No abstract

Methods: Three emergency physicians including an attending emergency physician with greater than 100 ultrasound-guided blocks experience, an emergency physician ultrasound fellow, and a resident emergency physician were prospectively evaluated. The resident and fellow received a standardized training module developed by the attending emergency physician. A randomized cohort of ED patients was generated using bed numbers to prevent a biased selection of patients. Time to set up and identification of external anatomical landmarks was recorded. Times to acquisition of an optimal ultrasound image and accuracy of identification of six anatomical structures (internal carotid, sternocleidomastoid, anterior scalene muscle, middle scalene muscle, and the C5, C6 and C7 roots of the brachial plexus) as well the ideal in-plane needling tract were recorded. Subjects were asked to rate their confidence in structure identification for each scan (Table ) Results: Twenty patients were enrolled for a total of 40 ultrasound examinations. Seventy percent were female; the mean body mass index (BMI) was 31, ranging from 15 to 53. The average set-up time was 1 minute and 30 seconds. Ultrasonographic landmarks were successfully identified in all patients by the attending emergency physician. Mean scanning times were 25 seconds and 1 minute, 32 seconds for the attending and resident/fellow respectively. There were 2 instances where the resident or fellow failed to correctly identify the interscalene brachial plexus; these were both middleaged patients who were severely (BMI>35) or very severely obese (BMI >40) (Figure ).Conclusions: In this randomly selected cohort of ED patients, both attending and resident-level providers were able to quickly and accurately identify the important anatomic and ultrasonographic structures needed to perform an ultrasound-guided interscalene brachial plexus block. Severely obese patients may pose a challenge to providers early in training. More study is needed to better understand how emergency physicians can acquire and maintain competency performing ultrasound-guided regional anesthesia.

Point-of-care ultrasonography (POCUS) is increasingly utilized in emergency departments (EDs) throughout Thailand. Although emergency medicine (EM) residents are trained in POCUS, Thai medical students receive limited training. An introductory POCUS course was implemented for medical students to prepare them for internships. Objective: This study described the perception and use of POCUS by graduates of an introductory POCUS course. Materials and Methods: Medical students who completed the POCUS course were surveyed during their intern year from 2012 to 2015. The survey collected demographic characteristics. The Likert Scale was used to assess POCUS practice patterns and perceptions of the course. Results: There were 230 respondents (98% response rate). All thought that POCUS was important. Furthermore, 96% of respondents felt that the POCUS course meaningfully impacted their ability to deliver care. POCUS use was greatest for obstetrics/gynecology and trauma cases. Over half of respondents (55.2%) felt very confident with using extended-Focused Assessment with Sonography in Trauma. Most respondents (81.8%) were positively impacted by the course, and 61.7% were satisfied with the scope of the course. Recommendations for improvement included increasing the course length, the content, and the hands-on time for POCUS practice. Conclusion:Graduates positively perceived the course and felt it dramatically impacted their clinical practice as novice physicians. An introductory POCUS course should be incorporated into the medical school curriculum to prepare graduates for practice. Future goals include increasing the scope of POCUS practice to help guide interns and residents in emergency patient care such as lung ultrasound in COVID-19 or pneumonia patients and studying the impact this course has on patient outcomes.

Study Objective: Unwarranted variation in health care is common. Emergency care is a significant contributor to the cost of health care and, due to its intense and episodic nature, includes substantial variability. Checklists have been utilized as a simple, inexpensive method of decreasing unwarranted variation and improving physician adherence to best clinical and communication practices in other settings; however, little is known about the utility of checklists in the emergency critical care setting.Methods: A prospective, observational, study was conducted to assess the effect of a visually oriented checklist on best practices for the care of critical care patients in an academic tertiary care emergency department (ED). A visual checklist was developed using best practice guidelines and included key activities that ideally occur during each care team huddle. Care delivery observations were made before and after implementation of the checklist intervention. For each observation, registered nursing (RN) staff were surveyed regarding their understanding of the care plan and their comfort with emergency physician (EP) communication.Results: Following implementation, the proportion of EPs observed leading a summary team discussion increased by 31% (P ¼ .002). Significant improvements in the proportion of EPs discussing current knowledge of the patient (59%, P < .001), the working diagnosis (33.2%, P ¼ .002), the care plan (9%, P ¼ .026), and the disposition plan (24%, P ¼ .006) were all noted. A non-significant increase (62% vs 67%) in EP discussions of stabilizing interventions was observed. Significant changes in the proportion of EPs observed asking RNs to call with changes in patient status (P ¼ .562) or questions regarding patient care (P ¼ .420) were not noted. RN ratings of their understanding of care goals (P ¼ .002), comfort with communication amongst providers (P ¼ .025) and feelings of being a valued team-member (P ¼ .018) all improved significantly. RNs' perceptions of the degree to which their EP colleagues shared valuable clinical information did not change (P ¼ .228).Conclusions: Implementation of a visually oriented checklist in the form of visual cues led to an increased level of provider communication as demonstrated by improved EP adherence to best communication practices and improved emergency RN satisfaction with communication between members of the care team.

Study Objective: Early identification of bacterial infection or sepsis is critical as early treatment improves outcomes. Unfortunately, there are limited diagnostic tests available that quickly and reliably identify sepsis or bacterial infection. sPLA2-IIA levels have been shown to be elevated in animal models of sepsis as well as several preliminary human studies. We sought to identify threshold values of sPLA2-IIA that predict sepsis and bacterial infection as compared to normal controls in an emergency department (ED) population.Methods: The study site is a community-based tertiary care facility. Study subjects were consenting adult patients who met 2 or more systemic inflammatory response syndrome (SIRS) criteria with clinical diagnosis of infectious source likely (septic patients). Control subjects were non-septic consenting adults undergoing blood draw for other ED indications (abdominal pain, chest pain, neurological complaints, etc). Septic patients were evaluated by hospital protocol with blood cultures, lactate, and chemistries. During the course of other laboratory evaluation both groups of patients had an extra aliquot of blood drawn, blind-coded, and sent to an outside laboratory for quantitative analysis of sPLA2-IIA levels using an enzyme linked immunoassay (EIA). The laboratory personnel did not have access to patient clinical data. sPLA2-IIA levels were reported by patient study number to the clinical investigators. Study investigators reviewed patients inpatient medical record for laboratory, imaging, and microbiology results, as well as clinical course. All data were entered into a standardized spreadsheet by a trained data abstractor. Data was non-parametric in distribution and was analyzed with descriptive statistics, Chi Square, and Mann-Whitney test. The study was IRB approved.Results: Compared to the controls, sepsis/severe sepsis patients were significantly older (64.1 versus 48.4, p¼0.003). We have enrolled 10 patients with severe sepsis, 15 with sepsis, and 18 controls. Patients with sepsis/severe sepsis had a median sPLA2-IIA level of 115 ng/ml (IQR 61.9-261) as compared to controls (median 16ng/ml, IQR 9-23.8, p <0.0001). sPLA2-IIA levels were not helpful in distinguishing sepsis from severe sepsis (p¼0.60). Using a cut-off value of 50ng/ml as a threshold value for sepsis/ severe sepsis, sPLA2-IIA EIA had a sensitivity of 0.76 ) and a specificity of 94.4 (CI 70.6-99.7). sPLA2-IIA displayed a weak correlation with lactate, with an r of 0.22.Conclusions: sPLA2-IIA measurement shows potential as a specific marker for sepsis/severe sepsis and may be clinically useful to identify a high-risk subset of patients with infectious processes. Further study is warranted to identify predictive value of trends in sPLA2-IIA during disease course in septic patients and to clarify the impact of age on sPLA2-IIA, if any.