The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear.
In 14 U.S. hospitals with high adherence to quality measures for the ...treatment of pneumonia, we provided guidance for clinicians about national clinical practice recommendations for the treatment of lower respiratory tract infections and the interpretation of procalcitonin assays. We then randomly assigned patients who presented to the emergency department with a suspected lower respiratory tract infection and for whom the treating physician was uncertain whether antibiotic therapy was indicated to one of two groups: the procalcitonin group, in which the treating clinicians were provided with real-time initial (and serial, if the patient was hospitalized) procalcitonin assay results and an antibiotic use guideline with graded recommendations based on four tiers of procalcitonin levels, or the usual-care group. We hypothesized that within 30 days after enrollment the total antibiotic-days would be lower - and the percentage of patients with adverse outcomes would not be more than 4.5 percentage points higher - in the procalcitonin group than in the usual-care group.
A total of 1656 patients were included in the final analysis cohort (826 randomly assigned to the procalcitonin group and 830 to the usual-care group), of whom 782 (47.2%) were hospitalized and 984 (59.4%) received antibiotics within 30 days. The treating clinician received procalcitonin assay results for 792 of 826 patients (95.9%) in the procalcitonin group (median time from sample collection to assay result, 77 minutes) and for 18 of 830 patients (2.2%) in the usual-care group. In both groups, the procalcitonin-level tier was associated with the decision to prescribe antibiotics in the emergency department. There was no significant difference between the procalcitonin group and the usual-care group in antibiotic-days (mean, 4.2 and 4.3 days, respectively; difference, -0.05 day; 95% confidence interval CI, -0.6 to 0.5; P=0.87) or the proportion of patients with adverse outcomes (11.7% 96 patients and 13.1% 109 patients; difference, -1.5 percentage points; 95% CI, -4.6 to 1.7; P<0.001 for noninferiority) within 30 days.
The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection. (Funded by the National Institute of General Medical Sciences; ProACT ClinicalTrials.gov number, NCT02130986 .).
Study objective We assess the diagnostic accuracy of emergency physician–performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical ...pathology. Methods We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. Results Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval CI 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). Conclusion The test characteristics of emergency physician–performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.
Most medical schools teach cardiopulmonary resuscitation (CPR) during the final year in course curriculum to prepare students to manage the first minutes of clinical emergencies. Little is known ...regarding the optimal method of instruction for this critical skill. Simulation has been shown in similar settings to enhance performance and knowledge. We evaluated the comparative effectiveness of high-fidelity simulation training vs. standard manikin training for teaching medical students the American Heart Association (AHA) guidelines for high-quality CPR.
This was a prospective, randomized, parallel-arm study of 70 fourth-year medical students to either simulation (SIM) or standard training (STD) over an eight-month period. SIM group learned the AHA guidelines for high-quality CPR via an hour session that included a PowerPoint lecture with training on a high-fidelity simulator. STD group learned identical content using a low-fidelity Resusci Anne® CPR manikin. All students managed a simulated cardiac arrest scenario with primary outcome based on the AHA guidelines definition of high-quality CPR (specifies metrics for compression rate, depth, recoil, and compression fraction). Secondary outcome was time to emergency medical services (EMS) activation. We analyzed data via Kruskal-Wallis rank sum test. Outcomes were performed on a simulated cardiac arrest case adapted from the AHA Advanced Cardiac Life Support (ACLS) SimMan® Scenario manual.
Students in the SIM group performed CPR that more closely adhered to the AHA guidelines of compression depth and compression fraction. Mean compression depth was 4.57 centimeters (cm) (95% confidence interval CI 4.30-4.82) for SIM and 3.89 cm (95% CI 3.50-4.27) for STD, p=0.02. Mean compression fraction was 0.724 (95% CI 0.699-0.751) for SIM group and 0.679 (95% CI 0.655-0.702) for STD, p=0.01. There was no difference for compression rate or recoil between groups. Time to EMS activation was 24.7 seconds (s) (95% CI 15.7-40.8) for SIM group and 79.5 s (95% CI 44.8-119.6) for STD group, p=0.007.
High-fidelity simulation training is superior to low-fidelity CPR manikin training for teaching fourth-year medical students implementation of high-quality CPR for chest compression depth and compression fraction.
The KBindER (K
Binders in Emergency Room and hospitalized patients) clinical trial is the first head-to-head evaluation of oral potassium binders (cation-exchange resins) for acute hyperkalemia ...therapy.
Emergency room and hospitalized patients with a blood potassium level ≥ 5.5 mEq/L are randomized to one of four study groups: potassium binder drug (sodium polystyrene sulfonate, patiromer, or sodium zirconium cyclosilicate) or nonspecific laxative (polyethylene glycol). Exclusion criteria include recent bowel surgery, ileus, diabetic ketoacidosis, or anticipated dialysis treatment within 4 h of treatment drug. Primary endpoints include change in potassium level at 2 and 4 h after treatment drug. Length of hospital stay, next-morning potassium level, gastrointestinal side effects and palatability will also be analyzed. We are aiming for a final cohort of 80 patients with complete data endpoints (20 per group) for comparative statistics including multivariate adjustment for kidney function, diabetes mellitus, congestive heart failure, metabolic acidosis, renin-angiotensin-aldosterone system inhibitor prescription, and treatment with other agents to lower potassium (insulin, albuterol, loop diuretics).
The findings from our study will inform decision-making guidelines on the role of oral potassium binders in the treatment of acute hyperkalemia.
ClinicalTrials.gov Identifier: NCT04585542 . Registered 14 October 2020.
The 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing ...purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students' documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines.
We conducted a prospective study of fourth-year medical students' simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students' simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics.
We found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams.
New curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.
Study objective Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency ...department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. Methods Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. Results Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). Conclusion In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.
Objectives
The established benefits of point‐of‐care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education. This study sought ...to measure the educational success of a comprehensive and integrated 4‐year point‐of‐care ultrasound curriculum.
Methods
We integrated a curriculum consisting of traditional didactics combined with asynchronous learning modules and hands‐on practice on live models with skilled sonographers into all 4 years of education at a Liaison Committee on Medical Education–accredited US Medical School. Each graduating student was administered an exit examination with 48 questions that corresponded to ultrasound milestones.
Results
Ninety‐five percent (n = 84) of fourth‐year medical students completed the exit examination. The mean score was 79.5% (SD, 10.2%), with mean scores on the ultrasound physics and anatomy subsections being 77.1% (SD, 11.0%) and 85.9% (SD, 21.0%), respectively.
Conclusions
A comprehensive 4‐year point‐of‐care ultrasound curriculum integrated into medical school may successfully equip graduating medical students with a fundamental understanding of ultrasound physics, anatomy, and disease recognition.
Our goal was to evaluate the feasibility and effectiveness of using telesimulation to deliver an emergency medical services (EMS) course on mass casualty incident (MCI) training to healthcare ...providers overseas.
We conducted a feasibility study to establish the process for successful delivery of educational content to learners overseas via telesimulation over a five-month period. Participants were registrants in an EMS course on MCI triage broadcast from University of California, Irvine Medical Simulation Center. The intervention was a Simple Triage and Rapid Treatment (START) course. The primary outcome was successful implementation of the course via telesimulation. The secondary outcome was an assessment of participant thoughts, feelings, and attitudes via a qualitative survey. We also sought to obtain quantitative data that would allow for the assessment of triage accuracy. Descriptive statistics were used to express the percentage of participants with favorable responses to survey questions.
All 32 participants enrolled in the course provided a favorable response to all questions on the survey regarding their thoughts, feelings, and attitudes toward learning via telesimulation with wearable/mobile technology. Key barriers and challenges identified included dependability of Internet connection, choosing appropriate software platforms to deliver content, and intercontinental time difference considerations. The protocol detailed in this study demonstrated the successful implementation and feasibility of providing education and training to learners at an off-site location.
In this feasibility study, we were able to demonstrate the successful implementation of an intercontinental MCI triage course using telesimulation and wearable/mobile technology. Healthcare providers expressed a positive favorability toward learning MCI triage via telesimulation. We were also able to establish a process to obtain quantitative data that would allow for the calculation of triage accuracy for further experimental study designs.
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