CT pulmonary angiograms in patients with acute pulmonary embolism

Computed tomographic (CT) angiography is associated with a non-negligible lifetime attributable risk of cancer. The risk is considerably greater for women and younger patients. Recognizing that there are risks from radiation, the purpose of this investigation was to assess the frequency of follow-up CT angiograms in patients with acute pulmonary embolism. This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in three emergency departments from January 2013 to December 2014. Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients. At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %). Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %). Among young women (aged ≤29 years) with pulmonary embolism, 10 of 21 (47.6 %) had at least 1 follow-up and 4 of 21 (19.0 %) had 2 or more follow-ups in 1 year. Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up. Follow-up CT angiograms were obtained in a significant proportion of patients with pulmonary embolism, including young women, the group with the highest risk. Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women.

Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories

Incorporating simulation-based medical education techniques is paramount to ongoing training of emergency physicians. Effective procedure laboratories give learners hands-on experience in life-saving procedures they may otherwise not have clinical exposure to and also prevent skill decay. Using procedural education, adult learning theory, deliberate practice, and mastery learning strategies, the authors offer 10 tips to educators for designing an effective emergency medicine procedure laboratory.

A Novel Simulation Technician Laboratory Design: Results of a Survey-Based Study

Objective 

The purpose of this study was to elicit feedback from simulation technicians prior to developing the first simulation technician-specific simulation laboratory in Akron, OH.

Background

Simulation technicians serve a vital role in simulation centers within hospitals/health centers around the world. The first simulation technician degree program in the US has been approved in Akron, OH. To satisfy the requirements of this program and to meet the needs of this special audience of learners, a customized simulation lab is essential. 

Method

A web-based survey was circulated to simulation technicians prior to completion of the lab for the new program. The survey consisted of questions aimed at identifying structural and functional design elements of a novel simulation center for the training of simulation technicians. Quantitative methods were utilized to analyze data.

Results

Over 90% of technicians (n=65) think that a lab designed explicitly for the training of technicians is novel and beneficial. Approximately 75% of respondents think that the space provided appropriate audiovisual (AV) infrastructure and space to evaluate the ability of technicians to be independent. The respondents think that the lab needed more storage space, visualization space for a large number of students, and more space in the technical/repair area.

Conclusions 

A space designed for the training of simulation technicians was considered to be beneficial. This laboratory requires distinct space for technical repair, adequate bench space for the maintenance and repair of simulators, an appropriate AV infrastructure, and space to evaluate the ability of technicians to be independent.