Evaluation of an international emergency medicine intervention in Tuscany.

OBJECTIVE: To measure the effectiveness of a 9-month emergency medicine 'train the trainers' program in Tuscany, Italy. METHODS: A total of 81 physicians with emergency department experience completed a training course in Italy. The course included 120 h of didactic lectures, 700 h of clinical rotations and 30 h of practical workshops. The effect of the training course was measured by written multiple-choice and oral case-simulation examinations, and a precourse and postcourse self-assessment instrument using a four-point Likert scale, to describe the ability to care for different types of emergency medicine patients. RESULTS: Twenty-four physicians completed the course in 2003-2004 and 57 physicians completed the course in 2004-2005. A comparison of an identical examination given as a posttest to the first group and a pretest to the second group demonstrated significant improvement on a 75-question multiple-choice examination (38.7 vs. 46.2 points, P<0.001). Improvement was also seen in oral case examinations, in pediatrics (17.8 vs. 37.3 points, P<0.001) and neurology (24.8 vs. 34.5, P<0.001). In the self-assessment survey, when asked to describe the ability to diagnose and provide initial treatment for several types of patients before and after the course, significant improvement was reported by 13 of 20 participants (65%). When asked to describe the ability to perform a variety of procedures, significant improvement was seen in seven of sixteen (44%). CONCLUSIONS: When measured by written examinations, oral examinations and physician self-assessment, a train the trainers program, designed as part of an international emergency medicine collaboration, was efficacious.

A comparison between the efficacy of lectures given by emergency and non-emergency physicians in an international emergency medicine educational intervention.

OBJECTIVE: The Tuscan Emergency Medicine Initiative is an international collaboration designed to create a sustainable emergency medicine training and qualification process in Tuscany, Italy. Part of the program involves training all emergency physicians currently practicing in the region. This qualification process includes didactic lectures, clinical rotations and practical workshops for those with significant emergency department experience. Lectures in the didactic portion were given by both emergency medicine (EM) and non-EM faculty. We hypothesized that faculty who worked clinically in EM would give more effective lectures than non-EM faculty. METHODS: Fifty-one emergency physicians from the hospitals surrounding Florence completed the course, which included 48 one-hour lectures. Twenty lectures were given by practicing emergency physicians and 28 were given by non-EM faculty. Participants completed an evaluation at the end of each session using a 5-point Likert scale describing the pertinence of the lecture to EM, the efficacy and clarity of the presentation, the accuracy of the information and the didactic ability of the lecturer. RESULTS: A mean of 38.5 evaluations was completed for each lecture. Every factor was significantly higher for lectures given by EM faculty: the pertinence of the lecture to EM (4.46 vs. 4.16, p < 0.001), the efficacy of the faculty (4.10 vs. 3.91, p < 0.001), the accuracy of the lecture content (4.16 vs 3.96, p < 0.001), and the didactic ability of the instructors (4.02 vs. 3.85, p = 0.001). CONCLUSIONS: When teaching EM, evaluations of lectures in this training intervention were higher for lectures given by EM faculty than by non-EM faculty.

Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism.

Echocardiographic right ventricular (RV) dysfunction is a well-established prognostic indicator in patients with acute pulmonary embolism. However, the possibility of implementing a rapid and effective triage with biohumoral markers such as brain natriuretic peptide (BNP) may be of value. Sixty-one patients with a first documented episode of acute pulmonary embolism without shock and previous left ventricular dysfunction were prospectively studied. All patients underwent echocardiography and rapid BNP testing on admission. Patients were followed up for in-hospital death, progression to shock, and nonfatal pulmonary embolism recurrence. Overall, 35 patients (57%) had echocardiographic evidence of RV dysfunction on admission, and its prevalence increased progressively with increasing levels of BNP. A BNP level <85 pg/ml was highly accurate in excluding RV dysfunction. No patient in the lower tertile of BNP values (1.1 to 85.0 pg/ml) had RV dysfunction, compared with 75% in the middle tertile (88.7 to 487.0 pg/ml) and 100% in the upper tertile (527 to 1,300 pg/ml). Overall, 11 patients (18%), belonging to the upper tertile, progressed to shock during admission, 4 of whom died. The association of RV dysfunction with a BNP level in the upper tertile (>or=527 pg/ml) showed incremental prognostic value over RV dysfunction alone (in-hospital death and progression to shock were 55% and 31%, respectively). In the present study, BNP represented a powerful predictor of in-hospital clinical deterioration, with substantial incremental prognostic value over echocardiography alone.

Effectiveness of a multidisciplinary chest pain unit for the assessment of coronary syndromes and risk stratification in the Florence area.

BACKGROUND: In patients seen at the emergency department (ED) with chest pain (CP), noninvasive diagnostic strategies may differentiate patients at high or intermediate risk from those at low-risk for cardiovascular events and optimize the use of high-cost resources. However, in welfare healthcare systems, the feasibility, accuracy, and potential benefits of such management strategy need further investigation. METHODS: A total of 13,762 consecutive patients with CP were screened, and their conditions were defined as high, intermediate, and low risk for short-term cardiovascular events. Patients at high and intermediate risk were admitted. Patients at low risk were discharged from the ED if first line (<6 hours, including electrocardiogram, troponins, and serum cardiac markers) or second line short-term evaluation (<24 hours, including echocardiogram, rest or stress 99m-Tc myocardial scintigraphy, exercise tolerance test, or stress-echocardiography) had negative results. Patients with a diagnosis of coronary artery disease (CAD) were admitted. Patients without evidence of cardiovascular disease underwent screening for psychiatric and gastroesophageal disorders. Inhospital mortality rate was assessed in all patients. RESULTS: Among patients at high and intermediate risk (n = 9335), 2420 patients had acute myocardial infarction (26%, 10.6% mortality rate), 3764 had unstable angina (40%, 1.1% mortality rate), 129 had aortic dissection (1.4%, 23.3% mortality rate), and 408 had pulmonary embolism (4%, 27.6% mortality rate). The remaining 2614 had chronic coronary heart disease in the context of multiple pathology (n = 2256) or pleural or pericardial diseases (n = 358). Among patients at low risk (n = 4427), 2672 were discharged at <6 hours (60%, 0.2% incidence rate of nonfatal CAD at 6 months) and 870 patients were discharged at <24 hours (20%, no CAD at follow-up). The remaining 885 patients were recognized as having CAD (20%, 1.1% inhospital mortality rate). Finally, half of the patients without CAD had active gastroesophageal or anxiety disorders. CONCLUSION: An effective screening program with an observation area inside the ED (1) could be implemented in a public healthcare environment and contribute significantly to the reduction of admissions, (2) could optimize the management of patients at high and intermediate risk and succeed in recognizing CAD in 20% of patients at low risk, and (3) could allow screening for alternative causes of CP in patients without evidence of CAD.