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108: Radiographic Imaging of Minor Pediatric Head Trauma Between General and Pediatric Emergency Physicians
ICEM 2008 Scientific Abstract Program joint American Academy of Pediatrics (AAP) and American College of Emergency Physicians (ACEP) pediatric guidelines were used to construct the equipment survey. An interview elicited previous knowledge of the AAP/ACEP guidelines and factors that influence equipment availability. Results: The 9 EDs (2 pediatric and 7 mixed adult-pediatric) had a mean census of 15,392 pediatric patients per year. EDs possessed an average of 77% (range 58%-90%) of items on the equipment list. 40% of items on the survey were possessed by all EDs. 27 items were possessed by less than 50% of EDs. No EDs possessed CO2 detection methods to monitor endotracheal tube placement and 5 of 7 sizes of laryngeal mask airways. One third of respondents were previously aware of the AAP/ACEP equipment guidelines. Perceived barriers to equipment unavailability included limited resources, length of procurement process, lack of manpower to use equipment and rarity of usage of equipment. Conclusions: The EDs studied possessed the majority of items listed by the AAP/ ACEP guidelines, although a wide variation was noted among hospitals surveyed. Most of the items missing were rarely used, expensive and/or not crucial for resuscitation. Resource constraints were the most prevalent barrier to equipment availability.
108
Radiographic Imaging of Minor Pediatric Head Trauma Between General and Pediatric Emergency Physicians
Maloy K, Sharpe R, Sharpe M, Place R/Georgetown University, Washington, DC; INOVA Fairfax Hospital, Fairfax, VA
Study Objectives: Clear criteria have not been established to precisely identify the subset of children at risk for intracranial injury (ICI) after sustaining a minor head trauma. Increased availability of computed tomography (CT) and perceptions of increasing medicolegal liability effect the threshold for ordering diagnostic imaging. The decision to obtain diagnostic imaging remains sensitive to judgment and practice style and may be influenced by training type. Our null hypothesis was that there would be no difference in head CT ordering rates by general and pediatric emergency physicians for children under two years of age. Methods: We retrospectively reviewed the charts of children under two years of age presenting to 11 hospitals within a single contract network system with ICD-9 codes suggestive of minor head trauma. Children presenting with mechanism of injury or physical exam findings suggestive of major head trauma were excluded. The primary outcome measure was an order for a head CT; utilization of skull radiographs was also recorded. Physicians were classified as pediatric emergency medicine (PEM) physicians if they had completed a pediatric emergency medicine fellowship or a dual residency (emergency medicine and pediatrics) while general emergency medicine (GEM) physicians had completed an emergency medicine residency. Imaging utilization was compared between PEM and GEM physicians. Data was analyzed by summary statistics with confidence intervals, chi square statistics, and odds ratios with 95% confidence intervals. Alpha was set at 0.05 where appropriate. Results: Four hundred forty-five charts were identified and 252 met inclusion criteria. PEM physicians saw 110 (43%) children with minor head trauma and GEM physicians saw 142 (56%). Baseline clinical features were not significantly different between analyzed groups. The rate of ICI was 1.5% (2/110) in the GEM group and 2.7% (3/110) in the PEM group and was not statistically different between groups (p ⬎ 0.05). Of children evaluated, head CT was ordered in 48% (53/110) by PEM physicians and in 30% (42/142) by GEM physicians. PEM patients were exposed to CT radiation more frequently than GEM patients, with an odds ratio of 2.21 (95% CI: 1.31-3.71). Skull radiography utilization rate was not statistically different; 4.2% (6/142) in the GEM group and 4.5% (5/110) in the PEM group (p ⬎ 0.05). Conclusion: Patients evaluated by pediatric emergency physicians were significantly more likely to receive a head CT in the evaluation of minor head trauma than patients evaluated by physicians with general emergency training. Further investigation into the reason for more aggressive diagnostic evaluation by pediatric emergency physicians is warranted.
109
Factors Influencing Self-Directed Objective Setting by Off-Service Residents in Emergency Medicine
Tenn-Lyn NA, Bandiera GW, Hodges BD, Regehr G/University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
Study Objectives: To explore and determine factors influencing the selection of emergency medicine (EM) learning objectives by off-service residents. Methods: Participants: First-year (PGY-1) residents from a variety of specialties who were about to start their EM rotation as identified their rotation by university rotation rosters.
504 Annals of Emergency Medicine
Setting: A university affiliated full service inner city academic emergency department (ED) with an annual census of 57,000 patients. Design: We circulated a form containing 30 objectives derived from a cross-section of body systems/content areas shown in a prior study to be frequently chosen, not chosen at all, or chosen with intermediate frequency by off-service residents in the emergency department. Participants indicated whether each learning objective was important to them, and their reasons for selecting or rejecting it. Thirty minutes later, responses were used as stimuli in focus group discussions to explore the factors that influence residents’ choice of learning objectives for their emergency medicine rotations broadly, and with respect to objectives presented in the reflection exercise specifically. Standardized instigating questions and additional questions adapted from the participants’ reflection exercise responses were used to facilitate discussion. Focus groups were tape-recorded and transcribed with identification of the participant’s specialty only. Analysis: Focus group data were analyzed using qualitative methods (Rubin and Rubin, 1995) and meaning condensation techniques (Kvale, 1996). Results: Data saturation was reached after 3 focus groups (12 residents) 66, 74 and 82 minutes in duration. The focus groups resulted in 80 pages of text and 488 occurrences of codes, with 37 discrete codes emerging after iterative analysis of the data. Factors influencing how off-service residents choose their learning objectives in EM naturally fell into 3 categories: 1) internal (individual) factors (21 codes, 58% of all occurrences) involving self-assessment, self-directed learning, interests outside of one’s specialty, past experiences and emotions; 2) external (supervisor/mentor) factors (5 codes, 15% of all occurrences); and 3) external (regional/national) factors, involving specialty and service (10 codes, 27% of all occurrences). Specialty was the most commonly cited single factor influencing selection of objectives (48 occurrences; 9.84% of all occurrences). Conclusion: It is difficult to predict an individual resident’s objectives because multiple factors influencing objective setting interact with each other in synergistic and opposing ways at the levels of the individual, clinical supervisor and specialty. External supervision, in addition to self-directedness and selawareness, is integral to guide the objective setting process through to satisfactory learning outcomes. Mentor figures need to develop and enhance their understanding of the role that teachers play in integrating and mitigating the tensions between the internal and external factors. Opportunities for faculty development in this area are apparent.
110
Medical Student Interest in Emergency Medicine and Participation in a Student Organization in the Netherlands
Mulligan TM, Fierstra J, Grewal S/Erasmus University, Rotterdam, The Netherlands
Study Objective: The development of emergency medicine started in the 1960’s and 70’s in the United States. At present time there are only 6 countries in the world that have a fully developed specialty of emergency medicine. The Netherlands is one of the 25⫹ countries that have started training residents to become emergency physicians. We want to investigate the interest in emergency medicine among medical students of the Erasmus University Medical Center of Rotterdam by presenting them a 10-point questionnaire. Methods: A 10-point questionnaire was distributed among first, second and third year medical students of the Erasmus University Medical Center of Rotterdam. It was distributed and collected to them on the same day and during general lectures. The questionnaire was developed to take less than 10 minutes to fill in and was completely voluntary and anonymous. Results: We distributed a total number of 800 questionnaires to the medical students who were present that day. Five-hundred-thirty-four medical students (188 first year, 157 second year and 189 third year) filled in the questionnaire, a response rate of 67% among the medical students who were attending this day general lectures. There was very high interest in emergency medicine according to the results across the several categories in our questionnaire. But despite this fact there are as yet no specific student organizations, didactic or practical training courses or official student rotations in emergency medicine. The narrowing of this gap can be facilitated by establishing an Emergency Medicine Student Organization, and by restructuring of the medical school curriculum to include academic, didactic courses in emergency medicine, along with official required or elective rotations in the emergency department. Conclusion: There is a high amount of interest in emergency medicine among first, second and third year medical students of the Erasmus University Medical Center of Rotterdam. This outcome can be supportive for the establishment of an Emergency Medicine Student Organization and by restructuring of the medical
Volume , . : April
108
Radiographic Imaging of Minor Pediatric Head Trauma Between General and Pediatric Emergency Physicians
Maloy K, Sharpe R, Sharpe M, Place R/Georgetown University, Washington, DC; INOVA Fairfax Hospital, Fairfax, VA
Study Objectives: Clear criteria have not been established to precisely identify the subset of children at risk for intracranial injury (ICI) after sustaining a minor head trauma. Increased availability of computed tomography (CT) and perceptions of increasing medicolegal liability effect the threshold for ordering diagnostic imaging. The decision to obtain diagnostic imaging remains sensitive to judgment and practice style and may be influenced by training type. Our null hypothesis was that there would be no difference in head CT ordering rates by general and pediatric emergency physicians for children under two years of age. Methods: We retrospectively reviewed the charts of children under two years of age presenting to 11 hospitals within a single contract network system with ICD-9 codes suggestive of minor head trauma. Children presenting with mechanism of injury or physical exam findings suggestive of major head trauma were excluded. The primary outcome measure was an order for a head CT; utilization of skull radiographs was also recorded. Physicians were classified as pediatric emergency medicine (PEM) physicians if they had completed a pediatric emergency medicine fellowship or a dual residency (emergency medicine and pediatrics) while general emergency medicine (GEM) physicians had completed an emergency medicine residency. Imaging utilization was compared between PEM and GEM physicians. Data was analyzed by summary statistics with confidence intervals, chi square statistics, and odds ratios with 95% confidence intervals. Alpha was set at 0.05 where appropriate. Results: Four hundred forty-five charts were identified and 252 met inclusion criteria. PEM physicians saw 110 (43%) children with minor head trauma and GEM physicians saw 142 (56%). Baseline clinical features were not significantly different between analyzed groups. The rate of ICI was 1.5% (2/110) in the GEM group and 2.7% (3/110) in the PEM group and was not statistically different between groups (p ⬎ 0.05). Of children evaluated, head CT was ordered in 48% (53/110) by PEM physicians and in 30% (42/142) by GEM physicians. PEM patients were exposed to CT radiation more frequently than GEM patients, with an odds ratio of 2.21 (95% CI: 1.31-3.71). Skull radiography utilization rate was not statistically different; 4.2% (6/142) in the GEM group and 4.5% (5/110) in the PEM group (p ⬎ 0.05). Conclusion: Patients evaluated by pediatric emergency physicians were significantly more likely to receive a head CT in the evaluation of minor head trauma than patients evaluated by physicians with general emergency training. Further investigation into the reason for more aggressive diagnostic evaluation by pediatric emergency physicians is warranted.
109
Factors Influencing Self-Directed Objective Setting by Off-Service Residents in Emergency Medicine
Tenn-Lyn NA, Bandiera GW, Hodges BD, Regehr G/University Health Network, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
Study Objectives: To explore and determine factors influencing the selection of emergency medicine (EM) learning objectives by off-service residents. Methods: Participants: First-year (PGY-1) residents from a variety of specialties who were about to start their EM rotation as identified their rotation by university rotation rosters.
504 Annals of Emergency Medicine
Setting: A university affiliated full service inner city academic emergency department (ED) with an annual census of 57,000 patients. Design: We circulated a form containing 30 objectives derived from a cross-section of body systems/content areas shown in a prior study to be frequently chosen, not chosen at all, or chosen with intermediate frequency by off-service residents in the emergency department. Participants indicated whether each learning objective was important to them, and their reasons for selecting or rejecting it. Thirty minutes later, responses were used as stimuli in focus group discussions to explore the factors that influence residents’ choice of learning objectives for their emergency medicine rotations broadly, and with respect to objectives presented in the reflection exercise specifically. Standardized instigating questions and additional questions adapted from the participants’ reflection exercise responses were used to facilitate discussion. Focus groups were tape-recorded and transcribed with identification of the participant’s specialty only. Analysis: Focus group data were analyzed using qualitative methods (Rubin and Rubin, 1995) and meaning condensation techniques (Kvale, 1996). Results: Data saturation was reached after 3 focus groups (12 residents) 66, 74 and 82 minutes in duration. The focus groups resulted in 80 pages of text and 488 occurrences of codes, with 37 discrete codes emerging after iterative analysis of the data. Factors influencing how off-service residents choose their learning objectives in EM naturally fell into 3 categories: 1) internal (individual) factors (21 codes, 58% of all occurrences) involving self-assessment, self-directed learning, interests outside of one’s specialty, past experiences and emotions; 2) external (supervisor/mentor) factors (5 codes, 15% of all occurrences); and 3) external (regional/national) factors, involving specialty and service (10 codes, 27% of all occurrences). Specialty was the most commonly cited single factor influencing selection of objectives (48 occurrences; 9.84% of all occurrences). Conclusion: It is difficult to predict an individual resident’s objectives because multiple factors influencing objective setting interact with each other in synergistic and opposing ways at the levels of the individual, clinical supervisor and specialty. External supervision, in addition to self-directedness and selawareness, is integral to guide the objective setting process through to satisfactory learning outcomes. Mentor figures need to develop and enhance their understanding of the role that teachers play in integrating and mitigating the tensions between the internal and external factors. Opportunities for faculty development in this area are apparent.
110
Medical Student Interest in Emergency Medicine and Participation in a Student Organization in the Netherlands
Mulligan TM, Fierstra J, Grewal S/Erasmus University, Rotterdam, The Netherlands
Study Objective: The development of emergency medicine started in the 1960’s and 70’s in the United States. At present time there are only 6 countries in the world that have a fully developed specialty of emergency medicine. The Netherlands is one of the 25⫹ countries that have started training residents to become emergency physicians. We want to investigate the interest in emergency medicine among medical students of the Erasmus University Medical Center of Rotterdam by presenting them a 10-point questionnaire. Methods: A 10-point questionnaire was distributed among first, second and third year medical students of the Erasmus University Medical Center of Rotterdam. It was distributed and collected to them on the same day and during general lectures. The questionnaire was developed to take less than 10 minutes to fill in and was completely voluntary and anonymous. Results: We distributed a total number of 800 questionnaires to the medical students who were present that day. Five-hundred-thirty-four medical students (188 first year, 157 second year and 189 third year) filled in the questionnaire, a response rate of 67% among the medical students who were attending this day general lectures. There was very high interest in emergency medicine according to the results across the several categories in our questionnaire. But despite this fact there are as yet no specific student organizations, didactic or practical training courses or official student rotations in emergency medicine. The narrowing of this gap can be facilitated by establishing an Emergency Medicine Student Organization, and by restructuring of the medical school curriculum to include academic, didactic courses in emergency medicine, along with official required or elective rotations in the emergency department. Conclusion: There is a high amount of interest in emergency medicine among first, second and third year medical students of the Erasmus University Medical Center of Rotterdam. This outcome can be supportive for the establishment of an Emergency Medicine Student Organization and by restructuring of the medical
Volume , . : April