Training to Enhance the Knowledge and Comfort Level of Emergency Physicians Providing Care for Survivors of Sexual Assault.

INTRODUCTION: Although sexual assault (SA) is a substantial public health problem, emergency physicians do not universally undergo continuing education on caring for survivors of SA. The goal of this intervention was to develop a training course that improves physician understanding of trauma-sensitive care in the emergency department and equips physicians with knowledge of the specialized care required to treat SA survivors. METHODS: Thirty-nine attending emergency physicians underwent a 4-hour training on trauma-sensitive care for survivors of SA and completed prequestionnaires and postquestionnaires to assess training efficacy in improving knowledge base and comfort level providing care. The training consisted of didactic portions focused on the neurobiology of trauma, communication skills, and forensic evidence collection techniques and a simulation portion with standardized patients to practice evidence collection and a trauma-sensitive anogenital examination. RESULTS: Physicians demonstrated significantly improved performance (P < .05) on 12 of 18 knowledge-based questions. Physicians also showed significant improvement (P < .001) on 11 of 11 Likert scale questions that assessed comfort level communicating with survivors and using trauma-sensitive techniques during medical and forensic examinations. CONCLUSION: Physicians who received the training course demonstrated a significantly improved knowledge base and comfort level treating survivors of SA. Considering the prevalence of sexual violence, it is imperative that physicians are appropriately educated on trauma-sensitive care.

Mass-Casualty Training Exercise Using High-Fidelity Computerized Simulators and Involving Time and Resource Limitation.

PURPOSE: Training emergency department (ED) personnel in the care of victims of mass-casualty incidents (MCIs) is a highly challenging task requiring unique and innovative approaches. The purpose of this study was to retrospectively explore the value of high-fidelity simulators in an exercise that incorporates time and resource limitation as an optimal method of training health care personnel in mass-casualty care. METHODS: Mass-casualty injury patterns from an explosive blast event were simulated for 12 victims using high-fidelity computerized simulators (HFCS). Programmed outcomes, based on the nature of injuries and conduct of participants, ranged from successful resuscitation and survival to death. The training exercise was conducted five times with different teams of health care personnel (n = 42). The exercise involved limited time and resources such as blood, ventilators, and imaging capability. Medical team performance was observed and recorded. Following the exercise, participants completed a survey regarding their training satisfaction, quality of the exercise, and their prior experiences with MCI simulations. The Likert scale responses from the survey were evaluated using mean with 95% confidence interval, as well as median and inter-quartile range. For the categorical responses, the frequency, proportions, and associated 95% confidence interval were calculated. RESULTS: The mean rating on the quality of experiences related trainee survey questions (n = 42) was between 4.1 and 4.6 on a scale of 5.0. The mean ratings on a scale of 10.0 for quality, usefulness, and pertinence of the program were 9.2, 9.5, and 9.5, respectfully. One hundred percent of respondents believed that this type of exercise should be required for MCI training and would recommend this exercise to colleagues. The five medical team (n = 5) performances resulted in the number of deaths ranging from two (including the expectant victims) to six. Eighty percent of medical teams attempted to resuscitate the "expectant" infant and exhausted the O- blood supply. Sixty percent of medical teams depleted the supply of ventilators. Forty percent of medical teams treated "delayed" victims too early. CONCLUSION: A training exercise using HFCS for mass casualties and employing limited time and resources is described. This exercise is a preferred method of training among participating health care personnel.

Clinical predictors for laboratory-confirmed influenza infections: exploring case definitions for influenza-like illness.

OBJECTIVE: To identify clinical signs and symptoms (ie, "terms") that accurately predict laboratory-confirmed influenza cases and thereafter generate and evaluate various influenza-like illness (ILI) case definitions for detecting influenza. A secondary objective explored whether surveillance of data beyond the chief complaint improves the accuracy of predicting influenza. DESIGN: Retrospective, cross-sectional study. SETTING: Large urban academic medical center hospital. PARTICIPANTS: A total of 1,581 emergency department (ED) patients who received a nasopharyngeal swab followed by rRT-PCR testing between August 30, 2009, and January 2, 2010, and between November 28, 2010, and March 26, 2011. METHODS: An electronic surveillance system (GUARDIAN) scanned the entire electronic medical record (EMR) and identified cases containing 29 clinical terms relevant to influenza. Analyses were conducted using logistic regressions, diagnostic odds ratio (DOR), sensitivity, and specificity. RESULTS: The best predictive model for identifying influenza for all ages consisted of cough (DOR=5.87), fever (DOR=4.49), rhinorrhea (DOR=1.98), and myalgias (DOR=1.44). The 3 best case definitions that included combinations of some or all of these 4 symptoms had comparable performance (ie, sensitivity=89%-92% and specificity=38%-44%). For children <5 years of age, the addition of rhinorrhea to the fever and cough case definition achieved a better balance between sensitivity (85%) and specificity (47%). For the fever and cough ILI case definition, using the entire EMR, GUARDIAN identified 37.1% more influenza cases than it did using only the chief complaint data. CONCLUSIONS: A simplified case definition of fever and cough may be suitable for implementation for all ages, while inclusion of rhinorrhea may further improve influenza detection for the 0-4-year-old age group. Finally, ILI surveillance based on the entire EMR is recommended.

Comparing the accuracy of syndrome surveillance systems in detecting influenza-like illness: GUARDIAN vs. RODS vs. electronic medical record reports.

BACKGROUND: A highly sensitive real-time syndrome surveillance system is critical to detect, monitor, and control infectious disease outbreaks, such as influenza. Direct comparisons of diagnostic accuracy of various surveillance systems are scarce. OBJECTIVE: To statistically compare sensitivity and specificity of multiple proprietary and open source syndrome surveillance systems to detect influenza-like illness (ILI). METHODS: A retrospective, cross-sectional study was conducted utilizing data from 1122 patients seen during November 1­7, 2009 in the emergency department of a single urban academic medical center. The study compared the Geographic Utilization of Artificial Intelligence in Real-time for Disease Identification and Alert Notification (GUARDIAN) system to the Complaint Coder (CoCo) of the Real-time Outbreak Detection System (RODS), the Symptom Coder (SyCo) of RODS, and to a standardized report generated via a proprietary electronic medical record (EMR) system. Sensitivity, specificity, and accuracy of each classifier's ability to identify ILI cases were calculated and compared to a manual review by a board-certified emergency physician. Chi-square and McNemar's tests were used to evaluate the statistical difference between the various surveillance systems.ResultsThe performance of GUARDIAN in detecting ILI in terms of sensitivity, specificity, and accuracy, as compared to a physician chart review, was 95.5%, 97.6%, and 97.1%, respectively. The EMR-generated reports were the next best system at identifying disease activity with a sensitivity, specificity, and accuracy of 36.7%, 99.3%, and 83.2%, respectively. RODS (CoCo and SyCo) had similar sensitivity (35.3%) but slightly different specificity (CoCo = 98.9%; SyCo = 99.3%). The GUARDIAN surveillance system with its multiple data sources performed significantly better compared to CoCo (χ2 = 130.6, p < 0.05), SyCo (χ2 = 125.2, p < 0.05), and EMR-based reports (χ2 = 121.3, p < 0.05). In addition, similar significant improvements in the accuracy (>12%) and sensitivity (>47%) were observed for GUARDIAN with only chief complaint data as compared to RODS (CoCo and SyCo) and EMR-based reports. CONCLUSION: In our study population, the GUARDIAN surveillance system, with its ability to utilize multiple data sources from patient encounters and real-time automaticity, demonstrated a more robust performance when compared to standard EMR-based reports and the RODS systems in detecting ILI. More large-scale studies are needed to validate the study findings, and to compare the performance of GUARDIAN in detecting other infectious diseases.

The Rush University advanced trauma training program, a novel approach for military trauma training.

Nearly 90% of combat deaths occur on the battlefield before the casualty reaches a treatment facility. It has been shown that early intervention in trauma patients improves morbidity and mortality. Hence, the training of military health care providers in lifesaving measures is imperative to saving lives on the battlefield. To date, few courses exist to provide skills in combat-zone trauma stabilization and treatment. Even fewer offer training in the identification and treatment of post-traumatic stress disorders and traumatic brain injury. We set out to develop a multidisciplinary, comprehensive course to include didactic lectures as well as hands-on training and observational modules. Ten courses have been delivered to date. Thus far, feedback from military personnel and course participants has revealed the positive impact of the training program. In this manuscript, we present the layout of the program and its contents.

The impact of alternative diagnoses on the utility of influenza-like illness case definition to detect the 2009 H1N1 pandemic.

OBJECTIVE: To investigate the impact of excluding cases with alternative diagnoses on the sensitivity and specificity of the Centers for Disease Control and Prevention's (CDC) influenza-like illness (ILI) case definition in detecting the 2009 H1N1 influenza, using Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification, a disease surveillance system. DESIGN: Retrospective cross-sectional study design. SETTING: Emergency department of an urban tertiary care academic medical center. PATIENTS: 1,233 ED cases, which were tested for respiratory viruses from September 5, 2009 to May 5, 2010. MAIN OUTCOME MEASURE: The main outcome measures were positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of the ILI case definition (both including and excluding alternative diagnoses) to detect H1N1. RESULTS: There was a significant decrease in sensitivity (chi2 = 9.09, p < 0.001) and significant improvement in specificity (chi2 = 179, p < 0.001), after excluding cases with alternative diagnoses. CONCLUSION: When early detection of an influenza epidemic is of prime importance, pursuing alternative diagnoses as part of CDC's ILI case definition may not be warranted for public health reporting due to the significant decrease in sensitivity, in addition to the resources required for detecting these alternative diagnoses.

Seroprevalence study using oral rapid HIV testing in a large urban emergency department.

BACKGROUND: The Centers for Disease Control (CDC) recommends universal human immunodeficiency virus (HIV) testing for patients aged 13-64 years in health care settings where the seroprevalence is>0.1%. Rapid HIV testing has several advantages; however, recent studies have raised concerns about false positives in populations with low seroprevalence. STUDY OBJECTIVES: To determine the seroprevalence of HIV in our Emergency Department (ED) population, understand patient preferences toward rapid testing in the ED, and evaluate the performance of a rapid oral HIV test. METHODS: A serosurvey offered oral rapid HIV 1/2 testing (OraQuick ADVANCE, Bethlehem, PA) to a convenience sample of 1348 ED patients beginning August 2008. Subjects declining participation were asked to complete an opt-out survey. RESULTS: 1000 patients were tested. Twelve had positive results (1.2%), including one who had newly diagnosed HIV infection; 988 patients tested negative. Of these, 335 (33.3%) had never been tested; 640 had prior history of a negative HIV test. No false-positive rapid HIV results were detected; 98.7% received the results of their preliminary HIV test, including 100% of those who tested positive. Most subjects who declined testing cited either a recent negative HIV test (160/348) or low perceived risk (65/348). A minority cited a concern regarding their privacy (11/348) or that the test might delay their treatment (7/348). CONCLUSIONS: The seroprevalence estimate of 1.2% was above the rate recommended by the CDC for routine universal opt-out testing in our study population. The acceptance rate of rapid HIV testing and the percentage of patients receiving results approximated other recent reports.

Achieving high quality in ST-segment elevation myocardial infarction care: one urban academic medical center experience.

Management of acute myocardial infarction with ST elevation (STEMI) remains a challenge for academic institutions. There are numerous factors at play from the time electrocardiogram is obtained to the time the patient arrives to a catheterization laboratory and the balloon is inflated. Academic hospitals that are located in large urban centers have to deal with staff living long distances from the facility, and therefore, assembling the catheterization team after-hours and on the weekends becomes a difficult task to achieve. There are other factors that contribute to time delays, such as, administering electrocardiograms in timely fashion, having emergency physicians activate the catheterization team, instead of contacting the cardiologist to discuss the case, and other time-sensitive factors. All of the aforementioned issues contribute to the delay. Yet, primary percutaneous coronary intervention is clearly demonstrated as the modality of choice in treatment of STEMI, which improves patient's morbidity and mortality. Therefore, it is imperative that institutions do all they can to improve their protocols and meet the core measures in the treatment of STEMI patients, including the door-to-balloon time of less than 90 minutes. Our institution started a quality improvement program for STEMI care in 1993 and has showed progressive improvement in use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and other medication, culminating in 95% to 100% use of these medications in 2003-2004, when we operated in accordance with the Get With The Guidelines program. Door-to-balloon time in less than 90 minutes became a new phase in our quality improvement process, and we achieved 100% compliance in the last 2 years.

A comprehensive disaster training program to improve emergency physicians' preparedness: a 1-year pilot study.

OBJECTIVES: The main objective of this pilot study was to measure the effectiveness of a 1-year comprehensive training program on the long-term cognitive competence in disaster preparedness among attending emergency physicians (EPs). DESIGN: Ten attending EPs participated in a year-long training program in disaster preparedness and management. A baseline pretraining test and self-evaluation questionnaire were administered to the participants. Post-training written test and self-evaluation questionnaire were repeated at 12 months after the completion of the program. SETTING: The study took place at an urban tertiary care medical center from July 2007 to June 2008. INTERVENTIONS: The training program was divided into three main categories: didactic core topics, formally recognized courses, and a practicum (drill). MAIN OUTCOME MEASURES: Pretraining and posttraining test scores in addition to pretraining and posttraining self-assessments were compared for disaster preparedness in various areas. RESULTS: There was a statistically significant increase in the overall post-test versus pretest scores on the written examination for the entire group (44.4 vs. 29.8, p < 0.005). In addition, statistically significant increases in each area of disaster preparedness were noted for the self-assessments (2.7 +/- 0.82 vs. 3.9 +/- 0.56, p = 0.01), where 1 means not prepared at all and 5 means extremely well prepared. CONCLUSIONS: Disaster preparedness is an essential area of clinical competence for EPs. Participation in a yearlong pilot training program demonstrated a statistically significant increase in cognitive competence among a pilot sample of EPs. More research is needed to validate the content of the training program and its instruments of evaluation.

Emergency Department greeters reduce door-to-ECG time.

INTRODUCTION: Screening for Acute Coronary Syndrome in chest pain patients can be initiated with a 12-lead electrocardiogram (ECG). Current American College of Cardiology/American Heart Association guidelines recommends getting an ECG performed and reviewed within 10 minutes of the time these patients present to the Emergency Department (ED). One innovative method to improve door-to-ECG time is by placing a trained greeter in the triage section of the ED. METHODS: This study was conducted over a 3-week period from September to October 2006, in a large urban academic medical center. The greeter was stationed in the triage area, and screened every patient entering the ED for the following symptoms/complaints: chest pain, shortness of breath, acute mental status changes in nursing home patients, dizziness, and nausea with or without vomiting in diabetic patients. The greeter obtained the ECG in the qualified patients, or alerted the triage. Data was collected on ECGs for all ED patients who presented with the above complaints in the absence of a greeter. RESULTS: In the 3 weeks of the study, data was collected on 126 cases. The greeter had obtained 40 ECGs, and 86 ECGs were done without the greeter. The average door-to-ECG times were significantly different between the groups. The study found 8.8 minutes in the greeter group versus 29.6 minutes in the nongreeter group (P = 0.000). CONCLUSION: ED triage greeter can be effectively used to obtain timely ECGs in suspected Acute Coronary Syndrome patients.

Who should be admitted to the chest pain observation unit?: one urban hospital experience.

INTRODUCTION: Patients at low risk for coronary artery disease (CAD) can be safely treated in the chest pain observation unit (CPOU). The goal of the study is to identify the differences in risk profiles of patients with positive and negative workup. METHODS: The study is a retrospective CPOU chart review conducted over 6 months. Data collected included gender, age, race, history of diabetes, hypertension, hyperlipidemia, family history of CAD, smoking, test results, and disposition. SPSS-12 program was used to analyze the differences in patient's characteristics. RESULTS: Two hundred forty-three patients were admitted to CPOU, 86% completed their workup, and 82% were discharged. Twenty-four (10%) patients had positive stress test, of whom 13 (54%) had > or =3 risk factors. CONCLUSION: It is practical to admit patients to the CPOU. The study has shown that "ideal" patients for CPOU are those with < or =2 risk factors for CAD.