Internal medicine (IM) residency programs select applicants based on several metrics. Factors predicting success during residency are unclear across studies. To identify whether specific applicant or ...resident factors are associated with IM resident performance using ACGME milestones. We tested for associations between applicant factors available prior to the start of IM residency and resident factors measured during IM residency training, and resident performance on ACGME milestones across three consecutive years of IM training between 2015-2020. Univariable and multivariable linear regression modeling was used to test associations. Eighty-nine categorical IM residents that completed 3 consecutive years of training were included. Median age was 28 years (IQR 27-29) and 59.6% were male. Mean ACGME milestone scores increased with each post-graduate year (PGY) from 3.36 (SD 0.19) for PGY-1, to 3.80 (SD 0.15) for PGY-2, to 4.14 (SD 0.15) for PGY-3. Univariable modeling suggested referral to the clinical competency committee (CCC) for professionalism concerns was negatively associated with resident performance during each PGY. No applicant or resident factors included in the final multivariable regression models (age at starting residency, USMLE Step scores, interview score, rank list position, ITE scores) were associated with ACGME milestone scores for PGY-1 and PGY-2. Referral to the CCC for professionalism was negatively associated with resident performance during PGY-3. Residency selection factors did not predict resident milestone evaluation scores. Referral to the CCC was associated with significantly worse resident evaluation scores, suggesting professionalism may correlate with clinical performance.
For patients with hemodynamic instability undergoing rapid sequence intubation, experts recommend reducing the sedative medication dose to minimize the risk of further hemodynamic deterioration. ...Scant data support this practice for etomidate and ketamine. We sought to determine if the dose of etomidate or ketamine was independently associated with postintubation hypotension.
We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first intubation attempt was facilitated with etomidate or ketamine. We used multivariable modeling to determine whether drug dose in milligrams per kilogram of patient weight was independently associated with postintubation hypotension (systolic blood pressure < 100 mm Hg).
We analyzed 12,175 intubation encounters facilitated by etomidate and 1,849 facilitated by ketamine. The median drug doses were 0.28 mg/kg (interquartile range IQR 0.22 mg/kg to 0.32 mg/kg) for etomidate and 1.33 mg/kg (IQR 1 mg/kg to 1.8 mg/kg) for ketamine. Postintubation hypotension occurred in 1,976 patients (16.2%) who received etomidate and in 537 patients (29.0%) who received ketamine. In multivariable models, neither the etomidate dose (adjusted odds ratio aOR 0.95, 95% confidence interval CI 0.90 to 1.01) nor ketamine dose (aOR 0.97, 95% CI 0.81 to 1.17) was associated with postintubation hypotension. Results were similar in sensitivity analyses excluding patients with preintubation hypotension and including only patients intubated for shock.
In this large registry of patients intubated after receiving either etomidate or ketamine, we observed no association between the weight-based sedative dose and postintubation hypotension.
Background
Evidence‐based guidelines are often cited as a means of ensuring high‐quality care for all patients. Our objective was to assess whether emergency department (ED) adherence to core ...evidence‐based guidelines differed by patient sex and race/ethnicity and to assess the effect of ED guideline adherence on patient outcomes by sex and race/ethnicity.
Methods
We conducted a preplanned secondary analysis of data from a multicenter retrospective observational study evaluating variation in ED adherence to five core evidence‐based treatment guidelines including aspirin for acute coronary syndrome, door‐to‐balloon time for acute ST‐elevation myocardial infarction, systemic thrombolysis for acute ischemic stroke, antibiotic selection for inpatient pneumonia, and early management of severe sepsis/septic shock. This study was performed at six hospitals in Colorado with heterogeneous and diverse practice environments. Hierarchical generalized linear modeling was used to estimate adjusted associations between ED adherence and patient sex and race/ethnicity while controlling for other patient, physician, and environmental factors that could confound this association.
Results
A total of 1,880 patients were included in the study with a median (IQR) age of 62 (51–74) years. Males and non‐Hispanic whites comprised 59% and 71% of the cohort, respectively. While unadjusted differences were identified, our adjusted analyses found no significant association between ED guideline adherence and sex or race/ethnicity. Patients who did not receive guideline adherent care in the ED were significantly more likely to die while in the hospital (odds ratio = 2.0, 95% confidence interval = 1.3 to 3.2).
Conclusions
Longstanding, nationally reported evidence‐based guidelines can help eliminate sex and race/ethnicity disparities in quality of care. When providers know their care is being monitored and reported, their implicit biases may be less likely to impact care.
•This study examined the association between cannabis and/or alcohol use and MVC.•1,397 patients were recruited from emergence departments in 3 cannabis-legal states.•Case-control and case-crossover ...designs were used.•Cannabis alone was not associated with higher odds of MVC.•Alcohol use alone and with cannabis were associated with higher odds of MVC.
The objective of this study was to examine the relationship between cannabis and alcohol use and occurrence of motor vehicle collision (MVC) among patients in the emergency department (ED).
This was a cross-sectional study of visits to EDs in Denver, CO, Portland, OR, and Sacramento, CA by drivers who were involved in MVCs and presented with injuries (cases) and non-injured drivers (controls) who presented for medical care. We obtained blood samples and measured delta-9-THC and its metabolites. Alcohol levels were determined by breathalyzer or samples taken in the course of clinical care. Participants completed a research-assistant-administered interview consisting of questions about drug and alcohol use prior to their visit, context of use, and past-year drug and alcohol use. Multiple logistic regression was used to estimate the association between MVC and cannabis/alcohol use, adjusted for demographic characteristics. We then stratified participants based on levels of cannabis use and calculated the odds of MVC across these levels, first using self-report and then using blood levels for delta-9-THC in separate models. We conducted a case-crossover analysis, using 7-day look-back data to allow each participant to serve as their own control. Sensitivity analyses examined the influence of usual use patterns and driving in a closed (car, truck, van) versus open (motorcycle, motorbike, all-terrain vehicle) vehicle.
Cannabis alone was not associated with higher odds of MVC, while acute alcohol use alone, and combined use of alcohol and cannabis were both independently associated with higher odds of MVC. Stratifying by level of self-reported or measured cannabis use, higher levels were not associated with higher odds for MVC, with or without co-use of alcohol; in fact, high self-reported acute cannabis use was associated with lower odds of MVC (odds ratio OR 0.18, 95% confidence interval CI 0.05–0.65). In the case-crossover analysis, alcohol use alone or in combination with cannabis was associated with higher odds of MVC, while cannabis use alone was again associated with decreased odds of MVC.
Alcohol use alone or in conjunction with cannabis was consistently associated with higer odds for MVC. However, the relationship between measured levels of cannabis and MVC was not as clear. Emphasis on actual driving behaviors and clinical signs of intoxication to determine driving under the influence has the strongest rationale.
We sought to (1) characterize emergency department (ED) intubations in trauma patients and estimate (2) first-pass success and (3) the association between patient and intubation characteristics and ...first-pass success.
We performed a secondary analysis of a multicenter prospective observational cohort of ED intubations from the National Emergency Airway Registry (NEAR). Descriptive statistics were calculated for all patients who were intubated for trauma at 23 NEAR EDs between 2016 and 2018. We evaluated first-pass success in patients intubated by (1) emergency or pediatric emergency physicians, (2) using rapid sequence intubation or no medications, and (3) either direct laryngoscopy or video laryngoscopy. We used propensity score matching with a generalized linear mixed-effects model to estimate the associations between patient and intubation characteristics and first-pass success.
Of the 19,071 intubations in NEAR, 4,449 (23%) were for trauma, and nearly all (88%) had at least one difficult airway characteristic. Prevalence of first-pass success was 86.8% (95% confidence interval CI: 83.3% to 90.3%). Most patients were intubated with video laryngoscopy, and patients were more likely to be intubated on first-pass with video laryngoscopy as compared to direct laryngoscopy (90% versus 79%). After propensity score matching, video laryngoscopy remained associated with first-pass success (adjusted risk difference 11%, 95% CI: 8% to 14%; and OR 2.2, 95% CI: 1.6 to 2.9). Additionally, an initial impression of difficult airway, blood/vomit in the airway, and use of external laryngeal manipulation were all associated with decreased odds of first-pass success.
Emergency physicians are successful at intubating patients in the setting of trauma, and video laryngoscopy is associated with twice the odds of first-pass success when compared to direct laryngoscopy.
Article Note: The members of the Project COVERED Emergency Department Network are provided in the appendix. CDC disclaimer: The findings and conclusions in this article are those of the authors and ...do not necessarily represent the views of the Centers for Disease Control and Prevention. Supervising Editor: John H. Burton, MD. Funding information This project was funded by a cooperative agreement from the Centers for Disease Control and Prevention (U01CK000480) and was supported by the Institute for Clinical and Translational Science at the University of Iowa through a grant from the National Center for Advancing Translational Sciences at the National Institutes of Health (UL1TR002537). Byline: Walter A. Schrading, Stacy A. Trent, James H. Paxton, Robert M. Rodriguez, Morgan B. Swanson, Nicholas M. Mohr, David A. Talan,, Monica Bahamon, Jestin N Carlson, Makini Chisolm-Straker, Brian Driver, Brett Faine, James Galbraith, Philip A Giordano, John P Haran, Amanda Higgins, Jeremiah Hinson, Stacey House, Ahamed H Idris, Efrat Kean, Elizabeth Krebs, Michael C. Kurz, Lilly Lee, Stephen Y Liang, Stephen C Lim, Gregory Moran, Utsav Nandi, Kavitha Pathmarajah, Yesenia Perez, Richard Rothman, Jessica Shuck, Patricia Slev, Howard A. Smithline, Kimberly Souffront, Mark Steele, Michelle St. Romain, Amy Stubbs, Josh Tiao, Jesus R Torres, Lisandra Uribe, Arvind Venkat, Gregory Volturo, Kelli Wallace, Kurt D Weber
Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of ...realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective. Results For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.
A recent randomized trial found that using a bougie did not increase the incidence of successful intubation on first attempt in critically ill adults. The average effect of treatment in a trial ...population, however, may differ from effects for individuals.
We hypothesized that application of a machine learning model to data from a clinical trial could estimate the effect of treatment (bougie vs. stylet) for individual patients based on their baseline characteristics ("individualized treatment effects").
This was a secondary analysis of the BOUGIE (Bougie or Stylet in Patients Undergoing Intubation Emergently) trial. A causal forest algorithm was used to model differences in outcome probabilities by randomized group assignment (bougie vs. stylet) for each patient in the first half of the trial (training cohort). This model was used to predict individualized treatment effects for each patient in the second half (validation cohort).
Of 1,102 patients in the BOUGIE trial, 558 (50.6%) were the training cohort, and 544 (49.4%) were the validation cohort. In the validation cohort, individualized treatment effects predicted by the model significantly modified the effect of trial group assignment on the primary outcome (
value for interaction = 0.02; adjusted qini coefficient, 2.46). The most important model variables were difficult airway characteristics, body mass index, and Acute Physiology and Chronic Health Evaluation II score.
In this hypothesis-generating secondary analysis of a randomized trial with no average treatment effect and no treatment effect in any prespecified subgroups, a causal forest machine learning algorithm identified patients who appeared to benefit from the use of a bougie over a stylet and from the use of a stylet over a bougie using complex interactions between baseline patient and operator characteristics.
Given the wide usage of emergency point-of-care ultrasound (EUS) among emergency physicians (EPs), rigorous study surrounding its accuracy is essential. The Standards for Reporting of Diagnostic ...Accuracy (STARD) criteria were established to ensure robust reporting methodology for diagnostic studies. Adherence to the STARD criteria among EUS diagnostic studies has yet to be reported.
Our objective was to evaluate a body of EUS literature shortly after STARD publication for its baseline adherence to the STARD criteria.
EUS studies in 5 emergency medicine journals from 2005–2010 were evaluated for their adherence to the STARD criteria. Manuscripts were selected for inclusion if they reported original research and described the use of 1 of 10 diagnostic ultrasound modalities designated as “core emergency ultrasound applications” in the 2008 American College of Emergency Physicians Ultrasound Guidelines. Literature search identified 307 studies; of these, 45 met inclusion criteria for review.
The median STARD score was 15 (interquartile range IQR 12–17), representing 60% of the 25 total STARD criteria. The median STARD score among articles that reported diagnostic accuracy was significantly higher than those that did not report accuracy (17 IQR 15–19 vs. 11 IQR 9–13, respectively; p < 0.0001). Seventy-one percent of articles met ≥50% of the STARD criteria (56–84%) and 4% met >80% of the STARD criteria.
Significant opportunities exist to improve methodological reporting of EUS research. Increased adherence to the STARD criteria among diagnostic EUS studies will improve reporting and improve our ability to compare outcomes.
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