- Email: [email protected]
154 Fluid Resuscitation of Septic Patients at Risk for Fluid Overload
Research Forum Abstracts
151
Methicillin-Sensitive S. Aureus Contamination of Ultrasound Probes Using Several Conduction Media
Tansek R, Baranchuk N, Rose G, Siadecki SD, Saul T/Mount Sinai St. Luke’s Mount Sinai West, New York, NY
Study Objectives: Point-of-care ultrasound (POCUS) is integral to the care of patients in the emergency department. Unfortunately, ultrasound probes can act as fomites for pathogen transmission from patient to patient despite various cleaning methods and barrier precautions. It is pertinent to understand what factors contribute to this and how we can best reduce this risk. The objective of this study was to detect growth of methicillin-sensitive Staphylococcus aureus (MSSA) from POCUS probes after scanning an inoculated pork model with several types of conduction media to investigate the difference in pathogen transmission. Methods: A portion of store-bought pork shoulder was disinfected with chlorhexidine and allowed to dry. One mL of a cultured sample of abscessconcentration MSSA was used to inoculate the specimen. A linear transducer was cleansed with a sterilizing cloth and the end of the probe was then covered with a Tegaderm (3M, Maplewood, MN). One of three conduction media was applied to the pork shoulder: sterile saline, chlorhexidine, or sterile gel. The probe was then used to perform a soft tissue scan of the pork shoulder for one minute. After this, the probe was swabbed and cultured to detect transmission of MSSA. This was done four times for each of the three media types. Results: None of the four saline or four chlorhexidine probe swabs grew MSSA when cultured. Three of the four sterile gel probe swabs grew MSSA. Conclusions: These results suggest that sterile ultrasound gel may be more likely to transmit skin pathogens to the probe during POCUS in a simulated environment. However, larger studies and further exploration into this topic are necessary to draw clinical conclusions.
152
Point-of-Care Influenza Testing Does Not Significantly Shorten Time to Disposition Among Emergency Department Patients With an Influenza-Like Illness
Schechter-Perkins EM, Mitchell PM, Nelson KP, Liu J, Desormeau E, Reid M, Orr B, Miller NS/Boston University School of Medicine, Boston, MA; Boston University School of Public Health, Boston, MA; Boston Medical Center, Boston, MA
Study Objectives: Symptoms attributable to influenza-like illness are common presenting complaints to the emergency department (ED) during the winter months. The availability of anti-viral agents and the need to cohort patients with infectious diseases has increased the need to confirm the diagnosis of influenza (flu) prior to determining a disposition for patients. The objectives were to determine if time-todisposition (TTD) was shorter among patients who were tested for influenza using a point-of-care (POC) test in a hospital ED compared to those who were tested in the hospital core laboratory (lab) and to determine if there was a difference in antibiotic use between groups. Methods: This study was conducted at an urban, safety net, academic level 1 trauma center. We conducted a prospective study that enrolled a convenience sample of ED patients for whom influenza testing was physician-ordered per usual ED clinical protocols during peak influenza season 2017. After consenting, subjects were randomized to either core lab testing (Xpert Flu, Cepheid) or POC testing (cobas Liat Influenza A/B, Roche Diagnostics) performed in the ED. Run times for the core lab assays and POC were 55-75 minutes and 20 minutes respectively. Data collected included demographics, chief complaint, results of influenza test, time to test results (TTTR, defined as time from when order was entered until results were available in the Electronic Medical Record), whether antibiotics were given, and TTD (defined as the time from when a patient was placed in the ED treatment room until the disposition (either admit, observe, or discharge) was ordered in the medical record. Descriptive statistics were calculated and group comparisons were made using a two sample t-test. Results: Two hundred fifty-seven patients were approached of which 6 refused, and 51 were excluded (21 had comprehensive respiratory panels performed rather than exclusive influenza tests, 21 non-English speaking, 9 for other reasons). Two hundred subjects were enrolled, and 3 were dropped from the core laboratory arm due to incorrect test orders. Final study population included 97 in the core lab group and 100 in POC group. Demographic characteristics between core lab subjects and POC subjects were the same with respect to mean age, sex, and race. There were fewer flu
Volume 70, no. 4s : October 2017
positive results in the core lab group compared to the POC group (33.0% vs. 51.0%, p¼.01) but a similar percentage of influenza type A (84.4% vs. 86.3%), and discharged patients (83.5% vs. 78.0%). The mean TTTR was 140.0min (SD 318.1min) for the core lab and 35.2min (SD 19.9min) for POC (p¼.001). The mean TTD was 185.9min (SD 110.0) for the core lab group and 168.9min (SD 91.7) for POC (p¼0.26). Antibiotics were given to 14.4% of core lab subjects, and 14.0% of POC subjects (p¼0.93). Conclusions: Although use of a POC influenza test provided a more rapid time to test result than use of a core lab test, there was no statistically significant difference in time to disposition or antibiotic use between the groups. This is in contrast to other studies on POC testing in the ED setting. In this small study this finding may be due to the influence of other factors on disposition decisions in addition to diagnosis of influenza. Test implementation strategies for POC testing benefit from site-specific outcome studies in addition to reliance on published data from other institutions.
153
Pharmacist-Initiated Culture Follow-Up in the Emergency Department Reduces Time to Treatment Optimization
Olson A, Pegelow E, Cowell J, Feldman R, Stanton M, Ray J, Dang C/Froedtert & The Medical College of Wisconsin, Milwaukee, WI
Study Objectives: Urinary tract infections (UTI) and sexually transmitted infections (STI) are frequently encountered medical conditions in the emergency department (ED). Antimicrobial therapy prescribed for treatment is empiric due to the delay between obtaining a culture and growth of an organism to direct definitive therapy. A culture review and call-back process is paramount to ensuring appropriate therapy and preventing complications of inadequately treated infections for patients not requiring hospital admission. This project investigates if pharmacist-driven culture follow-up in the ED results in a reduction in time from final culture results to patient contact, when compared to the previous nurse driven process. Methods: This is a retrospective pre- and post-intervention analysis in a 40-bed Level 1 trauma center ED that has 72,000 annual visits. All patients with UTI or STI cultures drawn in the ED in whom a change in therapy was indicated after final cultures resulted were included. Pre-intervention, all cultures were reviewed by the third-shift charge nurse and forwarded to the designated advanced practice provider (APP). Pharmacists were consulted at the discretion of the APP. Post-intervention, all cultures were first reviewed by an ED pharmacist who then forwarded results and treatment recommendations to the designated APP. Data was collected via electronic health record from September 2015 to February 2016 and April 2016 to September 2016 for the pre- and post-intervention groups, respectively. The primary outcome measured was time from final culture result to patient contact by the APP. Secondary objectives included: prevalence of treatment failure defined as patient return to the ED within 72 hours (h) for the same medical problem, hospital admission within 30 days of ED visit for related conditions (UTI, pyelonephritis, urosepsis), and percentage of pharmacist recommendations. Statistical analysis was completed with Mann-Whitney U test for continuous data. Results: A total of 240 patients were included. Pre-intervention group consisted of 143 patients; 103 UTI patients and 40 STI patients. Post-intervention group consisted of 97 patients; 79 UTI and 18 STI patients. Post-intervention, patients were contacted a median of 19.83 hours earlier than in the pre-intervention group (CI 95%, 17.1522.5; p<0.001). Post-intervention, median contact time for UTI patients was 15.06 hours earlier (CI 95%, 8.35-19.03; p<0.001) and the median contact time for STI patients was 47.31 hours earlier (CI 95%, 29.1-67.41; p<0.001) than the preintervention group. Conclusions: Pharmacist-initiated culture review in the ED culture follow-up process reduces time from final culture results to initiation of optimal antibiotic treatment. Routine pharmacist involvement in the culture review process appears to have great value.
154
Fluid Resuscitation of Septic Patients at Risk for Fluid Overload
Akhter M, Hallare M, Roontiva A, Stowell J/University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ; Maricopa Integrated Health System, Phoenix, AZ
Study Objectives: Guidelines recommend rapid fluid resuscitation of at least 30 ml/kg in septic patients in order to improve outcomes. However, since fluid overload
Annals of Emergency Medicine S61
Research Forum Abstracts increases the risk of intubation, providers are wary to aggressively fluid-resuscitate septic patients who are at risk of fluid overload - namely, patients with congestive heart failure (CHF) or end-stage renal disease (ESRD). We sought to assess whether an initial fluid dose of 30 ml/kg in septic CHF or septic ESRD patients, compared to a fluidrestrictive strategy, leads to increased intubations. We also analyzed mortality rates and hospital length of stay (LOS). Methods: At our ED, data on septic patients > 17 years of age are prospectively tracked for quality metrics. Patients who trigger the sepsis flag are up-triaged for quicker provider evaluation to assess whether to implement a sepsis bundle, including whether or not to administer 30 ml/kg of fluids. All patients who are ultimately deemed to have had an infectious source that triggered the flag have multiple metrics logged and tracked. This prospectively collected set of data was retrospectively analyzed. Inclusion criteria were septic patients with past medical history of CHF or ESRD who were given fluids. Patients were excluded if they were under do-notresuscitate (DNR) or comfort-measures-only (CMO) status, as well as if amount of administered fluid was unknown. Primary outcome was intubation frequency. Secondary outcomes were hospital LOS and mortality. Student t-test and chi-square tests was used for analyses. Results: Table 1 demonstrates the outcomes in patients who were given at least 30 ml/kg compared to those who were not. In particular, there were no differences between groups in intubation rates. There were also no differences in hospital LOS or in mortality (although the sample was not sufficiently powered for mortality). Overall, 13.8% (95% CI 9.5%-19.2%) of septic patients with CHF and/or ESRD received 30 ml/kg of fluids in the ED whereas 21.0% (95% CI 18.7%-23.4%) of septic patients without either CHF or ESRD received 30 ml/kg of fluids in the ED (p<0.02). Conclusions: Our analysis suggests that patients with a history of CHF and/or ESRD who become septic and receive at least 30 ml/kg of fluids in the ED are not any more likely to be intubated than the patients who receive fluid-restrictive regimen of < 30 ml/kg. This analysis has limitations, including that there may be baseline differences between the patients who did receive 30 ml/kg of fluids in the ED vs. those who did not. However, our results are in line with some previously presented data. Therefore, an initial bolus of 30 ml/kg of fluids in septic CHF/ ESRD patients appears to be safe - possibly even beneficial - and can potentially be included in a triage bundle set for sepsis care in the ED. At our site, CHF/ESRD patients were significantly less likely to receive 30 ml/kg of fluids in the ED than non-CHF/ESRD patients, but adherence to the 30 ml/kg target was low for all patients. Implementing a 30 ml/kg fluid order from triage could enhance compliance with the Surviving Sepsis guidelines - and still leave providers the option of holding fluids when they clinically deem it appropriate.
procedures performed in the past year and confidence in performing five procedures: ultrasound-guided central line (CL) catheter placement, cricothyrotomy (Crich), precipitous vaginal delivery (PVD), intraosseous line (IO) placement, and thoracostomy tube (CT) placement. During the OPPE session, participants were guided through simulation-based performance of each procedure. A follow-up survey sent 2-8 weeks after the experience to each physician asked their confidence and their opinion of simulation for refreshing procedural skills, assessment, and likelihood of future participation. We analyzed the difference in procedural confidence between pre and post OPPE session using descriptive analysis and paired sample t-test. Results: The median number of yearly procedures performed per provider were: CL - 4, Crich - 1, PVD - 0, IO - 2, CT - 1. Pre- and post-simulation confidence is displayed in Figure 1, and showed a statistically significant improvement in procedural confidence in the post session for Crich, PVD, and CT, with an average post-session procedural confidence increase of 0.8, 0.73, and 0.53, respectively. Though there was no statistical difference in the procedural confidence between pre and post session for CL and IO, there was still a slight post-session increase of 0.4 and 0.14. Average agreement on a 5-point scale for acceptance of simulation as a way to refresh procedural skill and assess performance was 4.2 and 4.0 respectively. Average likelihood to participate in future simulation sessions was 4.7. Conclusions: Offering the ongoing professional practice evaluation in a simulated environment using procedure trainers is one way to increase experience with rare procedures and to improve confidence, while simultaneously demonstrating ongoing proficiency. The use of ultrasound for CL placement and the relative ease of IO line placement may contribute to lack of statistical significance on those procedures. This method was positively received by physicians as a means for refreshing procedural skill and assessing performance.
156 155
Impact of a Simulation-Based Ongoing Professional Practice Evaluation on Provider Procedural Confidence in Five Rare Procedures
Hock SM, Lee EM, Petty K, Shah SC, Sergel M/Rush University Medical Center, Chicago, IL; Northshore University HealthSystem, Evanston, IL; Rush University Medical College, Chicago, IL; John H Stroger Cook County Hospital, Chicago, IL
Study Objectives: Evaluation of procedural skills of practicing Emergency Physicians is a Joint Commission requirement known as the Ongoing Professional Practice Evaluation (OPPE). The authors have implemented a simulation-based OPPE, now in its second year. This study sought to determine the frequency of five rare procedures performed by each emergency physician, determine if the simulationbased OPPE increases confidence, and assess how the simulation format of OPPE is perceived by physicians. Methods: Study participants were board eligible/board certified practicing EPs from one academic institution. Twenty-five physicians consented to the study and completed the pre-survey, and fifteen physicians to date have completed both the pre and post surveys. The pre-simulation survey measured the number of
S62 Annals of Emergency Medicine
High Fidelity Cadaveric Simulation for Management of Patients With Upper Gastrointestinal Bleed
Nelson M, Calandrella C, Greco J, Slowey M/North Shore University Hospital, manhasset, NY
Study Objective: Simulation has emerged as a useful innovative modality for resident training under a controlled environment. However, it often lacks the consistency of real-time interventions. ACGME milestones aim to standardize faculty assessment of residents on proficiency; however, interactions with faculty can have limitations. Assessment is further challenged by the daily variety of cases limiting the ability to adequately monitor progression of the resident’s competency in a particular area. Our goal was to enhance resident training and evaluation by creating a high-fidelity cadaveric airway simulation complicated by a GI bleed. Methods: “Emesis” was prepared using coffee grounds, water, food coloring and gravy. Tubing was passed through the cadaver’s nares into the posterior oropharynx out of view of laryngoscopy. After an oral presentation of the case, residents were instructed to proceed with simulated management. “Emesis” was injected towards the larynx with pistons. Resident participants could request interventions and had access to both direct and video laryngoscopy, cricothyroidotomy kit and adjuncts. At 1 minute vitals deteriorated and further worsened with failure to intubate. Time to decision to intubate, and time to intubation were recorded.
Volume 70, no. 4s : October 2017
151
Methicillin-Sensitive S. Aureus Contamination of Ultrasound Probes Using Several Conduction Media
Tansek R, Baranchuk N, Rose G, Siadecki SD, Saul T/Mount Sinai St. Luke’s Mount Sinai West, New York, NY
Study Objectives: Point-of-care ultrasound (POCUS) is integral to the care of patients in the emergency department. Unfortunately, ultrasound probes can act as fomites for pathogen transmission from patient to patient despite various cleaning methods and barrier precautions. It is pertinent to understand what factors contribute to this and how we can best reduce this risk. The objective of this study was to detect growth of methicillin-sensitive Staphylococcus aureus (MSSA) from POCUS probes after scanning an inoculated pork model with several types of conduction media to investigate the difference in pathogen transmission. Methods: A portion of store-bought pork shoulder was disinfected with chlorhexidine and allowed to dry. One mL of a cultured sample of abscessconcentration MSSA was used to inoculate the specimen. A linear transducer was cleansed with a sterilizing cloth and the end of the probe was then covered with a Tegaderm (3M, Maplewood, MN). One of three conduction media was applied to the pork shoulder: sterile saline, chlorhexidine, or sterile gel. The probe was then used to perform a soft tissue scan of the pork shoulder for one minute. After this, the probe was swabbed and cultured to detect transmission of MSSA. This was done four times for each of the three media types. Results: None of the four saline or four chlorhexidine probe swabs grew MSSA when cultured. Three of the four sterile gel probe swabs grew MSSA. Conclusions: These results suggest that sterile ultrasound gel may be more likely to transmit skin pathogens to the probe during POCUS in a simulated environment. However, larger studies and further exploration into this topic are necessary to draw clinical conclusions.
152
Point-of-Care Influenza Testing Does Not Significantly Shorten Time to Disposition Among Emergency Department Patients With an Influenza-Like Illness
Schechter-Perkins EM, Mitchell PM, Nelson KP, Liu J, Desormeau E, Reid M, Orr B, Miller NS/Boston University School of Medicine, Boston, MA; Boston University School of Public Health, Boston, MA; Boston Medical Center, Boston, MA
Study Objectives: Symptoms attributable to influenza-like illness are common presenting complaints to the emergency department (ED) during the winter months. The availability of anti-viral agents and the need to cohort patients with infectious diseases has increased the need to confirm the diagnosis of influenza (flu) prior to determining a disposition for patients. The objectives were to determine if time-todisposition (TTD) was shorter among patients who were tested for influenza using a point-of-care (POC) test in a hospital ED compared to those who were tested in the hospital core laboratory (lab) and to determine if there was a difference in antibiotic use between groups. Methods: This study was conducted at an urban, safety net, academic level 1 trauma center. We conducted a prospective study that enrolled a convenience sample of ED patients for whom influenza testing was physician-ordered per usual ED clinical protocols during peak influenza season 2017. After consenting, subjects were randomized to either core lab testing (Xpert Flu, Cepheid) or POC testing (cobas Liat Influenza A/B, Roche Diagnostics) performed in the ED. Run times for the core lab assays and POC were 55-75 minutes and 20 minutes respectively. Data collected included demographics, chief complaint, results of influenza test, time to test results (TTTR, defined as time from when order was entered until results were available in the Electronic Medical Record), whether antibiotics were given, and TTD (defined as the time from when a patient was placed in the ED treatment room until the disposition (either admit, observe, or discharge) was ordered in the medical record. Descriptive statistics were calculated and group comparisons were made using a two sample t-test. Results: Two hundred fifty-seven patients were approached of which 6 refused, and 51 were excluded (21 had comprehensive respiratory panels performed rather than exclusive influenza tests, 21 non-English speaking, 9 for other reasons). Two hundred subjects were enrolled, and 3 were dropped from the core laboratory arm due to incorrect test orders. Final study population included 97 in the core lab group and 100 in POC group. Demographic characteristics between core lab subjects and POC subjects were the same with respect to mean age, sex, and race. There were fewer flu
Volume 70, no. 4s : October 2017
positive results in the core lab group compared to the POC group (33.0% vs. 51.0%, p¼.01) but a similar percentage of influenza type A (84.4% vs. 86.3%), and discharged patients (83.5% vs. 78.0%). The mean TTTR was 140.0min (SD 318.1min) for the core lab and 35.2min (SD 19.9min) for POC (p¼.001). The mean TTD was 185.9min (SD 110.0) for the core lab group and 168.9min (SD 91.7) for POC (p¼0.26). Antibiotics were given to 14.4% of core lab subjects, and 14.0% of POC subjects (p¼0.93). Conclusions: Although use of a POC influenza test provided a more rapid time to test result than use of a core lab test, there was no statistically significant difference in time to disposition or antibiotic use between the groups. This is in contrast to other studies on POC testing in the ED setting. In this small study this finding may be due to the influence of other factors on disposition decisions in addition to diagnosis of influenza. Test implementation strategies for POC testing benefit from site-specific outcome studies in addition to reliance on published data from other institutions.
153
Pharmacist-Initiated Culture Follow-Up in the Emergency Department Reduces Time to Treatment Optimization
Olson A, Pegelow E, Cowell J, Feldman R, Stanton M, Ray J, Dang C/Froedtert & The Medical College of Wisconsin, Milwaukee, WI
Study Objectives: Urinary tract infections (UTI) and sexually transmitted infections (STI) are frequently encountered medical conditions in the emergency department (ED). Antimicrobial therapy prescribed for treatment is empiric due to the delay between obtaining a culture and growth of an organism to direct definitive therapy. A culture review and call-back process is paramount to ensuring appropriate therapy and preventing complications of inadequately treated infections for patients not requiring hospital admission. This project investigates if pharmacist-driven culture follow-up in the ED results in a reduction in time from final culture results to patient contact, when compared to the previous nurse driven process. Methods: This is a retrospective pre- and post-intervention analysis in a 40-bed Level 1 trauma center ED that has 72,000 annual visits. All patients with UTI or STI cultures drawn in the ED in whom a change in therapy was indicated after final cultures resulted were included. Pre-intervention, all cultures were reviewed by the third-shift charge nurse and forwarded to the designated advanced practice provider (APP). Pharmacists were consulted at the discretion of the APP. Post-intervention, all cultures were first reviewed by an ED pharmacist who then forwarded results and treatment recommendations to the designated APP. Data was collected via electronic health record from September 2015 to February 2016 and April 2016 to September 2016 for the pre- and post-intervention groups, respectively. The primary outcome measured was time from final culture result to patient contact by the APP. Secondary objectives included: prevalence of treatment failure defined as patient return to the ED within 72 hours (h) for the same medical problem, hospital admission within 30 days of ED visit for related conditions (UTI, pyelonephritis, urosepsis), and percentage of pharmacist recommendations. Statistical analysis was completed with Mann-Whitney U test for continuous data. Results: A total of 240 patients were included. Pre-intervention group consisted of 143 patients; 103 UTI patients and 40 STI patients. Post-intervention group consisted of 97 patients; 79 UTI and 18 STI patients. Post-intervention, patients were contacted a median of 19.83 hours earlier than in the pre-intervention group (CI 95%, 17.1522.5; p<0.001). Post-intervention, median contact time for UTI patients was 15.06 hours earlier (CI 95%, 8.35-19.03; p<0.001) and the median contact time for STI patients was 47.31 hours earlier (CI 95%, 29.1-67.41; p<0.001) than the preintervention group. Conclusions: Pharmacist-initiated culture review in the ED culture follow-up process reduces time from final culture results to initiation of optimal antibiotic treatment. Routine pharmacist involvement in the culture review process appears to have great value.
154
Fluid Resuscitation of Septic Patients at Risk for Fluid Overload
Akhter M, Hallare M, Roontiva A, Stowell J/University of Arizona College of Medicine–Phoenix, Maricopa Integrated Health System, Phoenix, AZ; Maricopa Integrated Health System, Phoenix, AZ
Study Objectives: Guidelines recommend rapid fluid resuscitation of at least 30 ml/kg in septic patients in order to improve outcomes. However, since fluid overload
Annals of Emergency Medicine S61
Research Forum Abstracts increases the risk of intubation, providers are wary to aggressively fluid-resuscitate septic patients who are at risk of fluid overload - namely, patients with congestive heart failure (CHF) or end-stage renal disease (ESRD). We sought to assess whether an initial fluid dose of 30 ml/kg in septic CHF or septic ESRD patients, compared to a fluidrestrictive strategy, leads to increased intubations. We also analyzed mortality rates and hospital length of stay (LOS). Methods: At our ED, data on septic patients > 17 years of age are prospectively tracked for quality metrics. Patients who trigger the sepsis flag are up-triaged for quicker provider evaluation to assess whether to implement a sepsis bundle, including whether or not to administer 30 ml/kg of fluids. All patients who are ultimately deemed to have had an infectious source that triggered the flag have multiple metrics logged and tracked. This prospectively collected set of data was retrospectively analyzed. Inclusion criteria were septic patients with past medical history of CHF or ESRD who were given fluids. Patients were excluded if they were under do-notresuscitate (DNR) or comfort-measures-only (CMO) status, as well as if amount of administered fluid was unknown. Primary outcome was intubation frequency. Secondary outcomes were hospital LOS and mortality. Student t-test and chi-square tests was used for analyses. Results: Table 1 demonstrates the outcomes in patients who were given at least 30 ml/kg compared to those who were not. In particular, there were no differences between groups in intubation rates. There were also no differences in hospital LOS or in mortality (although the sample was not sufficiently powered for mortality). Overall, 13.8% (95% CI 9.5%-19.2%) of septic patients with CHF and/or ESRD received 30 ml/kg of fluids in the ED whereas 21.0% (95% CI 18.7%-23.4%) of septic patients without either CHF or ESRD received 30 ml/kg of fluids in the ED (p<0.02). Conclusions: Our analysis suggests that patients with a history of CHF and/or ESRD who become septic and receive at least 30 ml/kg of fluids in the ED are not any more likely to be intubated than the patients who receive fluid-restrictive regimen of < 30 ml/kg. This analysis has limitations, including that there may be baseline differences between the patients who did receive 30 ml/kg of fluids in the ED vs. those who did not. However, our results are in line with some previously presented data. Therefore, an initial bolus of 30 ml/kg of fluids in septic CHF/ ESRD patients appears to be safe - possibly even beneficial - and can potentially be included in a triage bundle set for sepsis care in the ED. At our site, CHF/ESRD patients were significantly less likely to receive 30 ml/kg of fluids in the ED than non-CHF/ESRD patients, but adherence to the 30 ml/kg target was low for all patients. Implementing a 30 ml/kg fluid order from triage could enhance compliance with the Surviving Sepsis guidelines - and still leave providers the option of holding fluids when they clinically deem it appropriate.
procedures performed in the past year and confidence in performing five procedures: ultrasound-guided central line (CL) catheter placement, cricothyrotomy (Crich), precipitous vaginal delivery (PVD), intraosseous line (IO) placement, and thoracostomy tube (CT) placement. During the OPPE session, participants were guided through simulation-based performance of each procedure. A follow-up survey sent 2-8 weeks after the experience to each physician asked their confidence and their opinion of simulation for refreshing procedural skills, assessment, and likelihood of future participation. We analyzed the difference in procedural confidence between pre and post OPPE session using descriptive analysis and paired sample t-test. Results: The median number of yearly procedures performed per provider were: CL - 4, Crich - 1, PVD - 0, IO - 2, CT - 1. Pre- and post-simulation confidence is displayed in Figure 1, and showed a statistically significant improvement in procedural confidence in the post session for Crich, PVD, and CT, with an average post-session procedural confidence increase of 0.8, 0.73, and 0.53, respectively. Though there was no statistical difference in the procedural confidence between pre and post session for CL and IO, there was still a slight post-session increase of 0.4 and 0.14. Average agreement on a 5-point scale for acceptance of simulation as a way to refresh procedural skill and assess performance was 4.2 and 4.0 respectively. Average likelihood to participate in future simulation sessions was 4.7. Conclusions: Offering the ongoing professional practice evaluation in a simulated environment using procedure trainers is one way to increase experience with rare procedures and to improve confidence, while simultaneously demonstrating ongoing proficiency. The use of ultrasound for CL placement and the relative ease of IO line placement may contribute to lack of statistical significance on those procedures. This method was positively received by physicians as a means for refreshing procedural skill and assessing performance.
156 155
Impact of a Simulation-Based Ongoing Professional Practice Evaluation on Provider Procedural Confidence in Five Rare Procedures
Hock SM, Lee EM, Petty K, Shah SC, Sergel M/Rush University Medical Center, Chicago, IL; Northshore University HealthSystem, Evanston, IL; Rush University Medical College, Chicago, IL; John H Stroger Cook County Hospital, Chicago, IL
Study Objectives: Evaluation of procedural skills of practicing Emergency Physicians is a Joint Commission requirement known as the Ongoing Professional Practice Evaluation (OPPE). The authors have implemented a simulation-based OPPE, now in its second year. This study sought to determine the frequency of five rare procedures performed by each emergency physician, determine if the simulationbased OPPE increases confidence, and assess how the simulation format of OPPE is perceived by physicians. Methods: Study participants were board eligible/board certified practicing EPs from one academic institution. Twenty-five physicians consented to the study and completed the pre-survey, and fifteen physicians to date have completed both the pre and post surveys. The pre-simulation survey measured the number of
S62 Annals of Emergency Medicine
High Fidelity Cadaveric Simulation for Management of Patients With Upper Gastrointestinal Bleed
Nelson M, Calandrella C, Greco J, Slowey M/North Shore University Hospital, manhasset, NY
Study Objective: Simulation has emerged as a useful innovative modality for resident training under a controlled environment. However, it often lacks the consistency of real-time interventions. ACGME milestones aim to standardize faculty assessment of residents on proficiency; however, interactions with faculty can have limitations. Assessment is further challenged by the daily variety of cases limiting the ability to adequately monitor progression of the resident’s competency in a particular area. Our goal was to enhance resident training and evaluation by creating a high-fidelity cadaveric airway simulation complicated by a GI bleed. Methods: “Emesis” was prepared using coffee grounds, water, food coloring and gravy. Tubing was passed through the cadaver’s nares into the posterior oropharynx out of view of laryngoscopy. After an oral presentation of the case, residents were instructed to proceed with simulated management. “Emesis” was injected towards the larynx with pistons. Resident participants could request interventions and had access to both direct and video laryngoscopy, cricothyroidotomy kit and adjuncts. At 1 minute vitals deteriorated and further worsened with failure to intubate. Time to decision to intubate, and time to intubation were recorded.
Volume 70, no. 4s : October 2017