- Email: [email protected]
315 EMFTherapeutic Hypothermia and Vasopressor Dependency After Cardiac Arrest
Research Forum Abstracts passive leg raise testing changes in cardiac index or stroke volume. Routine clinical estimations of volume responsiveness not guided by dynamic changes in cardiac index or stroke volume index may lead to inadequate or excess fluid administration. The impact of ED fluid administration guided by dynamic changes in cardiac index or stroke volume index on morbidity and mortality is unknown.
313
Evaluation of the Management and Outcome of Patients With Occult Hypoperfusion in the Emergency Department
Lawniczak RA, Jones-Bamman C, Dugas A, Giberson T, Cocchi MN, Donnino M/ Beth Israel Deaconess Medical Center, Boston, MA; Johns Hopkins, Baltimore, MD
Study Objective: Occult hypoperfusion (normal blood pressure in face of elevated lactic acid) has been previously described in patients who present with sepsis. Whether this population should undergo immediate placement of a central line for hemodynamic management or receive a trial of therapy (fluids/antibiotics) remains controversial, and current practice remains largely unexplored. The aim of this study was to evaluate current practice of emergency physicians in an academic center and to evaluate the potential adverse events that might occur in the population without early line placement. Methods: We performed a retrospective chart review (2008-2009) of patients who presented to the emergency department of a tertiary care center that evaluates approximately 50,000 adult patients/year. Inclusion criteria consisted of 2 or more SIRS criteria, suspected or confirmed infection, lactate ⬎ 4 mmol/L, and normotension (defined by systolic blood pressure ⬎ 90 mmHg). Patients with seizures, trauma, or other non-infectious causes of elevated lactate were excluded. Placement of a central venous catheter was at the discretion of the clinical team while in the emergency department (ED) and delayed placement was defined as greater than 2 hours post-lactate result. The primary outcome of adverse event for those without a central venous catheter placement was defined by decompensation over the ensuing 24 hours requiring central line placement for hypotension and/or transfer from the ward to the intensive care unit. Secondary outcomes included the mortality between groups. All data were analyzed using descriptive statistics. Results: 80 patients who met the described criteria were evaluated. The average age of the cohort was 70 ⫹/- 18 years. Of the 80 patients evaluated, 20 (25%) had a central venous catheter placed in the ED while 60 (75%) did not. Of those who did not have a central venous catheter placed in the ED, (27/60; 45%) were admitted to the general ward and (33/60; 55%) were admitted to the ICU. Of those admitted to the ward, 1 was transferred to the ICU during the following 24 hours; the indication for transfer was respiratory distress which resolved without intubation. Of the patients that were admitted without a central venous catheter, (3/60; 5%) went on to require a central venous catheter in the ICU within 24 hours of admission. Of the 20 patients who had a central venous catheter placed in the ED, 3 had a “delayed” placement. 17/20 were placed within 2 hours of the resulting lactate and the majority of these patients exhibited other-organ injury, most commonly respiratory failure (35%; 7/ 20). Of the 3 with delayed placement, 1 was performed for lack of any venous access and the other 2 were placed based on the lactate and not from a change in hemodynamic status (ie, these patients did not decompensate). In-hospital mortality for the group with central line placement in the ED was 35% (7/20) and for the group without line placement was 17% (10/16). Conclusions: In this retrospective study of patients presenting with suspected infection, lactic acidosis, and normotension, ED clinicians did not place a central venous catheter in the majority of cases. For those cases where a central venous catheter was placed, other-organ injury (such as overt respiratory failure) was frequently present and the overall mortality was higher, likely reflecting the clinicians’ accurate judgment of which patients were more severely ill. For the patients who did not have a central line placed in the ED, the percent of adverse events in the ensuing 24 hours was minimal.
314
Incidence of Clinical Deterioration in a Low Acuity Population of Emergency Department Sepsis Patients
Wise AM, Glaspey LJ, Ni SA, Kirchhoff MA, Trzeciak S, Hollenberg SM, Arnold RC/Robert Wood Johnson Medical School - Camden, Camden, NJ; Cooper University Hospital, Camden, NJ
Study Objectives: Sepsis patients with evidence of tissue hypoperfusion are at increased risk of organ dysfunction and disease progression. The objective of this
Volume , . : October
study was to describe the incidence of this “PRE-SHOCK” population within the emergency department (ED) and the associated incidence of clinical deterioration requiring intensive care unit (ICU) transfer or in-hospital mortality. Methods: Design: Single-center, prospective observational study. Setting: In an urban, tertiary care academic medical center, this study utilized the Lactate Utilization Registry, a prospectively collected ED-based quality improvement initiative to evaluate the clinical assessment of lactate in sepsis. Participants: The PRE-SHOCK patient population was defined a priori as adult ED patients with serum lactate 2.0 - 3.9 mmol/L or transient hypotension (any systolic blood pressure ⬍ 90 mmHg) who were treated with antibiotics and admitted to a general medical floor. All consecutive PRE-SHOCK patients were identified over a 1-year period. Exclusion criteria included pregnancy, acute trauma, or overt shock while in the ED (mechanical ventilation, vasopressor utilization, or lactate ⱖ 4.0). Outcomes: Any transfer to the ICU or in-hospital death. Results: The Lactate Utilization Registry identified 273 PRE-SHOCK patients from 2649 screened patients (incidence 10%). The average age was 60⫾17 years, with 54% female. The average lactate was 2.37⫾0.75 mmol/L; 80% had a lactate ⬎ 2.0 mmol/L and 36% had transient hypotension. Subjects with an isolated lactate elevation represented 62% of the population, 20% had only transient hypotension, and 18% had both. Within the PRE-SHOCK population, 43% were transferred to the ICU from the medical floor with an overall in-hospital mortality rate of 7% (18/275). In subjects with both lactate ⬎ 2.0 and transient hypotension, 67% (33/49) required ICU transfer or had an in-hospital mortality compared to 37% (84/224) of those with only 1 sign of tissue hypoperfusion (z⫽3.69; p ⬍ 0.001). Conclusions: The PRE-SHOCK patient population represents a cohort of ED sepsis patients with a clinically low suspicion for deterioration, ICU transfer or death. The PRE-SHOCK criteria identified a population with a high rate of critical care utilization and in-hospital death. The combined occurrence of lactate elevation and transient hypotension associated with clinical deterioration further supports the predefined PRE-SHOCK criteria. The PRE-SHOCK population definition could provide clinical guidance to identify patients who are likely to decompensate.
315
EMF
Therapeutic Hypothermia and Vasopressor Dependency After Cardiac Arrest
Roberts BW/Cooper University Hospital, Camden, NJ
Study Objectives: In both of the original hypothermia trials, the presence of hemodynamic instability after return of spontaneous circulation was an exclusion criterion for entry into the trial. Therefore, the safety, feasibility, and efficacy of therapeutic hypothermia in patients with persistent hemodynamic instability after return of spontaneous circulation are unknown. An important first step in addressing this knowledge gap is to determine what happens to macrocirculatory hemodynamic indices when therapeutic hypothermia is applied. We compared the degree of vasopressor support requirement (defined by change in the cumulative vasopressor index), during the first 24 hours after return of spontaneous circulation, between vasopressor-dependent patients treated with hypothermia and vasopressor-dependent patients not treated with hypothermia. Methods: We performed a prospective observational cohort study of all consecutive cardiac arrest survivors (both in- and out-of-hospital) who were vasopressor-dependent after return of spontaneous circulation in 2 academic hospitals from October 2008 - April 2011. Patients were classified into 2 groups, according to whether they had initiation of therapeutic hypothermia or did not have initiation of therapeutic hypothermia. The decision on whether or not to initiate therapeutic hypothermia in patients who were vasopressor-dependent was based on clinician discretion. The cumulative vasopressor index was calculated hourly for the first 6 hours as well as worst cumulative vasopressor index for time 6-24 hours after return of spontaneous circulation. The primary outcome measure was ⌬ cumulative vasopressor index, defined as the difference between the worst cumulative vasopressor index 6-24 hours after return of spontaneous circulation and initial cumulative vasopressor index (defined as 0-1 hour after return of spontaneous circulation). Results: Out of 69 consecutive patients, 32 had initiation of therapeutic hypothermia and 37 did not have initiation of therapeutic hypothermia. The mean ⌬ cumulative vasopressor index was 1.9 (95% confidence interval 0.2 to 3.6) in the hypothermia group and 1.4 (95% confidence interval 0.3 to 2.5) in the normothermia group (p ⫽ 0.63). Complication rates in both groups did not differ. Conclusion: We did not find a significant difference in vasopressor support requirement during the first 24 hours after return of spontaneous circulation between vasopressor-dependent patients who had initiation of therapeutic hypothermia and
Annals of Emergency Medicine S283
Research Forum Abstracts vasopressor-dependent patients who did not have initiation of therapeutic hypothermia. Our findings suggest therapeutic hypothermia does not increase vasopressor support requirement in vasopressor-dependent patients who achieve return of spontaneous circulation; however, further research is needed to determine the safety, feasibility, and efficacy of therapeutic hypothermia in patients with persistent hemodynamic instability after return of spontaneous circulation.
316
Implementation of the E-portfolio to Postgraduate Year-1 Residency Training in Emergency Medicine: Assessments of Curriculum Improvement and Online Feedback
Chen CK, Huan MN, Chang YC, Chen KF, Chen JC/Chang Gung Memorial Hospital, New Taipei City (R.O.C.), Taiwan
Study Objectives: E-Portfolio has become the development tendency of medical education. To collect the learning process of the students systematically and comprehensively, and to present its study achievement by the digitizing way, not only reflect student’s study achievement, but also present student’s learning process. The teacher may understand the student’s condition immediately (case severity, study content), and by way of the bidirectional feedback records to examine the study course, achieves the goal of the comprehensive study. Methods: According to stipulation, each student registers at least 10 cases every day in the e-portfolio (90 cases each month). We count student’s case numbers, analyze its complete rate, the case severity, and the distribution of the chief complaints. We analyze curriculum understanding before and after the teaching, analyze the students’ and teachers’ bidirectional feedback records, and count the satisfactory ratio of the students to the teachers for the curriculum. Results: The emergency department of Linkou Chang Gung Memorial Hospital accepts the PGY students from July, 2009 till January, 2011 for the emergency medical treatment 1 month-long training. Up to 205 students were trained by eportfolio registers system. Each student must registered for 90 cases each month (register 10 examples at least every day). 76.2% students finished the cases completely, and the incomplete rate was around 92⬃98%. The case severity according to triage analysis: Critically ill cases (triage 1, 2 degree) occupy 44%, mild case (triage 3, 4, 5 degree) 56%. According to the chief complaints by the registers analysis, critically ill cases complain mainly of difficult breathing and chest pain; mild cases mainly of abdominal pain and fever. The poison, the respiratory failure, and the shock are the last ones from the registers. The registered cases of the students cannot cover all core curriculum; the missing components of chief complaint (such as vaginal bleeding) need a better way to strengthening learning. Before studying the curriculum, the majority of students chooses D (62%) or E (35%). But after 1 month-long study, most students have been able to achieve A (12%), B (41%) or C (46%). Bidirectional feedback records showed satisfied or very satisfied to the teachers and the study at 90%, ordinary at 8%, and unsatisfied or very unsatisfied less than 2%. Conclusions: Implementation of e-portfolio has remarkably helped the shortterm PGY emergency medical treatment medicine practice training results analysis and the core curriculum improvement.
317
Stroke Simulation Training: Is Stroke Management Missing in Residency Training?
Reed K, Wood S, Jacobson L, Chang E, Milzman D/Georgetown University Hospital and Washington Hospital Center, Washington, DC
Study Objectives: With the continued expansion of “Stroke Teams” in the emergency department (ED) and inpatient setting, the opportunities for emergency medicine residents to gain the required knowledge for managing patients with acute non-hemorrhagic cerebrovascular accidents may be in decline. Therefore, we sought to estimate the incidence of emergency medicine resident involvement in acute cerebrovascular accident care and to develop a simulation model for the identification and management of acute non-hemorrhagic cerebrovascular accident for emergency medicine resident education and competency training. Methods: The study occurred at a simulation center of a 950-bed urban teaching hospital. A survey was completed by emergency medicine residents on the number of acute cerebrovascular accidents cases they have encountered, their comfort with managing patients with acute cerebrovascular accident (1-5 Likert scale), as well as a pre-test to identify baseline knowledge of acute cerebrovascular accident management. On the day of training, emergency medicine attendings reviewed
S284 Annals of Emergency Medicine
common cerebrovascular accidents presentations, calculation of National Institutes of Health (NIH) stroke scale, identification of absolute contraindications to thrombolytics, calculation of accurate tissue plasminogen activator (TPA) dosing and its correct administration. Next, PGY1-3 emergency medicine residents encountered a scenario with a simulated patient (standardized actor with family member) presenting with an acute non-hemorrhagic cerebrovascular accident ⬍ 4.5 hours after onset of symptoms at a community hospital without acute stroke care capabilities. Residents in groups of 3-4 were required to identify the diagnosis of an acute nonhemorrhagic cerebrovascular accident, calculate a NIH stroke scale, discuss possible thrombolytic therapy with a tertiary stroke center neurologist, obtain informed consent for TPA, calculate a correct dose and administer TPA while arranging transfer to a stroke center. A debriefing session was held afterwards reviewing the case, critical actions, and basic stroke management with a stroke team attending. A posttest and survey was administered 6 weeks following simulation training to assess the benefits of intensive simulation training and retention of gained knowledge. Results: Twenty emergency medicine residents successfully completed acute cerebrovascular accident simulation training. While all residents 20/20 (100%) have participated in stroke cases involving the use of TPA, no resident 0/20 (0%) had calculated an NIH stroke scale or directed TPA therapy (ie, obtained consent, calculated dose, ordered TPA). Mean pre-training self-rated, stroke-care confidence to calculate an NIH stroke scale and administer TPA for acute stroke were 1.7 (95% CI: 1.38-2.02) and 1.4 (95% CI: 1.18-1.62), respectively. Post-training values increased to 3.0 (95%CI: 2.48-3.5) and 2.8 (95% CI: 2.38-3.22), respectively (p⫽0.04). Pretest mean score was 48% and increased to 73% post-training (p⬍0.05). Conclusion: The management of acute stroke is required as part of emergency medicine residency training and board certification. While acute cerebrovascular accident is a relatively common ED presentation, a paucity of real-life training opportunities to manage these patients may be occurring due to the advent of “Stroke Teams.” Our study shows that residents do not appear to be obtaining the needed skills to manage acute non-hemorrhagic cerebrovascular accident and correctly administer thrombolytics in live patients. This reproducible simulation model provides a novel approach to teaching emergency medicine residents and could facilitate maintenance of skills required for certification and performance of acute stroke care.
318
Computed Tomography Scans in the Emergency Department: Awareness of Radiation Risks and Effect on Ordering Among Different Levels of Practice
Trotter M, Nichols W, Reed III JF, Bounds R/Christiana Care Health Services, Newark, DE
Study Objectives: The purpose of this study was to determine if attending, physician assistant, and resident practitioners are aware of the current estimated radiation risks associated with computed tomography scans and whether this knowledge affects their ordering practices in the emergency department. Methods: An anonymous electronic survey was sent to all residents, physician assistants, and attendings in emergency medicine, surgery, and internal medicine at a single academic tertiary care referral Level 1 trauma center with an annual ED volume over 160,000 visits. The survey was pilot tested and validated in a sample of the target population using qualitative methodology. Those who do not routinely order computed tomography scans were excluded. All data was analyzed using the Pearson’s chi squared, and a p-value of ⬍0.05 was considered statistically significant. Results: There were 220 survey responses: 51% (112) attending, 11% (25) physician assistant, and 38% (83) resident. Response rates were 22% for attendings (112/502), 64% for physician assistant s (25/39), and 57% for residents (83/145). Six additional respondents were excluded for not routinely ordering abdominal computed tomography scans. Overall, 54% reported having some formal training on the radiation risks of computed tomography scans, and 79% believed there was an increased lifetime attributable risk (LAR) of cancer associated with computed tomography scans. Only 24% responded correctly that 1 abdominal computed tomography scan is equivalent to between 100 and 500 chest x-rays, with 62% underestimating the equivalent radiation dose. 43% responded correctly that the commonly quoted lifetime attributable risk of fatal cancer associated with 1 abdominal computed tomography scan is on the order of 1 in 2000. Compared with attendings (8%) and residents (8%), more physician assistants (32%) “almost always” discuss the risks of radiation with patients (p⫽0.017). Attendings (45%) and residents (52%) were more likely to discuss these risks
Volume , . : October
313
Evaluation of the Management and Outcome of Patients With Occult Hypoperfusion in the Emergency Department
Lawniczak RA, Jones-Bamman C, Dugas A, Giberson T, Cocchi MN, Donnino M/ Beth Israel Deaconess Medical Center, Boston, MA; Johns Hopkins, Baltimore, MD
Study Objective: Occult hypoperfusion (normal blood pressure in face of elevated lactic acid) has been previously described in patients who present with sepsis. Whether this population should undergo immediate placement of a central line for hemodynamic management or receive a trial of therapy (fluids/antibiotics) remains controversial, and current practice remains largely unexplored. The aim of this study was to evaluate current practice of emergency physicians in an academic center and to evaluate the potential adverse events that might occur in the population without early line placement. Methods: We performed a retrospective chart review (2008-2009) of patients who presented to the emergency department of a tertiary care center that evaluates approximately 50,000 adult patients/year. Inclusion criteria consisted of 2 or more SIRS criteria, suspected or confirmed infection, lactate ⬎ 4 mmol/L, and normotension (defined by systolic blood pressure ⬎ 90 mmHg). Patients with seizures, trauma, or other non-infectious causes of elevated lactate were excluded. Placement of a central venous catheter was at the discretion of the clinical team while in the emergency department (ED) and delayed placement was defined as greater than 2 hours post-lactate result. The primary outcome of adverse event for those without a central venous catheter placement was defined by decompensation over the ensuing 24 hours requiring central line placement for hypotension and/or transfer from the ward to the intensive care unit. Secondary outcomes included the mortality between groups. All data were analyzed using descriptive statistics. Results: 80 patients who met the described criteria were evaluated. The average age of the cohort was 70 ⫹/- 18 years. Of the 80 patients evaluated, 20 (25%) had a central venous catheter placed in the ED while 60 (75%) did not. Of those who did not have a central venous catheter placed in the ED, (27/60; 45%) were admitted to the general ward and (33/60; 55%) were admitted to the ICU. Of those admitted to the ward, 1 was transferred to the ICU during the following 24 hours; the indication for transfer was respiratory distress which resolved without intubation. Of the patients that were admitted without a central venous catheter, (3/60; 5%) went on to require a central venous catheter in the ICU within 24 hours of admission. Of the 20 patients who had a central venous catheter placed in the ED, 3 had a “delayed” placement. 17/20 were placed within 2 hours of the resulting lactate and the majority of these patients exhibited other-organ injury, most commonly respiratory failure (35%; 7/ 20). Of the 3 with delayed placement, 1 was performed for lack of any venous access and the other 2 were placed based on the lactate and not from a change in hemodynamic status (ie, these patients did not decompensate). In-hospital mortality for the group with central line placement in the ED was 35% (7/20) and for the group without line placement was 17% (10/16). Conclusions: In this retrospective study of patients presenting with suspected infection, lactic acidosis, and normotension, ED clinicians did not place a central venous catheter in the majority of cases. For those cases where a central venous catheter was placed, other-organ injury (such as overt respiratory failure) was frequently present and the overall mortality was higher, likely reflecting the clinicians’ accurate judgment of which patients were more severely ill. For the patients who did not have a central line placed in the ED, the percent of adverse events in the ensuing 24 hours was minimal.
314
Incidence of Clinical Deterioration in a Low Acuity Population of Emergency Department Sepsis Patients
Wise AM, Glaspey LJ, Ni SA, Kirchhoff MA, Trzeciak S, Hollenberg SM, Arnold RC/Robert Wood Johnson Medical School - Camden, Camden, NJ; Cooper University Hospital, Camden, NJ
Study Objectives: Sepsis patients with evidence of tissue hypoperfusion are at increased risk of organ dysfunction and disease progression. The objective of this
Volume , . : October
study was to describe the incidence of this “PRE-SHOCK” population within the emergency department (ED) and the associated incidence of clinical deterioration requiring intensive care unit (ICU) transfer or in-hospital mortality. Methods: Design: Single-center, prospective observational study. Setting: In an urban, tertiary care academic medical center, this study utilized the Lactate Utilization Registry, a prospectively collected ED-based quality improvement initiative to evaluate the clinical assessment of lactate in sepsis. Participants: The PRE-SHOCK patient population was defined a priori as adult ED patients with serum lactate 2.0 - 3.9 mmol/L or transient hypotension (any systolic blood pressure ⬍ 90 mmHg) who were treated with antibiotics and admitted to a general medical floor. All consecutive PRE-SHOCK patients were identified over a 1-year period. Exclusion criteria included pregnancy, acute trauma, or overt shock while in the ED (mechanical ventilation, vasopressor utilization, or lactate ⱖ 4.0). Outcomes: Any transfer to the ICU or in-hospital death. Results: The Lactate Utilization Registry identified 273 PRE-SHOCK patients from 2649 screened patients (incidence 10%). The average age was 60⫾17 years, with 54% female. The average lactate was 2.37⫾0.75 mmol/L; 80% had a lactate ⬎ 2.0 mmol/L and 36% had transient hypotension. Subjects with an isolated lactate elevation represented 62% of the population, 20% had only transient hypotension, and 18% had both. Within the PRE-SHOCK population, 43% were transferred to the ICU from the medical floor with an overall in-hospital mortality rate of 7% (18/275). In subjects with both lactate ⬎ 2.0 and transient hypotension, 67% (33/49) required ICU transfer or had an in-hospital mortality compared to 37% (84/224) of those with only 1 sign of tissue hypoperfusion (z⫽3.69; p ⬍ 0.001). Conclusions: The PRE-SHOCK patient population represents a cohort of ED sepsis patients with a clinically low suspicion for deterioration, ICU transfer or death. The PRE-SHOCK criteria identified a population with a high rate of critical care utilization and in-hospital death. The combined occurrence of lactate elevation and transient hypotension associated with clinical deterioration further supports the predefined PRE-SHOCK criteria. The PRE-SHOCK population definition could provide clinical guidance to identify patients who are likely to decompensate.
315
EMF
Therapeutic Hypothermia and Vasopressor Dependency After Cardiac Arrest
Roberts BW/Cooper University Hospital, Camden, NJ
Study Objectives: In both of the original hypothermia trials, the presence of hemodynamic instability after return of spontaneous circulation was an exclusion criterion for entry into the trial. Therefore, the safety, feasibility, and efficacy of therapeutic hypothermia in patients with persistent hemodynamic instability after return of spontaneous circulation are unknown. An important first step in addressing this knowledge gap is to determine what happens to macrocirculatory hemodynamic indices when therapeutic hypothermia is applied. We compared the degree of vasopressor support requirement (defined by change in the cumulative vasopressor index), during the first 24 hours after return of spontaneous circulation, between vasopressor-dependent patients treated with hypothermia and vasopressor-dependent patients not treated with hypothermia. Methods: We performed a prospective observational cohort study of all consecutive cardiac arrest survivors (both in- and out-of-hospital) who were vasopressor-dependent after return of spontaneous circulation in 2 academic hospitals from October 2008 - April 2011. Patients were classified into 2 groups, according to whether they had initiation of therapeutic hypothermia or did not have initiation of therapeutic hypothermia. The decision on whether or not to initiate therapeutic hypothermia in patients who were vasopressor-dependent was based on clinician discretion. The cumulative vasopressor index was calculated hourly for the first 6 hours as well as worst cumulative vasopressor index for time 6-24 hours after return of spontaneous circulation. The primary outcome measure was ⌬ cumulative vasopressor index, defined as the difference between the worst cumulative vasopressor index 6-24 hours after return of spontaneous circulation and initial cumulative vasopressor index (defined as 0-1 hour after return of spontaneous circulation). Results: Out of 69 consecutive patients, 32 had initiation of therapeutic hypothermia and 37 did not have initiation of therapeutic hypothermia. The mean ⌬ cumulative vasopressor index was 1.9 (95% confidence interval 0.2 to 3.6) in the hypothermia group and 1.4 (95% confidence interval 0.3 to 2.5) in the normothermia group (p ⫽ 0.63). Complication rates in both groups did not differ. Conclusion: We did not find a significant difference in vasopressor support requirement during the first 24 hours after return of spontaneous circulation between vasopressor-dependent patients who had initiation of therapeutic hypothermia and
Annals of Emergency Medicine S283
Research Forum Abstracts vasopressor-dependent patients who did not have initiation of therapeutic hypothermia. Our findings suggest therapeutic hypothermia does not increase vasopressor support requirement in vasopressor-dependent patients who achieve return of spontaneous circulation; however, further research is needed to determine the safety, feasibility, and efficacy of therapeutic hypothermia in patients with persistent hemodynamic instability after return of spontaneous circulation.
316
Implementation of the E-portfolio to Postgraduate Year-1 Residency Training in Emergency Medicine: Assessments of Curriculum Improvement and Online Feedback
Chen CK, Huan MN, Chang YC, Chen KF, Chen JC/Chang Gung Memorial Hospital, New Taipei City (R.O.C.), Taiwan
Study Objectives: E-Portfolio has become the development tendency of medical education. To collect the learning process of the students systematically and comprehensively, and to present its study achievement by the digitizing way, not only reflect student’s study achievement, but also present student’s learning process. The teacher may understand the student’s condition immediately (case severity, study content), and by way of the bidirectional feedback records to examine the study course, achieves the goal of the comprehensive study. Methods: According to stipulation, each student registers at least 10 cases every day in the e-portfolio (90 cases each month). We count student’s case numbers, analyze its complete rate, the case severity, and the distribution of the chief complaints. We analyze curriculum understanding before and after the teaching, analyze the students’ and teachers’ bidirectional feedback records, and count the satisfactory ratio of the students to the teachers for the curriculum. Results: The emergency department of Linkou Chang Gung Memorial Hospital accepts the PGY students from July, 2009 till January, 2011 for the emergency medical treatment 1 month-long training. Up to 205 students were trained by eportfolio registers system. Each student must registered for 90 cases each month (register 10 examples at least every day). 76.2% students finished the cases completely, and the incomplete rate was around 92⬃98%. The case severity according to triage analysis: Critically ill cases (triage 1, 2 degree) occupy 44%, mild case (triage 3, 4, 5 degree) 56%. According to the chief complaints by the registers analysis, critically ill cases complain mainly of difficult breathing and chest pain; mild cases mainly of abdominal pain and fever. The poison, the respiratory failure, and the shock are the last ones from the registers. The registered cases of the students cannot cover all core curriculum; the missing components of chief complaint (such as vaginal bleeding) need a better way to strengthening learning. Before studying the curriculum, the majority of students chooses D (62%) or E (35%). But after 1 month-long study, most students have been able to achieve A (12%), B (41%) or C (46%). Bidirectional feedback records showed satisfied or very satisfied to the teachers and the study at 90%, ordinary at 8%, and unsatisfied or very unsatisfied less than 2%. Conclusions: Implementation of e-portfolio has remarkably helped the shortterm PGY emergency medical treatment medicine practice training results analysis and the core curriculum improvement.
317
Stroke Simulation Training: Is Stroke Management Missing in Residency Training?
Reed K, Wood S, Jacobson L, Chang E, Milzman D/Georgetown University Hospital and Washington Hospital Center, Washington, DC
Study Objectives: With the continued expansion of “Stroke Teams” in the emergency department (ED) and inpatient setting, the opportunities for emergency medicine residents to gain the required knowledge for managing patients with acute non-hemorrhagic cerebrovascular accidents may be in decline. Therefore, we sought to estimate the incidence of emergency medicine resident involvement in acute cerebrovascular accident care and to develop a simulation model for the identification and management of acute non-hemorrhagic cerebrovascular accident for emergency medicine resident education and competency training. Methods: The study occurred at a simulation center of a 950-bed urban teaching hospital. A survey was completed by emergency medicine residents on the number of acute cerebrovascular accidents cases they have encountered, their comfort with managing patients with acute cerebrovascular accident (1-5 Likert scale), as well as a pre-test to identify baseline knowledge of acute cerebrovascular accident management. On the day of training, emergency medicine attendings reviewed
S284 Annals of Emergency Medicine
common cerebrovascular accidents presentations, calculation of National Institutes of Health (NIH) stroke scale, identification of absolute contraindications to thrombolytics, calculation of accurate tissue plasminogen activator (TPA) dosing and its correct administration. Next, PGY1-3 emergency medicine residents encountered a scenario with a simulated patient (standardized actor with family member) presenting with an acute non-hemorrhagic cerebrovascular accident ⬍ 4.5 hours after onset of symptoms at a community hospital without acute stroke care capabilities. Residents in groups of 3-4 were required to identify the diagnosis of an acute nonhemorrhagic cerebrovascular accident, calculate a NIH stroke scale, discuss possible thrombolytic therapy with a tertiary stroke center neurologist, obtain informed consent for TPA, calculate a correct dose and administer TPA while arranging transfer to a stroke center. A debriefing session was held afterwards reviewing the case, critical actions, and basic stroke management with a stroke team attending. A posttest and survey was administered 6 weeks following simulation training to assess the benefits of intensive simulation training and retention of gained knowledge. Results: Twenty emergency medicine residents successfully completed acute cerebrovascular accident simulation training. While all residents 20/20 (100%) have participated in stroke cases involving the use of TPA, no resident 0/20 (0%) had calculated an NIH stroke scale or directed TPA therapy (ie, obtained consent, calculated dose, ordered TPA). Mean pre-training self-rated, stroke-care confidence to calculate an NIH stroke scale and administer TPA for acute stroke were 1.7 (95% CI: 1.38-2.02) and 1.4 (95% CI: 1.18-1.62), respectively. Post-training values increased to 3.0 (95%CI: 2.48-3.5) and 2.8 (95% CI: 2.38-3.22), respectively (p⫽0.04). Pretest mean score was 48% and increased to 73% post-training (p⬍0.05). Conclusion: The management of acute stroke is required as part of emergency medicine residency training and board certification. While acute cerebrovascular accident is a relatively common ED presentation, a paucity of real-life training opportunities to manage these patients may be occurring due to the advent of “Stroke Teams.” Our study shows that residents do not appear to be obtaining the needed skills to manage acute non-hemorrhagic cerebrovascular accident and correctly administer thrombolytics in live patients. This reproducible simulation model provides a novel approach to teaching emergency medicine residents and could facilitate maintenance of skills required for certification and performance of acute stroke care.
318
Computed Tomography Scans in the Emergency Department: Awareness of Radiation Risks and Effect on Ordering Among Different Levels of Practice
Trotter M, Nichols W, Reed III JF, Bounds R/Christiana Care Health Services, Newark, DE
Study Objectives: The purpose of this study was to determine if attending, physician assistant, and resident practitioners are aware of the current estimated radiation risks associated with computed tomography scans and whether this knowledge affects their ordering practices in the emergency department. Methods: An anonymous electronic survey was sent to all residents, physician assistants, and attendings in emergency medicine, surgery, and internal medicine at a single academic tertiary care referral Level 1 trauma center with an annual ED volume over 160,000 visits. The survey was pilot tested and validated in a sample of the target population using qualitative methodology. Those who do not routinely order computed tomography scans were excluded. All data was analyzed using the Pearson’s chi squared, and a p-value of ⬍0.05 was considered statistically significant. Results: There were 220 survey responses: 51% (112) attending, 11% (25) physician assistant, and 38% (83) resident. Response rates were 22% for attendings (112/502), 64% for physician assistant s (25/39), and 57% for residents (83/145). Six additional respondents were excluded for not routinely ordering abdominal computed tomography scans. Overall, 54% reported having some formal training on the radiation risks of computed tomography scans, and 79% believed there was an increased lifetime attributable risk (LAR) of cancer associated with computed tomography scans. Only 24% responded correctly that 1 abdominal computed tomography scan is equivalent to between 100 and 500 chest x-rays, with 62% underestimating the equivalent radiation dose. 43% responded correctly that the commonly quoted lifetime attributable risk of fatal cancer associated with 1 abdominal computed tomography scan is on the order of 1 in 2000. Compared with attendings (8%) and residents (8%), more physician assistants (32%) “almost always” discuss the risks of radiation with patients (p⫽0.017). Attendings (45%) and residents (52%) were more likely to discuss these risks
Volume , . : October