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Bridging the Gap: Evaluation of an Electrocardiogram Curriculum for Advanced Practice Clinicians. 缩小差距:评估针对高级临床医师的心电图课程。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18085
Steven Lindsey, Tim P Moran, Meredith A Stauch, Alexis L Lynch, Kristen Grabow Moore

Background: Training programs for advanced practice providers (APP) often have significant variability in their curriculum, including electrocardiogram (ECG) education. Despite limitations in formal ECG training, APPs in the emergency department (ED) may be the first practitioner to interpret an ECG. Foundations of Emergency Medicine (FoEM) offers free, open-access curricula that are widely used for resident education. We sought to improve APP ECG interpretation skills by implementing the FoEM ECG I course.

Methods: This was a single-site, pre- and post-intervention study of 23 APPs at our high-acuity, urban ED. In the fall of 2020, APP learners enrolled in a FoEM ECG I course led by faculty and senior resident instructors. The course consisted of six virtual, small-group, active-learning ECG workshops. Participants completed a 15-question multiple-choice test before, immediately after, and six months post-intervention to quantify knowledge acquisition. Additionally, a pre- and post-intervention knowledge, attitudes, and practices survey was administered on ECG interpretation skills and to evaluate the course. We evaluated change in ECG knowledge scores using a Wilcoxon signed-rank test. Changes in self-assessed knowledge were evaluated using an ordinal logistic mixed-effects regression.

Results: A total of 23 APPs enrolled in the course. Knowledge assessments showed APPs improved from the pre-test (median 9/15, interquartile range [IQR] 7-11) to the post-test (median 12/15, IQR 10-13; P = 0.001). Test scores did not significantly change from the post-test to the delayed post-test (median 12/15, IQR 12-13; P = 0.30). Respondents' subjective rating of their skill did not significantly change (P = 0.06). Respondents reported no change in their likelihood of approaching an attending when uncertain of the correct interpretation of an ECG (P = 0.16). Overall, 91% were satisfied with the course and 96% agreed that the course difficulty was appropriate.

Conclusion: The FoEM ECG course provided a standardized curriculum that improved APP knowledge for interpreting ECGs. Despite this, the course did not alter APPs' willingness to approach physicians for guidance with interpretation of abnormal ECGs. These findings may inform expansion of this concept for other programs who desire formalized APP ECG education.

背景:针对高级医疗服务提供者(APP)的培训计划通常在课程设置上存在很大差异,包括心电图(ECG)教育。尽管正规的心电图培训存在局限性,但急诊科(ED)的 APP 可能是第一位解释心电图的从业人员。急诊医学基础(FoEM)提供免费、开放的课程,广泛用于住院医师教育。我们试图通过实施 FoEM 心电图 I 课程来提高 APP 心电图解读技能:这是一项单点、干预前和干预后研究,对象是我们高危城市急诊室的 23 名 APP。2020 年秋季,APP 学员参加了由教师和资深住院医师指导的 FoEM 心电图 I 课程。该课程包括六个虚拟、小组、主动学习的心电图研讨会。学员在干预前、干预后和干预后六个月分别完成了 15 道选择题的测试,以量化知识掌握情况。此外,我们还就心电图解读技能和课程评估进行了干预前和干预后的知识、态度和实践调查。我们使用 Wilcoxon 符号秩检验来评估心电图知识得分的变化。采用序数逻辑混合效应回归法评估自我评估知识的变化:共有 23 名 APP 参加了课程。知识评估结果显示,从测试前(中位数9/15,四分位数间距[IQR] 7-11)到测试后(中位数12/15,四分位数间距[IQR] 10-13;P = 0.001),APPs的知识水平有所提高。从测试后到延迟测试后,测试分数没有明显变化(中位数为 12/15,IQR 为 12-13;P = 0.30)。受试者对自己技能的主观评价没有明显变化(P = 0.06)。受试者表示,在不确定心电图的正确解释时,他们向主治医生求助的可能性没有变化(P = 0.16)。总体而言,91% 的受访者对课程表示满意,96% 的受访者认为课程难度适当:结论:FoEM 心电图课程提供了标准化的课程,提高了 APP 对心电图解读的认识。尽管如此,该课程并未改变 APP 在解读异常心电图时向医生寻求指导的意愿。这些发现可为其他希望开展正规 APP 心电图教育的项目推广这一理念提供参考。
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引用次数: 0
Factors Associated with Overutilization of Computed Tomography Cervical Spine Imaging. 与过度使用计算机断层扫描颈椎成像相关的因素。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18570
Tessy La Torre Torres, Jonathan McGhee
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引用次数: 0
Novel Scoring Scale for Quality Assessment of Lung Ultrasound in the Emergency Department. 急诊科肺部超声质量评估的新评分标准。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18225
Jessica R Balderston, Taylor Brittan, Bruce J Kimura, Chen Wang, Jordan Tozer

Introduction: The use of a reliable scoring system for quality assessment (QA) is imperative to limit inconsistencies in measuring ultrasound acquisition skills. The current grading scale used for QA endorsed by the American College of Emergency Physicians (ACEP) is non-specific, applies irrespective of the type of study performed, and has not been rigorously validated. Our goal in this study was to determine whether a succinct, organ-specific grading scale designed for lung-specific QA would be more precise with better interobserver agreement.

Methods: This was a prospective validation study of an objective QA scale for lung ultrasound (LUS) in the emergency department. We identified the first 100 LUS performed in normal clinical practice in the year 2020. Four reviewers at an urban academic center who were either emergency ultrasound fellowship-trained or current fellows with at least six months of QA experience scored each study, resulting in a total of 400. The primary outcome was the level of agreement between the reviewers. Our secondary outcome was the variability of the scores given to the studies. For the agreement between reviewers, we computed the intraclass correlation coefficient (ICC) based on a two-way random-effect model with a single rater for each grading scale. We generated 10,000 bootstrapped ICCs to construct 95% confidence intervals (CI) for both grading systems. A two-sided one-sample t-test was used to determine whether there were differences in the bootstrapped ICCs between the two grading systems.

Results: The ICC between reviewers was 0.552 (95% CI 0.40-0.68) for the ACEP grading scale and 0.703 (95% CI 0.59-0.79) for the novel grading scale (P < 0.001), indicating significantly more interobserver agreement using the novel scale compared to the ACEP scale. The variance of scores was similar (0.93 and 0.92 for the novel and ACEP scales, respectively).

Conclusion: We found an increased interobserver agreement between reviewers when using the novel, organ-specific scale when compared with the ACEP grading scale. Increased consistency in feedback based on objective criteria directed to the specific, targeted organ provides an opportunity to enhance learner education and satisfaction with their ultrasound education.

简介:使用可靠的评分系统进行质量评估(QA)是限制超声采集技能测量不一致的当务之急。美国急诊医师学会(ACEP)认可的目前用于质量评估的分级表没有特异性,适用于任何类型的研究,而且尚未经过严格验证。本研究的目的是确定针对肺部特异性 QA 设计的简明、器官特异性分级表是否更精确,观察者之间的一致性是否更好:这是一项针对急诊科肺部超声检查(LUS)客观 QA 量表的前瞻性验证研究。我们确定了 2020 年正常临床实践中进行的前 100 例 LUS。一个城市学术中心的四名评审员对每项研究进行了评分,他们要么是受过急诊超声研究员培训的研究员,要么是具有至少六个月质量保证经验的现任研究员,共400人。主要结果是评审员之间的一致程度。我们的次要结果是研究评分的可变性。对于审稿人之间的一致性,我们根据双向随机效应模型计算了类内相关系数 (ICC),每个评分量表由一名审稿人进行评分。我们生成了 10,000 个引导 ICC,以构建两种评分系统的 95% 置信区间 (CI)。我们使用双侧单样本 t 检验来确定两种评分系统的引导 ICC 是否存在差异:结果:ACEP 分级表的审稿人间 ICC 为 0.552(95% CI 0.40-0.68),新分级表的审稿人间 ICC 为 0.703(95% CI 0.59-0.79):我们发现,与 ACEP 分级表相比,在使用新型器官特异性分级表时,审稿人之间的观察者间一致性更高。根据针对特定、目标器官的客观标准提高反馈的一致性为加强学习者的教育和提高他们对超声教育的满意度提供了机会。
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引用次数: 0
Stage B Heart Failure Is Ubiquitous in Emergency Patients with Asymptomatic Hypertension. 无症状高血压急诊患者普遍存在 B 期心衰
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.17990
Kimberly Souffront, Bret P Nelson, Megan Lukas, Hans Reyes Garay, Lauren Gordon, Thalia Matos, Isabella Hanesworth, Rebecca Mantel, Claire Shubeck, Cassidy Bernstein, George T Loo, Lynne D Richardson

Introduction: Hypertension is the leading risk factor for morbidity and mortality throughout the world and is pervasive in United States emergency departments (ED). This study documents the point prevalence of subclinical heart disease in emergency patients with asymptomatic hypertension.

Method: This was a prospective observational study of ED patients with asymptomatic hypertension conducted at two urban academic EDs that belong to an eight-hospital healthcare organization in New York. Adult (≥18 years of age) English- or Spanish-speaking patients who had an initial blood pressure (BP) ≥160/100 millimeters of mercury (mmHg) and second BP ≥140/90 mm Hg, and pending discharge, were invited to participate in the study. We excluded patients with congestive heart failure, renal insufficiency, and atrial fibrillation, or who were pregnant, a prisoner, cognitively unable to provide informed consent, or experiencing symptoms of hypertension. We assessed echocardiographic evidence of subclinical heart disease (left ventricular hypertrophy, and diastolic and systolic dysfunction).

Results: A total of 53 patients were included in the study; a majority were young (mean 49.5 years old, [SD 14-52]), self-identified as Black or Other (n = 39; 73.5%), and female (n = 30; 56.6%). Mean initial blood pressure was 172/100 mm Hg, and 24 patients (45.3%) self-reported a history of hypertension. Fifty patients completed an echocardiogram. All (100%) had evidence of subclinical heart disease, with 41 (77.4%) displaying left ventricular hypertrophy and 31 (58.5%) diastolic dysfunction. There was a significant relationship between diastolic dysfunction and female gender [x2 (1, n = 53) = 3.98; P = 0.046]; Black or other race [x2 (3, n = 53) = 9.138; P = 0.03] and Hispanic or other ethnicity [x2 (2, n = 53) = 8.03; P = 0.02]. Less than one third of patients demonstrated systolic dysfunction on echocardiogram, and this was more likely to occur in patients with diabetes mellitus [x2 (1, n = 51) = 4.84; P = 0.02].

Conclusion: There is a high probability that Black, Hispanic, and female patients with asymptomatic hypertension are on the continuum for developing overt heart failure. Emergency clinicians should provide individualized care that considers their unique health needs, cultural backgrounds, and social determinants of health.

导言:高血压是全世界发病率和死亡率的主要风险因素,在美国急诊科(ED)中也很普遍。本研究记录了无症状高血压急诊患者亚临床心脏病的发病率:这是一项针对无症状高血压急诊患者的前瞻性观察研究,在纽约的两家城市学术急诊室进行,这两家急诊室隶属于纽约的一家八医院医疗机构。邀请初次血压(BP)≥160/100 毫米汞柱(mmHg)和第二次血压≥140/90 毫米汞柱(mmHg)且即将出院的英语或西班牙语成人(≥18 岁)患者参与研究。我们排除了充血性心力衰竭、肾功能不全和心房颤动患者,或孕妇、囚犯、认知能力无法做出知情同意或出现高血压症状的患者。我们评估了亚临床心脏病(左心室肥大、舒张和收缩功能障碍)的超声心动图证据:本研究共纳入 53 名患者,其中大部分患者为年轻人(平均 49.5 岁,[SD 14-52]),自认为是黑人或其他族裔(39 人;73.5%),女性(30 人;56.6%)。初始平均血压为 172/100 mm Hg,24 名患者(45.3%)自述有高血压病史。50 名患者完成了超声心动图检查。所有患者(100%)都有亚临床心脏病的证据,其中 41 人(77.4%)显示左心室肥厚,31 人(58.5%)显示舒张功能障碍。舒张功能障碍与女性性别[x2 (1, n = 53) = 3.98; P = 0.046]、黑人或其他种族[x2 (3, n = 53) = 9.138; P = 0.03]和西班牙裔或其他种族[x2 (2, n = 53) = 8.03; P = 0.02]有明显关系。不到三分之一的患者在超声心动图上显示出收缩功能障碍,糖尿病患者更容易出现这种情况[x2(1,n = 51)= 4.84;P = 0.02]:结论:黑人、西班牙裔和女性无症状高血压患者极有可能发展为明显的心力衰竭。急诊医生应考虑到他们独特的健康需求、文化背景和健康的社会决定因素,为他们提供个性化的护理。
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引用次数: 0
Development and Validation of a Scoring Rubric for Editorial Evaluation of Peer-review Quality: A Pilot Study. 开发并验证用于同行评审质量编辑评估的评分标准:试点研究。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18432
Jeffrey N Love, Anne M Messman, Jonathan S Ilgen, Chris Merritt, Wendy C Coates, Douglas S Ander, David P Way

Introduction: Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review's value to a journal editor's decision-making. The graduate medical education editors of the Western Journal of Emergency Medicine Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor's scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration.

Methods: Using peer-review guidelines from several journals, the Special Issue's editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane's validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making.

Results: Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor's rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor's formal decision.

Conclusion: Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.

导言:尽管同行评审对出版物非常重要,但目前还没有一种普遍接受的编辑评价方法来评估同行评审对期刊编辑决策的价值。西部急诊医学杂志》教育研究与实践特刊(特刊)的研究生医学教育编辑开发并研究了整体编辑评分标准(HESR),目的是评估审稿质量,并强调审稿在多大程度上有助于对正在审议的投稿进行整体评价:方法:特刊编辑利用多家期刊的同行评审指南制定了评分标准,描述了从理想到不可接受的不同质量水平的同行评审。每位编辑使用该评分标准对一篇评论进行评估后,将分数提交给第三方进行盲评。我们将新评分标准的性能与之前使用的语义差异量表工具进行了比较。凯恩的有效性框架围绕三个基本假设对新的评分标准进行了评估:改善了分数的分布;编辑之间的相对一致性而非绝对的评分者之间的可靠性;统计证据表明,编辑重视对其决策贡献最大的同行评审:本研究的主题是 90 篇同行评审,所有评审均由两名编辑进行评估。与之前评分标准的高度倾斜分布相比,新评分标准的分布呈钟形,表明评分标准得到了充分利用。编辑之间的绝对一致度为中低,而编辑评分标准之间的相对一致度较高。最后,我们发现,评级较高的同行评审建议更有可能与编辑的正式决定一致:关于 HESR 的早期证据支持使用该工具来确定同行评审的质量以及其在为编辑决策提供信息方面的相对重要性。
{"title":"Development and Validation of a Scoring Rubric for Editorial Evaluation of Peer-review Quality: A Pilot Study.","authors":"Jeffrey N Love, Anne M Messman, Jonathan S Ilgen, Chris Merritt, Wendy C Coates, Douglas S Ander, David P Way","doi":"10.5811/westjem.18432","DOIUrl":"https://doi.org/10.5811/westjem.18432","url":null,"abstract":"<p><strong>Introduction: </strong>Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review's value to a journal editor's decision-making. The graduate medical education editors of the <i>Western Journal of Emergency Medicine</i> Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor's scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration.</p><p><strong>Methods: </strong>Using peer-review guidelines from several journals, the Special Issue's editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane's validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making.</p><p><strong>Results: </strong>Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor's rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor's formal decision.</p><p><strong>Conclusion: </strong>Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"25 2","pages":"254-263"},"PeriodicalIF":3.1,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11000557/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140855383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions. 全国神经系统复杂慢性病患儿急诊护理特点。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.17834
Kaileen Jafari, Kristen Carlin, Derya Caglar, Eileen J Klein, Tamara D Simon

Introduction: Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).

Methods: We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.

Results: There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs.

Conclusion: Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

简介:大多数儿科急诊都是在普通急诊科(GED)进行的,而普通急诊科的儿科经验较少,儿科急诊的准备程度较低,可能会影响对患者的护理。在普通急诊室,儿科经验较少、儿科急救准备不足可能会影响急救效果。儿科病人(如患有慢性、严重神经系统疾病的病人)在医疗上很容易受到普通急诊室不完善的护理服务的严重影响;然而,人们对他们在普通急诊室或儿科急诊室接受护理的特点却知之甚少。在这项研究中,我们的目标是比较患有慢性神经系统疾病的儿童在普通急诊室和儿科急诊室就诊的频率、特点和结果:我们对 2011-2014 年全国急诊科样本(NEDS)中 0-21 岁神经系统复杂慢性疾病(神经 CCC)患者的急诊就诊情况进行了回顾性分析。我们使用描述性统计方法比较了 GED 和 PED 的患者、医院和急诊就诊特征。我们使用多变量逻辑回归法评估了入院、转院、关键程序表现和死亡率等结果:我们的样本中有 387,813 例神经性 CCC ED 就诊(占 0-21 岁 ED 就诊人数的 0.3%)。主要是在普通急诊室就诊,就诊者的病情严重程度较高(30.1%为最高严重程度分类得分)。与普通急诊室就诊者相比,PED 神经 CCC 就诊者更年轻,更有可能患有并发症(32.9% 对 21%,P P 结论:在儿科急诊室护理患有神经 CCC 的儿童可减少资源使用,降低转院率和死亡率。确定儿科急诊室护理神经性 CCC 的特点可降低这一人群的费用和死亡率。
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引用次数: 0
Analysis of Anonymous Student Narratives About Experiences with Emergency Medicine Residency Programs. 分析匿名学生讲述的急诊医学住院医师培训项目经历。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.17973
Molly Estes, Jacob Garcia, Ronnie Ren, Mark Olaf, Shannon Moffett, Michael Galuska, Xiao Chi Zhang

Background: Academic emergency medicine (EM) communities have viewed anonymous online communities (AOC) such as Reddit or specialty-specific "applicant spreadsheets" as poor advising resources. Despite this, robust EM AOCs exist, with large user bases and heavy readership. Insights about applicants' authentic experiences can be critical for applicants and program leadership decision-making. To date, there are no EM studies to qualitatively assess EM AOC narratives during the application cycle. Our goal was to perform a qualitative analysis of students' EM program experiences through a publicly available AOC.

Methods: This was a qualitative analysis of a publicly available, time-stamped, user-locked AOC dataset: "Official 2020-2021 Emergency Medicine Applicant Spreadsheet." We extracted and then de-identified all data from selected sub-sheets entitled "Virtual Interview Impressions" and "Rotation Impressions." Four investigators used constant comparative method to analyze the data inductively, and they subsequently met to generate common themes discussed by students. Preliminary thematic analysis was conducted on a random sample of 37/183 (20%) independent narratives to create the initial codebook. This was used and updated iteratively to analyze the entire narrative set consisting of 841 discrete statements. Finally, two unique codes were created to distinguish whether the identified sub-themes, or program attributes, were likely "modifiable" or "non-modifiable."

Results: We identified six major themes: living and working conditions; interpersonal relationships; learning experiences, postgraduate readiness, and online/virtual supplements. Common sub-themes included patient population (13%); resident personality (7%); program leadership personality (7%); relationship with faculty/leadership (6%); geography (4%); practice setting (4%); program reputation (4%), and postgraduate year-3 experiences (4%). Modifiable sub-themes outnumbered non-modifiable sub-themes, 60.7% to 39.3%.

Conclusion: In this analysis of selected medical students' narratives in an AOC, the majority of identified themes represented topics that may serve as external feedback for EM residency programs and their clerkships. Selective use of AOCs may set a precedent for future program assessments by applicants and inform program leadership of important programmatic elements in the eyes of applicants. It elucidates important themes in their interactions or learning experiences with programs and creates opportunities for learner-centric program improvement.

背景:急诊医学(EM)学术界一直将 Reddit 等匿名在线社区(AOC)或特定专业的 "申请者电子表格 "视为糟糕的咨询资源。尽管如此,仍然存在着强大的急诊医学 AOC,它们拥有庞大的用户群和大量的读者。了解申请者的真实经历对申请者和项目领导决策至关重要。迄今为止,还没有任何关于在申请周期内对 EM AOC 叙述进行定性评估的 EM 研究。我们的目标是通过公开的AOC对学生的EM项目经历进行定性分析:这是对一个公开的、有时间戳的、用户锁定的 AOC 数据集进行的定性分析:"2020-2021年急诊医学申请官方电子表格"。我们从选定的 "虚拟面试印象 "和 "轮转印象 "子表中提取了所有数据,然后进行了去标识化处理。四名调查人员采用不断比较法对数据进行归纳分析,随后他们开会讨论学生们讨论的共同主题。对 37/183 份(20%)独立叙述中的随机样本进行了初步主题分析,以创建初始代码集。在分析由 841 个离散语句组成的整个叙述集时,使用并反复更新了该编码集。最后,我们创建了两个独特的代码,以区分所确定的次主题或计划属性是 "可修改 "还是 "不可修改":我们确定了六大主题:生活和工作条件;人际关系;学习经历;毕业后的准备情况;在线/虚拟补充。常见的次主题包括:患者群体(13%);住院医师个性(7%);项目领导个性(7%);与教师/领导的关系(6%);地理位置(4%);实践环境(4%);项目声誉(4%)以及研究生第三年的经历(4%)。可修改子主题的比例为 60.7%:39.3%:在对选定的医学生在 AOC 中的叙述进行的分析中,大部分已确定的主题代表了可作为 EM 住院医师培训项目及其实习的外部反馈的主题。有选择性地使用AOC可能会为申请者未来的项目评估开创先例,并让项目领导了解申请者眼中重要的项目要素。它阐明了他们与项目互动或学习经历中的重要主题,并为以学习者为中心的项目改进创造了机会。
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引用次数: 0
Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews. 根据健康记录和结构化访谈得出的精神健康诊断急诊室使用率低、高和极高的特征。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18327
Marie-Josée Fleury, Zhirong Cao, Guy Grenier

Introduction: Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD.

Methods: Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use.

Results: Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use.

Conclusion: Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

简介:被诊断出患有精神疾病的患者是急诊科(ED)使用频率最高的人群之一,这表明确定与他们使用急诊科频率相关的其他因素非常重要。在这项研究中,我们评估了患者的各种社会人口学和临床特征,以及与低急诊科就诊率(1-3 次/年)相关的服务使用情况,并与高急诊科就诊率(4-7 次/年)和超高急诊科就诊率(8 次/年以上)的精神疾病患者进行了比较:我们的研究在加拿大魁北克省的四个大型急诊室网络中进行。方法:我们的研究在加拿大魁北克省的四个大型急诊室网络中进行,在 2021-2022 年期间从这些急诊室随机招募了 299 名 MHD 患者。结构化访谈补充了来自网络健康记录的数据,提供了有关参与者概况及其护理质量的大量数据。我们使用多变量多项式逻辑回归法比较了低急诊室使用率与高急诊室使用率和极高急诊室使用率:在 12 个月的时间里,39% 的患者为急诊室使用率低的患者,37% 为急诊室使用率高的患者,24% 为急诊室使用率非常高的患者。与急诊室使用率低的患者相比,急诊室使用率高或非常高的患者表现出更多的暴力/不安行为或社会问题、慢性身体疾病以及未满足需求的障碍。曾住院 1-2 次的患者使用急诊室的高风险或极高风险低于未住院的患者。与急诊室使用率低的患者相比,急诊室使用率高和使用率极高的患者的人格障碍和自杀行为发生率分别更高。与男性相比,女性使用ED的几率更高。与居住在私人住房的患者相比,居住在出租房的患者有更大的可能成为ED使用率极高的患者。使用至少5次以上初级保健服务以及在使用急诊室服务的最后一年前两年经常使用急诊室服务的患者使用急诊室服务的几率非常高:使用急诊室的频率与患者的复杂问题和较高的未满足需求感知障碍有关。尽管使用了更多的初级医疗服务,但极高急诊室使用率患者的复发情况更为严重,如孤独和自杀行为。研究结果表明,通过整合危机解决和支持性住房服务,大大减少了这些弱势患者获得护理的障碍,并提高了护理的可及性和连续性。有时可能需要进行有限的住院治疗,以避免使用急诊室。
{"title":"Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews.","authors":"Marie-Josée Fleury, Zhirong Cao, Guy Grenier","doi":"10.5811/westjem.18327","DOIUrl":"https://doi.org/10.5811/westjem.18327","url":null,"abstract":"<p><strong>Introduction: </strong>Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD.</p><p><strong>Methods: </strong>Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use.</p><p><strong>Results: </strong>Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use.</p><p><strong>Conclusion: </strong>Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"25 2","pages":"144-154"},"PeriodicalIF":3.1,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11000562/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140858265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans. 急诊科计算机断层扫描延迟的根本原因分析。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.17831
Arjun Dhanik, Bryan A Stenson, Robin B Levenson, Peter S Antkowiak, Leon D Sanchez, David T Chiu

Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED.

Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1-July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis.

Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0-29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8-24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8-20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3-18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8-17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3-40.4).

Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

导言:解决急诊科(ED)拥堵问题的方案仍遥遥无期。随着人们对成像技术的依赖越来越大,计算机断层扫描(CT)的周转时间被认为是一个主要瓶颈。在这项研究中,我们试图找出与急诊科 CT 明显延迟相关的因素:方法:我们对 2021 年 5 月 1 日至 7 月 31 日期间一家城市三级医院急诊室完成的所有 CT 成像进行了回顾性分析。在此期间,共为 4344 名患者进行了 5685 次 CT 检查,从下达 CT 命令到完成检查的中位时间为 108 分钟(第一四分位 [Q1]:57分钟,第3四分位数[Q3]:182分钟,四分位数间距:0.5:182分钟,四分位数间距 [IQR]:125分钟:125 分钟)。异常值被定义为完成时间超过 369 分钟(Q3 + 1.5 × IQR)的研究。我们系统地查看了异常值病历,以确定与延迟相关的因素,并确定了五个因素:行为不合规或病情不稳定的患者;静脉注射 (IV) 管路问题;造影剂过敏;肾小球滤过率 (GFR) 问题;与成像方案相关的延迟(例如,需要静脉注射造影剂、要求口服和/或直肠造影剂)。我们采用改良 Wald 法计算置信区间 (CI)。通过卡帕分析评估了评分者之间的可靠性:我们共发现了 182 个异常值(占患者总数的 4.2%)。其中 15 例(8.2%)因 CT 时间戳不一致而被排除。在分析的 167 例异常值中,38 例延迟(22.8%,95% 置信区间 [CI] 17.0-29.7)是由于行为不合规或病情不稳定的患者造成的;30 例(18.0%,95% 置信区间 12.8-24.5)是由于静脉注射问题造成的。5)是由于静脉注射问题;24(14.4%,95% CI 9.8-20.6)是由于造影剂过敏;21(12.6%,95% CI 8.3-18.5)是由于 GFR 问题;20(12.0%,95% CI 7.8-17.9)与成像研究协议有关。55例(32.9%,95% CI 26.3-40.4)延误原因不明:我们的研究发现了与急诊室 CT 大幅延迟相关的可调节和不可调节因素。患者的行为、过敏和病情严重程度等因素无法控制。但是,有关难以进行静脉注射、在低 GFR 环境中使用造影剂以及研究方案的机构政策可以进行修改,这样最多可捕获 42.6% 的异常值。
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引用次数: 0
Space Ultrasound: A Proposal for Competency-based Ultrasound Training for In-flight Space Medicine. 太空超声波:为飞行中的太空医学提供基于能力的超声波培训的建议。
IF 3.1 3区 医学 Q2 EMERGENCY MEDICINE Pub Date : 2024-03-01 DOI: 10.5811/westjem.18422
Chanel Fischetti, Emily Frisch, Michael Loesche, Andrew Goldsmith, Ben Mormann, Joseph S Savage, Roger Dias, Nicole Duggan

Space travel has transformed in the past several years. Given the burgeoning market for space tourism, in-flight medical emergencies are likely to be expected. Ultrasound is one of the few diagnostic and therapeutic modalities available for astronauts in space. However, while point-of-care ultrasound (POCUS) is available, there is no current standard of training for astronaut preparation. We suggest an organized and structured methodology by which astronauts should best prepare for space with the medical equipment available on board. As technology continues to evolve, the assistance of other artificial intelligence and augmented reality systems are likely to facilitate training and dynamic real-time needs during space emergencies. Summary: As space tourism continues to evolve, an organized methodology for POCUS use is advised to best prepare astronauts for space.

在过去几年中,太空旅行发生了巨大变化。鉴于太空旅游市场的蓬勃发展,预计会出现飞行中的医疗紧急情况。超声波是为数不多的可用于太空宇航员的诊断和治疗方式之一。然而,虽然可以使用护理点超声波(POCUS),但目前还没有针对宇航员准备工作的培训标准。我们建议采用一种有组织、有条理的方法,让宇航员利用机载医疗设备为进入太空做好最佳准备。随着技术的不断发展,其他人工智能和增强现实系统的辅助很可能会促进太空紧急情况下的培训和动态实时需求。小结:随着太空旅游的不断发展,建议为 POCUS 的使用制定一套有组织的方法,以便为宇航员进入太空做好最佳准备。
{"title":"Space Ultrasound: A Proposal for Competency-based Ultrasound Training for In-flight Space Medicine.","authors":"Chanel Fischetti, Emily Frisch, Michael Loesche, Andrew Goldsmith, Ben Mormann, Joseph S Savage, Roger Dias, Nicole Duggan","doi":"10.5811/westjem.18422","DOIUrl":"https://doi.org/10.5811/westjem.18422","url":null,"abstract":"<p><p>Space travel has transformed in the past several years. Given the burgeoning market for space tourism, in-flight medical emergencies are likely to be expected. Ultrasound is one of the few diagnostic and therapeutic modalities available for astronauts in space. However, while point-of-care ultrasound (POCUS) is available, there is no current standard of training for astronaut preparation. We suggest an organized and structured methodology by which astronauts should best prepare for space with the medical equipment available on board. As technology continues to evolve, the assistance of other artificial intelligence and augmented reality systems are likely to facilitate training and dynamic real-time needs during space emergencies. <b>Summary:</b> As space tourism continues to evolve, an organized methodology for POCUS use is advised to best prepare astronauts for space.</p>","PeriodicalId":23682,"journal":{"name":"Western Journal of Emergency Medicine","volume":"25 2","pages":"275-281"},"PeriodicalIF":3.1,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11000543/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140864838","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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Western Journal of Emergency Medicine
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