Emergency Medicine Attending Research Articles

P075: Constructing entrustment: understanding clinical supervisor dynamics in the oral case presentation

Introduction: The Oral Case Presentation (OCP) has been described as a unique form of inter-physician communication integral to the practice of medicine and represents the foundation of trainee-supervisor interactions. In recent years, entrustment has been identified as an essential element of trainee supervision and learning. Despite the growing body of knowledge concerning entrustment in medical education, the influence of trust on the educational dynamic surrounding the OCP remains unknown. The objectives of this study were to (1) describe the complex nature of the OCP from the perspective of the supervisor and (2) explore the central role the OCP plays in the dyadic relationship between supervisor and trainee during the delivery of patient care. Methods: Using a constructivist grounded theory approach, semi-structured interviews were conducted from 2015 to 2016 with a purposive sample of attending Emergency Medicine (EM) physicians from the University of Ottawa. Transcripts were reviewed independently by two investigators using line-by-line coding and constant comparative analysis. Emerging concepts were coded and key themes identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Results: Twenty-one attending EM physicians participated in this study (71% male). The mean number of years in practice was 14. The mean percentage of shifts with a trainee assigned was 86%. Factors relating to entrustment were identified as the principal influences on both the content of the OCP and decisions relating to trainee supervision during the OCP process. These factors included the trainee level, the trainee-supervisor relationship, the context and the task. The OCP was also found to play several important roles as supervisors balanced the delivery of patient care and trainee education. These roles were related to communication, teaching and trainee assessment. Conclusion: The OCP represents a core activity within the supervisor-trainee relationship in which trust plays a central role. Clinical supervisors value the OCP as a form of authentic assessment of skills and perceive it to be a key determinant in making entrustment decisions. Future studies designed to evaluate the utility of the OCP as an educational tool should consider entrustment as an essential element.

The diagnostic and prognostic value of the optic nerve sheath diameter on CT for diagnosis spontaneous subarachnoid hemorrhage

IntroductionThe aim of this study was to investigate the relationship between the optic nerve sheath diameter (ONSD) measured on non-contrast head computed tomography (CT) and the diagnosis and prognosis of spontaneous subarachnoid hemorrhage (SAH) on emergency department (ED) patients. MethodWe used a matched control group of patients with the same age and gender who were diagnosed in the ED with spontaneous SAH and who admitted to the ED with headache. Four emergency medicine attending physicians made the ONSD measurements. For measurements, the 3-mm posterior location where the optic nerve enters the eyeball was used. ResultsThis study was done with 61 spontaneous SAHs with an equal number of control patients. The median ONSD for control and spontaneous SAH groups was 5.76 [interquartile range (IQR): 0.96] mm and 6.72 (IQR: 1.42) mm, respectively (p<0.001). The area under the receiver operating characteristic curve was determined as 0.791 (confidence interval 95% 0.710–0.872). At an ONSD threshold value of 6.1 mm, the sensitivity and specificity of SAH was 72%. There was no significant relationship between ONSD and in-hospital mortality in spontaneous SAH patients (p>0.05). The intra-class correlation coefficients for inter and intra-rater reliability were 0.84 and 0.95, respectively. ConclusionIn patients with spontaneous SAH, the ONSD measured in the orbital sections of a head CT is strongly correlated with a SAH diagnosis. Assessment of ONSD in head CTs taken with spontaneous SAH suspicion may contribute to the diagnoses of spontaneous SAH.

Attending documentation contribution to billing at an academic ED with an electronic health record

IntroductionIn emergency medicine (EM), patient care documentation serves many functions, including supporting reimbursement. In addition, many electronic health record systems facilitate automatically populating certain data fields. As a result, in the academic model, the attending's note may now more often recapitulate many of the same elements found in the resident's or physician assistant's (PA) note. We sought to determine the value of additional attending documentation, and how often the attending documentation prevented a downcoding event. MethodsThis retrospective, cross-sectional study was exempted by the Institutional Review Board. We randomly reviewed 10 charts for each attending physician during the study period. Outcome measures included the frequency of prevented downcoding events, and the difference in this incidence between residents and PAs. Results530 charts were identified, but 6 were excluded as these patients left without being seen. 524 charts remained, of which 286 (45%) notes were written by residents and 238 (55%) notes were written by PAs. Attending documentation prevented 16 (3%) downcoding events, of which 11 were in patient encounters documented by residents and 5 were in encounters documented by PAs (p=0.057). ConclusionsIn this study of an academic medical center documentation model with an EHR, EM attending documentation of the history of present illness, review of systems, physical exam, and medical decision making portions prevented downcoding in a small number of cases. In addition, there was no significant difference in the incidence of prevented downcoding events between residents and PAs.

Individual Gestalt Is Unreliable for the Evaluation of Quality in Medical Education Blogs: A METRIQ Study

Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department.

IntroductionBenefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM).MethodsWe conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel.ResultsThe data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted.ConclusionThis survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use.

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Feasibility Testing of an Emergency Department Screening Tool To Identify Older Adults Appropriate for Palliative Care Consultation

Seriously ill older adults in the emergency department (ED) may benefit from palliative care referral, yet little is known about how to identify these patients. To assess the performance and determine the acceptability of a content-validated palliative care screening tool. We surveyed Emergency Medicine (EM) attending physicians at the end of their shifts using the screening tool and asked them to retrospectively apply it to all patients ≥65 years whom they had cared for. We conducted the survey for three consecutive weeks in October 2015. EM attending physicians at an urban, university-affiliated ED. Patient characteristics, acceptability rating, and time per patient screened. We approached 38 attending physicians to apply the screening tool for 69 eligible shifts. Physicians agreed to participate during 55 shifts (80%) and screened 207 patients. On 14 shifts (20%), physicians declined to participate. Mean age of the screened patients was 75 years, 51% were male, and 45% had at least one life-limiting illness. Overall, 67 patients (32%) screened positive for palliative care needs. Seventy percent of physicians (n = 33) found the screening tool acceptable to use and the average time of completion was 1.8 minutes per patient screened. A rapid screen of older adults for palliative care needs was acceptable to a majority of EM physicians and identified a significant number of patients who may benefit from palliative care referral. Further research is needed to improve acceptability and determine the appropriate care pathway for patients with palliative care needs.

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality.

IntroductionAttending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.MethodsWe performed a retrospective observational study of patients presenting to a university-affiliated, urban ED from October 1, 2007, through September 30, 2008. The main outcome measures were admission rate, fiscal indicators (Medicaid-denied payment days), and quality indicators (15- and 30-day ED returns; delayed hospital admissions). We asked each Attending to estimate their inpatient admission rate and correlated their personal assessment with actual admission rates.ResultsAdmission rates, even after adjusting for known confounders, were highly variable (15.2%–32.0%) and correlated with Medicaid denied-payment day rates (p=0.038). There was no correlation with quality outcome measures (30-day ED return or delayed hospital admission). There was no significant correlation between actual and self-described admission rate; the range of mis-estimation was 0% to 117%.ConclusionEmergency medicine attending admission rates at this institution are highly variable, unexplained by known confounding variables, and unrelated to quality of care, as measured by 30-day ED return or delayed hospital admission. Admission optimization represents an important untapped potential for cost reduction through avoidable hospitalizations, with no apparent adverse effects on quality.

Physician Communication in Pediatric End-of-Life Care: A Simulation Study.

The objective of this exploratory study is to describe communication between physicians and the actor parent of a standardized 8-year-old patient in respiratory distress who was nearing the end of life. Thirteen pediatric emergency medicine and pediatric critical care fellows and attendings participated in a high-fidelity simulation to assess physician communication with an actor-parent. Fifteen percent of the participants decided not to initiate life-sustaining technology (intubation), and 23% of participants offered alternatives to life-sustaining care, such as comfort measures. Although 92% of the participants initiated an end-of-life conversation, the quality of that discussion varied widely. Findings indicate that effective physician-parent communication may not consistently occur in cases involving the treatment of pediatric patients at the end of life in emergency and critical care units. The findings in this study, particularly that physician-parent end-of-life communication is often unclear and that alternatives to life-sustaining technology are often not offered, suggest that physicians need more training in both communication and end-of-life care.

Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States.

BackgroundThe use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed.MethodsThis was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process.ResultsThere was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003.ConclusionsThe survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.

Ionizing Radiation Knowledge Among Emergency Department Providers

PurposeThe aim of this study was to assess knowledge of ionizing radiation exposure from diagnostic imaging examinations among emergency department (ED) providers. MethodsAn electronic questionnaire was distributed to ED providers in a five-hospital university-affiliated health care system. Providers included attending emergency medicine (EM) physicians, EM residents, and midlevel providers (MLPs) (nurse practitioners and physicians assistants). Data were collected and analyzed. ResultsOne hundred six of 210 providers (41 attending physicians, 32 residents, and 31 MLPs) completed the survey, for a response rate of 50.5%. More than two in five providers (44.6%) could not correctly identify which of six common imaging modalities used ionizing radiation. MLPs were more likely to incorrectly identify radiography (25%) and fluoroscopy (29%) as modalities that did not use ionizing radiation (P = .01 and P = .25 respectively). Fewer attending physicians (14.6%) than residents (37.5%) were not very comfortable or were uncomfortable explaining the risks of radiation to patients. Nearly half of attending physicians (47.5%) and nearly three-quarters of residents (71.9%) were not very comfortable, were uncomfortable, or were extremely uncomfortable explaining the amount of radiation in certain imaging tests to patients. MLPs were more likely to incorrectly rank a selection of imaging tests by radiation exposure (P = .002). MLPs were more likely to incorrectly answer a question on the effects of ionizing radiation on patients (P = .01). ConclusionsAmong ED providers, there are knowledge gaps regarding the presence and effect of ionizing radiation in diagnostic imaging tests. MLPs were more likely to make factual errors, while EM residents were least comfortable counseling patients about radiation risks.

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

IntroductionAlthough emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department.MethodsWe developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation.ResultsOf 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0–1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education.ConclusionEM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0–1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.

The educational value of emergency department teaching: it is about time.

There is a paucity of research on the quality and quantity of clinical teaching in the emergency department (ED) setting. While many factors impact residents' perceptions of attending physicians' educational skill, the authors hypothesized that the amount of time residents spend with attending in direct teaching is a determinant of residents' perception of their shift's educational value. Researchers shadowed emergency medicine (EM) attendings during ED shifts, and recorded teaching time with each resident. Residents were surveyed on their assessment of the educational value (EV) of the shift and potential confounders, as well as the attending physician's teaching quality using the ER Scale. The study was performed in the EDs of two urban teaching hospitals affiliated with an EM residency program. Subjects were EM residents and rotators from other specialties. The main outcome measure was the regression of impact of teaching time on EV. Researchers observed 20 attendings supervising 47 residents (mean 2.35 residents per attending, range 2-3). The correlation between teaching time in minutes (mean 60.8, st.dev 25.6, range 7.6-128.1) and EV (mean 3.45 out of 5, st. dev 0.75, range 2-5) was significant (r=0.302, r 2=0.091, p<0.05). No confounders had a significant effect. The study shows a moderate correlation between the total time attendings spend directly teaching residents and the residents' perception of educational value over a single ED shift. The authors suggest that mechanisms to increase the time attending physicians spend teaching during clinical shifts may result in improved resident education.

Abstract TP298: Code Stroke Simulation Training Benefits Junior Neurology Residents

Introduction: Junior neurology residents frequently receive the first call for emergency neurological conditions, including acute ischemic stroke and intracerebral hemorrhage (ICH) (Code Stroke). Code Stroke simulations allow residents to gain experience in the evaluation and treatment of a potential stroke patient without compromising patient care. Simulations also give residents the opportunity to improve their skills through direct observation and feedback. We hypothesized that simulation training would increase junior neurology residents’ confidence, comfort level and preparedness in leading a Code Stroke. Methodology: Ten neurology residents in their first months of training each took turns leading a Code Stroke simulation – either assessment of an ischemic stroke patient for intravenous thrombolytics, coordination of an ischemic stroke patient for embolectomy, or management of an ICH patient. Standardized patients were used in each case. Emergency medicine, vascular neurology and neurointerventional radiology attendings were active participants in the cases and gave feedback. Residents completed a survey before and after the simulation. Results: On a 5-point Likert scale (1 – least true and 5 – most true), confidence in leading a Code Stroke significantly increased from 2.80 to 3.95 (p=0.01) and perceived preparedness for the next Code Stroke significantly improved from 2.80 to 4.30 (p&lt;0.01). Residents reported significantly improved comfort levels in rapidly assessing the National Institutes of Health Stroke Scale score (3.35 vs. 4.25, p=0.03) and rapidly assessing a Code Stroke patient for thrombolytics (3.15 vs. 4.25, p=0.02), making the decision to give thrombolytics (2.80 vs. 4.00, p=0.02) and assessing a patient for embolectomy (3.33 vs. 4.67, p=0.03). There was a perception of enhanced mutli-disciplinary collaboration with emergency medicine providers (3.55 vs. 4.40, p=0.04) and neurointerventional radiologists (3.00 vs. 4.50, p=0.07). Conclusion: Simulation training is a beneficial part of medical education for junior neurology residents and should be considered in addition to traditional didactics and clinical training.

Development and Implementation of an Emergency Medicine Podcast for Medical Students: EMIGcast.

Podcasts, episodic digital audio recordings downloaded through web syndication or streamed online, have been shown to be an effective instructional method in undergraduate health professions education, and are increasingly used for self-directed learning.1–6 Emergency medicine (EM) has embraced podcasting: over 80% of EM residents report listening to podcasts and a substantial number identify podcasts as the most valuable use of their educational time.4 Despite proven efficacy in undergraduate medical education and remarkable popularity with EM residents and attendings, there remain few EM podcasts targeted to medical students.5 Given that podcast effectiveness correlates with how well content matches the listener needs, a podcast specific to EM-bound medical students may optimally engage this target audience. 6

Combining transtracheal catheter oxygenation and needle-based Seldinger cricothyrotomy into a single, sequential procedure

BackgroundNeedle-based cricothyrotomy is a common procedure for emergency department patients requiring an emergent surgical airway. Percutaneous transtracheal jet ventilation is well studied to provide oxygenation. We propose to combine these procedures into a novel, single, and sequential procedure. MethodsThis study was a prospective manikin/human cadaver procedural feasibility study performed at a medical education center. Forty-eight emergency medicine attending physicians and fellows performed the procedure on a single TraumaMan (Simulab Corporation, Seattle, WA), and 26 were randomly selected to perform the procedure on fresh, unfixed human cadavers.The procedure is as follows: 15 gauge/6F catheter-over-needle punctures cricothyroid membrane, needle is removed, and Enk oxygen flow modulator is attached to the catheter (start to oxygenation). The Enk set is detached, a guide wire introduced, and Seldinger cricothyrotomy is performed (oxygenation to cricothyrotomy).Start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times were recorded. Manikin procedures were verified by direct visualization, and cadaver procedures were verified by video laryngoscopy. ResultsAll attempts were included in data analysis, and there was a 100% first-pass success rate. For the manikin trials, median start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times with interquartile ranges were 11 (8.5-13), 48 (42-57), and 59 (53-69) seconds, respectively. For the cadaver trials, median start-to-oxygenation, oxygenation-to-cricothyrotomy, and start-to-cricothyrotomy times with interquartile ranges were 12 (10-15), 59 (47-76), and 71 (61-94) seconds, respectively. Student t tests showed significant differences in start-to-oxygenation and oxygenation-to-cricothyrotomy times (P < .01) within the manikin and cadaver groups. ConclusionPercutaneous transtracheal jet ventilation and needle-based Seldinger cricothyrotomy can be performed by emergency medicine physicians, and a single, sequential procedure may significantly reduce time to oxygenation for patients already undergoing surgical cricothyrotomy.

Emergency Bedside Ultrasound to Identify Pediatric Appendicitis

Investigators at a single academic institution prospectively evaluated the accuracy of emergency department ultrasound for identifying acute appendicitis in children. After attending a 45-minute lecture and performing five studies under supervision, one pediatric emergency medicine attending physician and 12 fellows performed bedside ultrasound studies. A positive study result was defined as visualization …

Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation.

Advanced Trauma Life Support (ATLS) has been shown to improve outcomes related to trauma resuscitation; however, omissions from this protocol persist. The objective of this study was to evaluate the effect of a trauma resuscitation checklist on performance of ATLS tasks. Video recordings of resuscitations of children sustaining blunt or penetrating injuries at a Level I pediatric trauma center were reviewed for completion and timeliness of ATLS primary and secondary survey tasks, with and without checklist use. Patient and resuscitation characteristics were obtained from the trauma registry. Data were collected during two 4-month periods before (n = 222) and after (n = 213) checklist implementation. The checklist contained 50 items and included four sections: prearrival, primary survey, secondary survey, and departure plan. Five primary survey ATLS tasks (cervical spine immobilization, oxygen administration, palpating pulses, assessing neurologic status, and exposing the patient) and nine secondary survey ATLS tasks were performed more frequently (p ≤ 0.01 for all) and vital sign measurements were obtained faster (p ≤ 0.01 for all) after the checklist was implemented. When controlling for patient and event-specific characteristics, primary and secondary survey tasks overall were more likely to be completed (odds ratio [OR] = 2.66, primary survey; OR = 2.47, secondary survey; p < 0.001 for both) and primary survey tasks were performed faster (p < 0.001) after the checklist was implemented. Implementation of a trauma checklist was associated with greater ATLS task performance and with increased frequency and speed of primary and secondary survey task completion.

Challenging script concordance test reference standard by evidence: do judgments by emergency medicine consultants agree with likelihood ratios?

BackgroundWe aimed to compare the clinical judgments of a reference panel of emergency medicine academic physicians against evidence-based likelihood ratios (LRs) regarding the diagnostic value of selected clinical and paraclinical findings in the context of a script concordance test (SCT).FindingsA SCT with six scenarios and five questions per scenario was developed. Subsequently, 15 emergency medicine attending physicians (reference panel) took the test and their judgments regarding the diagnostic value of those findings for given diseases were recorded. The LRs of the same findings for the same diseases were extracted from a series of published systematic reviews. Then, the reference panel judgments were compared to evidence-based LRs. To investigate the test-retest reliability, five participants took the test one month later, and the correlation of their first and second judgments were quantified using Spearman rank-order coefficient.In 22 out of 30 (73.3%) findings, the expert judgments were significantly different from the LRs. The differences included overestimation (30%), underestimation (30%), and judging the diagnostic value in an opposite direction (13.3%). Moreover, the score of a hypothetical test-taker was calculated to be 21.73 out of 30 if his/her answers were based on evidence-based LRs.The test showed an acceptable test-retest reliability coefficient (Spearman coefficient: 0.83).ConclusionsAlthough SCT is an interesting test to evaluate clinical decision-making in emergency medicine, our results raise concerns regarding whether the judgments of an expert panel are sufficiently valid as the reference standard for this test.

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study.

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis. Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4h didactic and practical course and with 7.5MHz linear probe both in longitudinal and axial axes. Ninety-seven patients were included and analyzed. 27 (27.8%) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37%) of them had appendicitis according to their pathologic reports too. Forty-three (44.3%) of patients had appendicitis according to pathology reports. Only 19 (44.18%) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18%, specificity of 85.18%, positive predictive value of 70.37%, negative predictive value of 65.71% and overall accuracy of 67.01% in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis. Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.