Emergency Department Residents Research Articles

The effect of supervision of residents on quality of care in five university-affiliated emergency departments.

To assess the impact of direct supervision of resident physicians by attending physicians on quality of care in emergency departments. In 1993, compliance with process-of-care guidelines was measured for 3,667 patients cared for by residents in five emergency departments in Boston and Cambridge, Massachusetts. Those patients presented with abdominal pain, asthma/COPD, chest pain, hand laceration, head trauma, or vaginal bleeding. A follow-up survey to assess patient satisfaction and reported problems with care was completed by 1,094 randomly sampled patients. In multivariate analysis, residents directly supervised by attending physicians had significantly (p < .0001) higher adjusted mean percentage compliance with guidelines (64%) than did residents alone (55%). Better compliance was also associated with higher level of training of the resident and greater patient urgency. There was no significant difference between supervised and unsupervised residents in either adjusted patient satisfaction or reported problems with care. Direct supervision of residents in emergency departments is significantly associated with better compliance with guidelines, regardless of level of training. However, direct supervision was not shown to influence patients' experience with care.

Logistics in acute stroke management.

Results from the two National Institute of Neurological Disorders and Stroke (NINDS) studies indicate that administration of alteplase (recombinant tissue-type plasminogen activator; rt-PA) within 3 hours of symptom onset to appropriately selected patients with acute ischaemic stroke improves patient outcome. Several factors that delay time to treatment in patients with stroke have been identified, the most important of which is probably the failure of the patient (or family member) to recognise the signs and symptoms of stroke. Once the need for help is recognised, the initial point of access to emergency medical systems should be the local emergency number (e.g. 911 in the US) rather than the family physician. Patients with suspected stroke should be evaluated and treated by a physician as soon as possible, but this will depend to some extent on the level of expertise of the attending physicians and on available resources. The NINDS-sponsored National Symposium on the Rapid Identification and Treatment of Acute Stroke has recommended ideal time goals for all hospitals that treat patients with acute stroke. These goals include 25 minutes from arrival at an emergency department to computerised tomography scan, and 60 minutes from arrival to treatment. Recommendations for enhancing the logistics of treatment for patients with stroke may involve the following: improved education programmes for at-risk populations and their families and emergency medical system personnel, identification of acute stroke as a level one emergency similar to acute myocardial infarction or trauma, and modelling of treatment algorithms accordingly, acceptance of, and commitment to, the time guidelines recommended by the National Symposium on the Rapid Identification and Treatment of Acute Stroke. Effective and safe use of alteplase will also depend on rapid access to the highest level of neurological and radiological expertise. This may require major changes in the educational curriculum of emergency department residency and ongoing continuing education programmes, and/or more intensive radiological training for neurologists and neurologists-in-training.

Attending supervision of nonemergency medicine residents in a university hospital ED

There have been a limited number of studies assessing the impact of attending physician supervision of residents in the emergency department (ED). The objective of this study is to describe the changes in patient care when attending emergency physicians (AEPs) supervise nonemergency medicine residents in a university hospital ED. This was a prospective study including 1,000 patients, 32 second- and third-year nonemergency medicine residents and eight AEPs. The AEPs classified changes in care for each case as major, minor, or none, according to a 40-item data sheet list. There were 153 major changes and 353 minor changes by the AEP. The most common major changes were ordering laboratory or x-ray tests that showed a clinically significant abnormality, and eliciting important physical exam findings. Potentially limb- or life-threatening errors were averted by the AEP in 17 patients. Supervision of nonemergency medicine residents in the ED resulted in frequent and clinically important changes in patient care.

Abdominal pain in the ED: Stability and change over 20 years

Abdominal pain (AP) is a common presenting complaint in emergency department (ED) patients. A 1972 study reported that unsupervised surgical residents in a university hospital ED were unable to make a specific diagnosis in 41% of 1,000 AP patients. In the intervening time, ED availability of diagnostic technology has increased, and the reference hospital acquired full-time emergency medicine (EM) faculty. To assess what changes occurred in the evaluation and epidemiology of AP, a similar study was done at the same hospital. The study design was a review of records of 1,000 consecutive ED patients with AP seen in 1993 at a 58,000-visit public Level I trauma center ED. The percentage of ED patients (4% to 5%) with AP was unchanged. Frequency of hospital admission dropped from 27.4% (1972) to 18.3% (1993). There was marked increase in the specificity of diagnoses, with only 24.9% in 1993 diagnosed as undifferentiated abdominal pain (UDAP). There were eight cases of missed appendicitis in 1972 and none in 1993. One 1993 patient with acute cholecystitis was initially misdiagnosed as having UDAP. Advances in technology and EM faculty presence were temporally associated with improved diagnostic accuracy in patients with AP in a university hospital ED. As compared with 20 years ago, fewer patients required hospitalization, more were assigned a specific diagnosis, and there were fewer cases of missed surgical disease.

Rotating residents' impressions of an ED managed by career emergency physicians.

Rotating residents (RRs) were surveyed to determine their impressions of an emergency department (ED) run by career emergency physicians (EPs), in the hope of generating insights into controversies that occur between the ED and other hospital departments. A questionnaire was distributed to RRs at Taipei Veterans General Hospital in September 1993. The questionnaire inquired about basic data, workload, and ED training and teaching, and also asked respondents for their overall evaluation of emergency medicine and EPs. Of 117 questionnaires issued to residents who had rotated in the ED during the previous 5 years, 60 respondents from the departments of internal medicine, family medicine, chest medicine, neurology, and respiratory therapy completed and returned the questionnaires. Ninety percent believed the workload of the ED to be heavy, and 87% considered two to three months to be an appropriate ED training time. Only 40% were willing to extend their ED training time to achieve a more reasonable workload, and 83% considered their ED residency stressful, with too many patients and long working hours cited as the leading sources of stress. Fear of malpractice suits and difficult interaction with patients and patients' families were also cited as stressful factors. All RRs considered ED training important; self-learning and the accumulation of ED experience, as well as the conference on emergency pitfalls, were the two aspects of training most favored, garnering approval by 92% and 80%, respectively. The overall impression of the RRs on emergency medicine and the performance of EPs was favorable.(ABSTRACT TRUNCATED AT 250 WORDS)

Longitudinal Assessment of Cocaine Toxicity in Emergency Department Patients

Longitudinal data are necessary to identify changes in drug abuse and resultant toxicity. The development of COC-LOG, a longitudinal database used to assess cocaine-associated emergency department patient visits at Truman Medical Center, the University of Missouri-Kansas City, is described. COC-LOG currently contains 1,054 patient visits. The data demonstrate that cocaine toxicity has remained relatively constant in our emergency department (ED) over the last 4 years. The majority of cocaine use is through smoking crack, and major differences in toxicity are not seen between this route and IV cocaine use. The relatively low prevalence of severe cardiac toxicity and deaths has lead to a series of projects to evaluate cocaine toxicity's clinical course. Electrocardiographic abnormalities are common, but do not frequently indicate severe clinical toxicity. In the first 3 years after ED discharge, deaths in cocaine patients occur almost twice as frequently as in age-, race-, and sex-matched control ED patients. Urine drug testing of pregnant patients suggests that documentation of recent cocaine use by history alone underestimates the prevalence of cocaine use in ED patients approximately four-fold. COC-LOG is a useful method of following cocaine's impact on department patients. Study results can be applied to patient care and the education of ED faculty, residents, students, and personnel.

Aminophylline in the Emergency Department: Maximizing Safety and Efficacy

An experimental technique designed to predict theophylline doses needed to attain therapeutic theophylline concentrations in 43 emergency department (ED) patients was compared with a standard conventional regimen in 46 ED patients. The experimental protocol utilized a computer-assisted dosage prediction program that incorporated baseline theophylline concentration rapidly obtained using a bedside assay. The standard protocol used conventional loading and infusion rates, as well as an estimate of time of last theophylline dose based on patient history. Plasma theophylline concentrations, estimated 1 and 6 hours after commencement of aminophylline therapy in each regimen, were compared. The experimental protocol was equally rapid but much more accurate in achieving targeted theophylline concentrations. Experimental dosage prediction was associated with a higher proportion of theophylline concentrations in the therapeutic range at 1 (81 percent vs 26 percent; p less than 0.001) and 6 hours (91 percent vs 37 percent; p less than 0.001). There was a trend toward fewer toxic concentrations recorded at 1 (0 percent vs 7 percent; p = 0.27) and 6 hours (0 percent vs 10 percent; p = 0.08). This protocol, which was performed quickly and without difficulty by residents in a busy hospital ED, offers an opportunity to improve the efficacy and decrease the toxicity of theophylline use in asthma emergencies.

Sonographic Detection of Abdominal Free Fluid: Emergency Residents vs Radiology Residents

BackgroundFocused assessment with sonography for trauma (FAST) has become a part of initial examinations in trauma care at emergency departments (ED).ObjectivesThe goal of the present study was to evaluate the accuracy of FASTs performed by emergency residents (ER) in detection of abdominal free fluid following blunt trauma.Materials and MethodsIn this study, the reports of ERs performing FASTs on 286 admitted patients following blunt trauma were compared with those of radiology residents (RR) in relation to presence of abdominal free fluid. In addition, the reports of the two resident groups were compared with the final abdominal outcome, based on the results of abdominal computed tomography (CT) and clinical follow up.ResultsThe ERs had reported abdominal free fluid in 20 (6.9%) patients while RRs performing FAST had positive results in 22 (7.6%) patients. The reports of FASTs revealed significant correlation between the two resident groups (P < 0.001). ERs performing FASTs had 90% sensitivity and 98.5% specificity in comparison to RRs sonography reports. Furthermore, ER-performed FASTs had 96.5% accuracy in relation to final outcome.ConclusionsFollowing training, ED residents can perform FAST with high accuracy and specificity, similar to RR residents, in patients with blunt abdominal trauma.