Development and Validation of a Lecture Assessment Tool for Emergency Medicine Residents.

BACKGROUND: Delivering quality lectures is a critical skill for residents seeking careers in academia yet no validated tools for assessing resident lecture skills exist. OBJECTIVES: The authors sought to develop and validate a lecture assessment tool. METHODS: Using a nominal group technique, the authors derived a behaviorally anchored assessment tool. Baseline characteristics of resident lecturers including prior lecturing experience and perceived comfort with lecturing were collected. Faculty and senior residents used the tool to assess lecturer performance at weekly conference. A postintervention survey assessed the usability of the form and the quantity and quality of the feedback. Analysis of variance was used to identify relationships in performance within individual domains to baseline data. Generalizability coefficients and scatterplots with jitter were used to assess inter-rater reliability. RESULTS: Of 64 residents assessed, most (68.8%) had previous lecturing experience and 6.3% had experience as a regional/national speaker. There was a significant difference in performance within the domains of Content Expertise (p < 0.001), Presentation Design/Structure (p = 0.014), and Lecture Presence (p = 0.001) for first-year versus fourth-year residents. Residents who had higher perceived comfort with lecturing performed better in the domains of Content Expertise (p = 0.035), Presentation Design/Structure (p = 0.037), and Lecture Presence (p < 0.001). We found fair agreement between raters in all domains except Goals and Objectives. Both lecturers and evaluators perceived the feedback delivered as specific and of adequate quantity and quality. Evaluators described the form as highly useable. CONCLUSIONS: The derived behaviorally anchored assessment tool is a sufficiently valid instrument for the assessment of resident-delivered lectures.

Combined Approach to Lysis Utilizing Eptifibatide and Recombinant Tissue-Type Plasminogen Activator in Acute Ischemic Stroke-Full Dose Regimen Stroke Trial.

BACKGROUND AND PURPOSE: The Combined Approach to Lysis Utilizing Eptifibatide and Recombinant Tissue-Type Plasminogen Activator (r-tPA; CLEAR) in Acute Ischemic Stroke (AIS) and CLEAR-Enhanced Regimen (CLEAR-ER) trials demonstrated safety of reduced dose r-tPA plus the glycoprotein 2b/3a inhibitor, eptifibatide, in AIS compared with r-tPA alone. The objective of the CLEAR-Full Dose Regimen (CLEAR-FDR) trial was to estimate the rate of symptomatic intracerebral hemorrhage (sICH) in AIS patients treated with the combination of full-dose r-tPA plus eptifibatide. METHODS: CLEAR-FDR was a single-arm, prospective, open-label, multisite study. Patients aged 18 to 85 years treated with 0.9 mg/kg IV r-tPA within 3 hours of symptom onset were enrolled. After obtaining consent, eptifibatide (135 µg/kg bolus and 2-hour infusion at 0.75 µg/kg per minute) was administered. The primary end point was the proportion of patients who experienced sICH within 36 hours. An independent clinical monitor adjudicated if an sICH had occurred and an independent neuroradiologist reviewed all images. The stopping rule was 3 sICHs within the first 19 patients or 4 sICHs within 29 patients. RESULTS: From October 2013 to December 2014, 27 patients with AIS were enrolled. Median age was 73 years (range, 34-85; interquartile range, 65-80) and median National Institute of Health stroke scale score was 12 (range, 6-26; interquartile range, 9-16). One sICH (3.7%; 95% confidence interval, 0.7%-18%) was observed. CONCLUSIONS: These results demonstrate comparable safety of full-dose r-tPA plus eptifibatide with historical rates of sICH with r-tPA alone and support proceeding with a phase 3 trial evaluating full-dose r-tPA combined with eptifibatide to improve outcomes after AIS.

Is ED disposition associated with intracerebral hemorrhage mortality?

BACKGROUND: Early deterioration is common in intracerebral hemorrhage (ICH). Treatment at tertiary care centers has been associated with lower ICH mortality. Guidelines recommend aggressive care for 24 hours irrespective of the initial outlook. We examined the frequency of and factors associated with transfer to tertiary centers in ICH patients who initially presented at nontertiary emergency departments (EDs). We also compared observed with expected mortality in transferred and nontransferred patients using published short-term mortality predictors for ICH. METHODS: Adult patients who resided in a 5-county region and presented to nontertiary EDs with nontraumatic ICH in 2005 were identified. Intracerebral hemorrhage score and ICH Grading Scale (ICH-GS) were determined. Of 16 local hospitals, 2 were designated tertiary care centers. Logistic regression was used to assess factors associated with transfer. RESULTS: Of 205 ICH patients who presented to nontertiary EDs, 80 (39.0%) were transferred to a tertiary center. In multivariate regression, better baseline function (modified Rankin scale 0-2 versus 3-5; odds ratio, 0.42, 95% confidence interval, 0.21-0.85, P = .016) and black race (odds ratio, 2.28, 95% confidence interval 1.01-5.12, P = .046) were associated with transfer. A trend toward higher 30-day mortality was observed in nontransferred patients (32.5% versus 45.6%, P = .06). The ICH-GS overestimated mortality for all patients, while the ICH Score adequately predicted mortality. CONCLUSIONS: We found no significant difference in mortality between transferred and nontransferred patients, but the trend toward higher mortality in nontransferred patients suggests that further evaluation of ED disposition decisions for ICH patients is warranted. Expected ICH mortality may be overestimated by published tools.

Neurologic education in emergency medicine training programs.

OBJECTIVES: Neurologic complaints are a frequent cause of emergency department visits. The morbidity and mortality of neurologic complaints such as headache and stroke can be extensive. Thus, emergency medicine residency programs should ensure adequate training in such neurologic emergencies. The authors sought to determine what methods are being used to educate residents on neurologic emergencies. METHODS: A two-page survey was mailed to directors of all 126 accredited emergency medicine residency programs in the United States. The number and types of lectures to residents, required rotations, and electives offered were assessed. Means, standard deviations (SDs), and proportions are used to describe the data. Ninety-five percent confidence intervals of proportions (95% CIs) were calculated. RESULTS: The response rate was 78% (98 of 126). Programs had a mean (+/- SD) of 5.4 (+/- 1.0) hours of didactic lectures per week, with a mean of 12.0 (+/- 5.9) lecture hours devoted to neurologic emergencies annually. A neurology rotation was required for 16 of the 92 programs providing these data (17.4%; 95% CI = 10.6% to 27.0%), and a neurosurgery rotation was required for 14 of these 92 programs (15.2%; 95% CI = 8.9% to 24.6%). One program (1.1%; 95% CI = 0.1% to 6.8%) required both a neurology and a neurosurgery rotation, and one program (1.1%; 95% CI = 0.1% to 6.8%) required either a neurology or a neurosurgery rotation. On 15 of the 32 required neurologic rotations (46.9%; 95% CI = 29.5% to 65.0%), time was spent only in the intensive care unit. The remaining 17 rotations used outpatient clinic and general floor neurology settings. Electives in neurology, neurosurgery, or neuroradiology were available for 32 programs (32.7%; 95% CI = 24.2% to 42.4%) but were seldom used. CONCLUSIONS: Currently, the primary method of educating residents to treat neurologic emergencies is through didactic lectures, as opposed to clinical rotations in neurology or neurosurgery. Improving resident education in neurologic emergencies within the current educational format must focus on improving didactic lectures in neurologic topics. Expanding clinical rotations or electives to enhance education in neurologic emergencies also warrants future attention.