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362: 1,199 Case Series: Powered Intraosseous Insertion Provides Safe and Effective Vascular Access for Emergency Patients
Research Forum Abstracts
360
The Emergency Department Involvement in a OneYear Longitudinal Integrated Clerkship for ThirdYear Medical Students
Stein JC, O’Malley R, Orjuela D/University of California, San Francisco, CA
Study Objectives: The clinical education of third year medical students in the United States is challenged by increasing transitions in health care and the erosion of the relationship between the patient, student and health care team. Other institutions in community-based medical settings have reported successes using integrated clerkship models to help students learn core competencies in each discipline through longitudinal relationships with patients and faculty. The Parnassus Integrated Student Clinical Experience (PISCES) is the first program of this model to be piloted at an academic medical center. We sought to create and evaluate an integrated clerkship experience for third-year medical students. The emergency department (ED) was a critical part of this pilot because of its unique ability to incorporate undifferentiated patients in the learning experience as well as to expose students to continuity of care from one of the main points of entry. Methods: We designed a year-long pilot program at UCSF Parnassus Medical Center during 2007-2008. Eight medical students worked longitudinally with preceptors from each of the core disciplines in place of their third-year hospital curriculum. During this period, students worked bi-weekly shifts in the ED where they participated in the evaluation and treatment of undifferentiated patients and subsequently followed those patients through completion of their hospitalization. Selected patients encountered during ED shifts became part of the student’s patient cohort which they followed for the entire year. Students were surveyed at mid-year and year-end to assess their perceptions of this experience. Results: Six of the 8 PISCES students completed a mid-year satisfaction survey regarding the ED experience which showed a mean score 4.5, where 5 was highest (sd ⫹/⫺0.84). Eight PISCES students completed a year-end survey. Students rated their confidence in developing a differential diagnosis of undifferentiated patients with a mean of 4.88 (SD ⫹/⫺ 0.35), where 5 was highest. They rated their confidence in formulating diagnostic and treatment plans on undifferentiated patients with a mean of 5.0 (SD ⫹/⫺ 0.0). Students rated their understanding the patient perspective of transitions of care from ED to admitting services with a mean of 4.5 (SD ⫹/⫺ 0.53). Students additionally rated how well the EM component of PISCES supported achievement of stated learning objectives for the following core clerkships (4 was highest): internal medicine 4.0 (SD ⫹/⫺ 0.0), neurology 3.5 (SD ⫹/⫺ 0.76), pediatrics 3.25 (SD ⫹/⫺1.04), surgery 2.8 (SD ⫹/⫺ 0.64), ob/gyn 2.75 (SD ⫹/⫺ 0.89), psychiatry 2.63 (SD ⫹/⫺ 0.52) and family/community medicine 2.63 (SD ⫹/⫺ 0.74). Conclusions: Satisfaction with the EM component of a longitudinal integrated clerkship experience was high. By year end, students participating in this pilot had high confidence levels regarding the evaluation and treatment of undifferentiated patients and understanding the patient experience of transitions of care. Although the program strongly supported learning objectives in medicine, pediatrics and neurology, medical student learning may benefit from greater emphasis on surgery, psychiatry, family medicine and ob/gyn in the emergency department. Based on the success of the PISCES pilot year, the program will be expanded to 16 students for the 2008-2009 year.
361
Emergency Medicine Intern Use of Objective Structured Clinical Examination in Emergency Medicine Training
Shih RD, Silverman M, Mayer C/Morristown Memorial Hospital, Morristown, NJ
Background: Objective Structured Clinical Examination (OSCE) has been used extensively in medical schools for assessment and teaching purposes. Its use in emergency medicine assessment is limited. Little information exists regarding its usefulness in this setting. Study Objective: To assess emergency medicine intern self-perceived usefulness of OSCEs. Methods: All emergency medicine interns underwent OSCE examinations utilizing 7 standardized patient encounters on the same day. These encounters included scenarios involving: abdominal pain, dyspnea, obesity, panic attack, medical error, autopsy and pharmaceutical representative interaction. After the OSCE examinations, all participants were asked to complete a closed-question suvey. Questions assessed included previous OSCE experience in medical school, utility of each scenario, feedback, overall usefulness, utility of yearly OSCE in residency and whether they recommended the OSCEs for next year’s interns. All questions assessing
S152 Annals of Emergency Medicine
usefulness utilized a 100 mm visual analog scale (VAS), 0 ⫽ no usefulness and 100 mm ⫽ extremely usefull. The VAS scores are reported as averages with two faculty members reviewing all data. Results: 100% of participants had participated in previous OSCEs in medical school with most having more than 5 sessions in the past. The usefulness of individual scenarios were assessed: Abdominal pain: 48.8; Dyspnea: 50.3; Obesity: 47; Panic attack: 48.1, Medical error: 42.9; Autopsy: 58.8; and Pharmaceutical representative interaction: 43.8. The VAS usefulness of the OSCE was 40.8. The usefulness of the OSCE feedback was 36.5. 100% of the emergency medicine interns felt that yearly OSCEs would not be useful and 100% felt that the OSCEs would not be useful for next year’s interns. Conclusions: Emergency medicine interns did not feel that the use of Objective Structured Clinical Examination (OSCE) were useful for their emergency medicine training.
362
1,199 Case Series: Powered Intraosseous Insertion Provides Safe and Effective Vascular Access for Emergency Patients
Fowler RL, Pierce A, Nazeer S, Philbeck TE, Miller LJ/UT Southwestern Medical Center, Dallas, TX; Vidacare Corporation, San Antonio, TX
Study Objectives: For more than 2 decades, intraosseous access (IO) has been a standard of care for pediatric emergencies when conventional intravenous (IV) access cannot be obtained. Following the introduction of a battery-powered IO insertion device (EZ-IO®, Vidacare Corporation, San Antonio, TX, USA), it was recognized that a large clinical trial was needed to demonstrate the safety and effectiveness of intraosseous devices for all patients requiring emergency vascular access. Methods: A retrospective analysis was conducted from data reported to the Vidacare Intraosseous Databank by medical providers utilizing the powered insertion device. From these data, we measured the insertion success rate, time required for insertion, device ease of use (on a scale of 1 [Easy] to 10 [Difficult]), patient pain levels during insertion and infusion, types of fluid and drugs administered, and immediate reported complications of insertion. Results: There were 1,199 eligible patients in the study, 55% of whom were male. Both successful insertion and infusion were achieved in 92% of the patients. Insertion time was 10 seconds or less in 84% of the one-attempt successful cases reporting time to insertion. There were 57 complications (4.8%), but none significant. The most frequently reported complication was extravasation (0.8%); followed by leakage (0.4%) and removal problems (0.2%). For patients with a GCS score ⱖ13, the mean insertion pain score was 3.4⫾3.3 (n⫽73), and the mean infusion pain score was 5.4⫾3.7 (n⫽47). The device was rated easy to use 72% of the time (n⫽745) and the mean ease of use score was 1.7⫾1.7. Conclusion: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to adult and pediatric patients in emergency situations. The relatively minor reported complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of emergency patients.
363
Analytical and Clinical Evaluation of Four D-dimer Methods
Padurean AM, Lund B, Gifford G, Hanson G, Kirchick HJ/AmeriPath Milwaukee, Milwaukee, WI; Wheaton Franciscan Healthcare, Milwaukee, WI; Biosite, an Inverness Company, San Diego, CA
Study Objectives: Pulmonary embolism (PE) and deep venous thrombosis (DVT) are serious conditions with potentially fatal outcomes. Early recognition and therapy can prevent death or other serious complications. D-dimer has become the primary target for early detection of thrombosis with a well-recognized advantage of having a high negative predictive value (NPV). Given the need to provide a fast and reliable D-dimer result, the Wheaton Franciscan Laboratories conducted a method evaluation on four different FDA cleared D-Dimer assays: Biosite Triage®, BioMerieux mini-Vidas®, Instrumentation Laboratory HemosIL for the Beckman Coulter ACL Advance®, and Dade Behring CDDMR TestPak for the Stratus CS®. Methods: This study was granted IRB waiver. Patients included in this study were emergency department presenters and in-patients for whom a D-dimer was ordered. The laboratory ran the D-dimer as usual and saved the extra plasma for testing on the other vendor platforms. Once the additional testing was complete, all four D-dimer results were used for analysis. Additional data included sex, age, imaging studies and final discharge diagnosis. Analytical and clinical correlations
Volume , . : October
360
The Emergency Department Involvement in a OneYear Longitudinal Integrated Clerkship for ThirdYear Medical Students
Stein JC, O’Malley R, Orjuela D/University of California, San Francisco, CA
Study Objectives: The clinical education of third year medical students in the United States is challenged by increasing transitions in health care and the erosion of the relationship between the patient, student and health care team. Other institutions in community-based medical settings have reported successes using integrated clerkship models to help students learn core competencies in each discipline through longitudinal relationships with patients and faculty. The Parnassus Integrated Student Clinical Experience (PISCES) is the first program of this model to be piloted at an academic medical center. We sought to create and evaluate an integrated clerkship experience for third-year medical students. The emergency department (ED) was a critical part of this pilot because of its unique ability to incorporate undifferentiated patients in the learning experience as well as to expose students to continuity of care from one of the main points of entry. Methods: We designed a year-long pilot program at UCSF Parnassus Medical Center during 2007-2008. Eight medical students worked longitudinally with preceptors from each of the core disciplines in place of their third-year hospital curriculum. During this period, students worked bi-weekly shifts in the ED where they participated in the evaluation and treatment of undifferentiated patients and subsequently followed those patients through completion of their hospitalization. Selected patients encountered during ED shifts became part of the student’s patient cohort which they followed for the entire year. Students were surveyed at mid-year and year-end to assess their perceptions of this experience. Results: Six of the 8 PISCES students completed a mid-year satisfaction survey regarding the ED experience which showed a mean score 4.5, where 5 was highest (sd ⫹/⫺0.84). Eight PISCES students completed a year-end survey. Students rated their confidence in developing a differential diagnosis of undifferentiated patients with a mean of 4.88 (SD ⫹/⫺ 0.35), where 5 was highest. They rated their confidence in formulating diagnostic and treatment plans on undifferentiated patients with a mean of 5.0 (SD ⫹/⫺ 0.0). Students rated their understanding the patient perspective of transitions of care from ED to admitting services with a mean of 4.5 (SD ⫹/⫺ 0.53). Students additionally rated how well the EM component of PISCES supported achievement of stated learning objectives for the following core clerkships (4 was highest): internal medicine 4.0 (SD ⫹/⫺ 0.0), neurology 3.5 (SD ⫹/⫺ 0.76), pediatrics 3.25 (SD ⫹/⫺1.04), surgery 2.8 (SD ⫹/⫺ 0.64), ob/gyn 2.75 (SD ⫹/⫺ 0.89), psychiatry 2.63 (SD ⫹/⫺ 0.52) and family/community medicine 2.63 (SD ⫹/⫺ 0.74). Conclusions: Satisfaction with the EM component of a longitudinal integrated clerkship experience was high. By year end, students participating in this pilot had high confidence levels regarding the evaluation and treatment of undifferentiated patients and understanding the patient experience of transitions of care. Although the program strongly supported learning objectives in medicine, pediatrics and neurology, medical student learning may benefit from greater emphasis on surgery, psychiatry, family medicine and ob/gyn in the emergency department. Based on the success of the PISCES pilot year, the program will be expanded to 16 students for the 2008-2009 year.
361
Emergency Medicine Intern Use of Objective Structured Clinical Examination in Emergency Medicine Training
Shih RD, Silverman M, Mayer C/Morristown Memorial Hospital, Morristown, NJ
Background: Objective Structured Clinical Examination (OSCE) has been used extensively in medical schools for assessment and teaching purposes. Its use in emergency medicine assessment is limited. Little information exists regarding its usefulness in this setting. Study Objective: To assess emergency medicine intern self-perceived usefulness of OSCEs. Methods: All emergency medicine interns underwent OSCE examinations utilizing 7 standardized patient encounters on the same day. These encounters included scenarios involving: abdominal pain, dyspnea, obesity, panic attack, medical error, autopsy and pharmaceutical representative interaction. After the OSCE examinations, all participants were asked to complete a closed-question suvey. Questions assessed included previous OSCE experience in medical school, utility of each scenario, feedback, overall usefulness, utility of yearly OSCE in residency and whether they recommended the OSCEs for next year’s interns. All questions assessing
S152 Annals of Emergency Medicine
usefulness utilized a 100 mm visual analog scale (VAS), 0 ⫽ no usefulness and 100 mm ⫽ extremely usefull. The VAS scores are reported as averages with two faculty members reviewing all data. Results: 100% of participants had participated in previous OSCEs in medical school with most having more than 5 sessions in the past. The usefulness of individual scenarios were assessed: Abdominal pain: 48.8; Dyspnea: 50.3; Obesity: 47; Panic attack: 48.1, Medical error: 42.9; Autopsy: 58.8; and Pharmaceutical representative interaction: 43.8. The VAS usefulness of the OSCE was 40.8. The usefulness of the OSCE feedback was 36.5. 100% of the emergency medicine interns felt that yearly OSCEs would not be useful and 100% felt that the OSCEs would not be useful for next year’s interns. Conclusions: Emergency medicine interns did not feel that the use of Objective Structured Clinical Examination (OSCE) were useful for their emergency medicine training.
362
1,199 Case Series: Powered Intraosseous Insertion Provides Safe and Effective Vascular Access for Emergency Patients
Fowler RL, Pierce A, Nazeer S, Philbeck TE, Miller LJ/UT Southwestern Medical Center, Dallas, TX; Vidacare Corporation, San Antonio, TX
Study Objectives: For more than 2 decades, intraosseous access (IO) has been a standard of care for pediatric emergencies when conventional intravenous (IV) access cannot be obtained. Following the introduction of a battery-powered IO insertion device (EZ-IO®, Vidacare Corporation, San Antonio, TX, USA), it was recognized that a large clinical trial was needed to demonstrate the safety and effectiveness of intraosseous devices for all patients requiring emergency vascular access. Methods: A retrospective analysis was conducted from data reported to the Vidacare Intraosseous Databank by medical providers utilizing the powered insertion device. From these data, we measured the insertion success rate, time required for insertion, device ease of use (on a scale of 1 [Easy] to 10 [Difficult]), patient pain levels during insertion and infusion, types of fluid and drugs administered, and immediate reported complications of insertion. Results: There were 1,199 eligible patients in the study, 55% of whom were male. Both successful insertion and infusion were achieved in 92% of the patients. Insertion time was 10 seconds or less in 84% of the one-attempt successful cases reporting time to insertion. There were 57 complications (4.8%), but none significant. The most frequently reported complication was extravasation (0.8%); followed by leakage (0.4%) and removal problems (0.2%). For patients with a GCS score ⱖ13, the mean insertion pain score was 3.4⫾3.3 (n⫽73), and the mean infusion pain score was 5.4⫾3.7 (n⫽47). The device was rated easy to use 72% of the time (n⫽745) and the mean ease of use score was 1.7⫾1.7. Conclusion: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to adult and pediatric patients in emergency situations. The relatively minor reported complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of emergency patients.
363
Analytical and Clinical Evaluation of Four D-dimer Methods
Padurean AM, Lund B, Gifford G, Hanson G, Kirchick HJ/AmeriPath Milwaukee, Milwaukee, WI; Wheaton Franciscan Healthcare, Milwaukee, WI; Biosite, an Inverness Company, San Diego, CA
Study Objectives: Pulmonary embolism (PE) and deep venous thrombosis (DVT) are serious conditions with potentially fatal outcomes. Early recognition and therapy can prevent death or other serious complications. D-dimer has become the primary target for early detection of thrombosis with a well-recognized advantage of having a high negative predictive value (NPV). Given the need to provide a fast and reliable D-dimer result, the Wheaton Franciscan Laboratories conducted a method evaluation on four different FDA cleared D-Dimer assays: Biosite Triage®, BioMerieux mini-Vidas®, Instrumentation Laboratory HemosIL for the Beckman Coulter ACL Advance®, and Dade Behring CDDMR TestPak for the Stratus CS®. Methods: This study was granted IRB waiver. Patients included in this study were emergency department presenters and in-patients for whom a D-dimer was ordered. The laboratory ran the D-dimer as usual and saved the extra plasma for testing on the other vendor platforms. Once the additional testing was complete, all four D-dimer results were used for analysis. Additional data included sex, age, imaging studies and final discharge diagnosis. Analytical and clinical correlations
Volume , . : October