Emergency Medicine Procedures Research Articles

Expanding FOAMed to Voice Activated Artificial Intelligence: Mental Practice of Emergency Medicine Procedures via Alexa

Expanding FOAMed to Voice Activated Artificial Intelligence: Mental Practice of Emergency Medicine Procedures via Alexa

Improving pediatric procedural skills and EPA assessments through an acute care procedural skills curriculum.

Acute procedural skill competence is expected by the end of pediatric residency training; however, the extent to which residents are actually competent is not clear. Therefore, a cross-sectional observational study was performed to examine the competency of pediatric residents in acute care procedures in emergency medicine. Pediatric residents underwent didactic/hands-on "Acute Procedure Day" where they performed procedures with direct supervision and received entrustable professional activity (EPA) assessments (scores from 1-5) for each attempt. Procedures included: bag-valve mask (BVM) ventilation, intubation, intraosseous (IO) line insertion, chest tube insertion, and cardiopulmonary resuscitation (CPR) with defibrillation. Demographic information, perceived comfort level, and EPA data were collected. Descriptive statistics and Pearson correlation for postgraduate year (PGY) versus EPA scores were performed. Thirty-six residents participated (24 PGY 1-2, and 12 PGY 3-4). Self-reported prior clinical exposure was lowest for chest tube placement (n = 3, 8.3%), followed by IOs (n = 19, 52.8%). During the sessions, residents showed the highest levels of first attempt proficiency with IO placement (EPA 4-5 in 28 residents/33 who participated) and BVM (EPA 4-5 in 27/33), and the lowest for chest tube placement (EPA 4-5 in 0/35), defibrillation (EPA 4-5 in 5/31 residents) and intubation (EPA 4-5 in 17/31). There was a strong correlation between PGY level and EPA score for intubation, but not for other skills. Entrustability in acute care skills is not achieved with current pediatrics training. Research is needed to explore learning curves for skill acquisition and their relative importance.

Emergency Medicine Procedures: A Review of Approved Instructional Resources from the World of Free Open Access Medical Education.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series was created in 2014 to address the Free Open Access Medical Education (FOAM) movement's decentralized nature and lack of inherent peer review. The AIR series provides a topic-based, curated list of online educational content vetted by academic emergency medicine (EM) faculty that meets individualized interactive instruction criteria for EM trainees. Relevant FOAM resources were identified from the top 50 FOAM websites using the Social Media Index and then scored by EM faculty using a validated instrument to identify the highest quality posts related to a topic. This article reviews FOAM resources pertaining to EM procedures that were labeled as an "Approved Instructional Resource" or "Honorable Mention" using the AIR series methodology.

Cardiopulmonary Resuscitation

Cardiopulmonary Resuscitation

Guided, motor, and mental imagery adjuncts to teaching central venous access.

Mental, motor, and guided imagery techniques are commonly used in sports psychology, but less often in medical education. Utilization of imagery-based techniques (IBTs) in combination with traditional teaching methods may provide a low-cost, innovative approach to improving outcomes in graduate medical education. The objective was to assess whether medical students demonstrate greater proficiency in the ability to obtain central venous access in simulation trainers following exposure to guided, mental, and motor imagery teaching methods in comparison to traditional methods. Volunteer fourth-year medical students during their emergency medicine rotation were randomly assigned to two groups, traditional plus imagery teaching or traditional teaching alone. The control group watched a video tutorial on central line placement methods. The study group watched the same video with the addition of imagery components. Participants filled out survey questions before and after the video and again after line placement. Proctors blinded to student group assignments then observed student placement of an internal jugular triple-lumen catheter on a simulation trainer and completed a standardized performance rubric. Sixty medical students participated. Two were excluded for having performed five or more lines either clinically or in a previous simulation. There was no difference in self-perceived competence in line placement prior to watching the video or in the number of lines previously performed between groups. The imagery group (n = 25) averaged 1.3 errors/need for intervention compared to 2.2 errors/need for intervention in the control group (n = 33; p = 0.045, 95% confidence interval [CI] 0.02 to 1.61). Time to place the line was similar-8.9 min for the control group versus 8.6 min for the imagery group (p = 0.74, 95% CI -1.39 to 1.95). The use of IBTs may be a promising adjunct to traditional medical teaching of procedures in emergency medicine.

Scheduling doesn't matter! A noninferiority study of block versus longitudinal scheduling for emergency medicine resident pediatric procedural training experience.

Emergency medicine (EM) residencies offer a wide variety of scheduling models for pediatric patient experience, including blocked weeks in pediatric emergency departments and longitudinal models with pediatric emergency pod/department shifts integrated within other clinical experiences. Concerns with autonomy, attending entrustment, and resident comfort imply that these different scheduling models may impact EM residents' pediatric procedure volumes. The purpose of this study is to quantitatively compare EM residents' pediatric procedure experience and volumes between block versus longitudinal scheduling models. We hypothesize noninferiority between the scheduling models. A retrospective review characterized the numbers and types of procedures performed by The Ohio State Emergency Medicine residents at the tertiary care pediatric hospital where residents' receive their pediatric emergency medicine clinical experience. Procedure numbers and variety were compared across six academic years: four with a block model, one reorganization year, and one integrated longitudinal year. 2552 procedures were performed by 266 resident academic years over the 6-year period. Overall, no statistically significant differences in the number of procedures performed per year or the variety of types of procedures performed per year were found when comparing the block and longitudinal models. Differences were seen in experience of PGY1 versus PGY3 residents between scheduling models and the overall experience and volumes of the PGY2 residents during the reorganization year. Our study quantitatively concluded that the longitudinal scheduling model is noninferior to the more traditional block scheduling model for emergency medicine residents' pediatric emergency medicine clinical experience when reviewing volumes and types of procedures performed in a pediatric emergency department. This suggests that procedural opportunities do not need to dictate scheduling models.

Extracurricular work experience and its association with training and confidence in emergency medicine procedures among medical students: a cross-sectional study from a Norwegian medical school

ObjectiveProficiency in basic emergency procedures is important for junior doctors, but the amount of practical exposure may vary. We studied the association between students’ extracurricular healthcare-related (ECHR) work experience and...

Procedural task trainer gaps in emergency medicine: A rift in the simulation universe.

We identified and quantified the gap between emergency medicine (EM) procedures currently taught using simulation versus those that educators would teach if they had better procedural task trainers. Additionally, we endeavored to describe which procedures were taught using homemade models and the barriers to creation and use of additional homemade models. Using a modified Delphi process, we developed a survey and distributed it to a convenience sample of EM simulationists via the Society for Academic Emergency Medicine Simulation Academy listserv. Survey items asked participants to identify procedures they thought should be taught using simulation ("most important"), do teach using simulation ("most frequent"), would teach if a simulator or model were available ("most needed"), and do teach using simulation with "homemade" models ("most frequent homemade"). Thirty-seven surveys were completed. The majority of respondents worked at academic medical centers and were involved in simulation-based education for at least 6 years. Three procedures ranked highly in overall teaching importance and currently taught categories. We identified four procedures that ranked highly as both important techniques to teach and would teach via simulation. Two procedures were selected as the most important procedures that the participants do teach via simulation but would like to teach in an improved way. We found 14 procedures that simulationists would teach if an adequate model was available, four of which are of high importance. This study captured data to illuminate the procedural model gap and inform future interventions that may address it and meet the overarching objective to create better and more readily available procedure models for EM simulation educators in the future. It offers an informed way of prioritizing procedures for which additional homemade models should be created and disseminated as well as barriers to be aware of and to work to overcome. Our work has implications for learners, educators, administrators, and industry.

A Goat Cadaver as a Cost-effective Resource for Teaching Emergency Medicine Procedures in Kijabe, Kenya.

A pediatric emergency medicine and critical care fellowship was recently developed in Kenya through the University of Nairobi/Kenyatta National Hospital and AIC Kijabe Hospital. As part of this training, a week-long trauma and emergency medicine course was developed with emphasis on trauma and emergency medicine procedures. Given limited resources, we developed a course with simulation of procedures centered around utilization of a goat cadaver. The aim of the study was to describe fellow and faculty experiences and perspectives when using a goat cadaver to teach emergency medicine procedures by simulation in Kijabe, Kenya. A 5-day course was given to 2 fellows with a variety of didactics and simulations after which fellows completed a questionnaire to rate their satisfaction with the content and teaching effectiveness. The course was rated very highly, with an average content satisfaction score of 4.5 5 and average teaching effectiveness score of 4.4 of 5. Qualitative faculty feedback was positive, with specific learnings allowing ongoing adaptation of this model. A goat cadaver is a cost-effective resource not often considered that can be adequately used to teach several emergency medicine skills by simulation.

Assessment of Pediatric Emergency Medicine Fellow Competency in Procedural Sedation: An Adjunct to the Recently Published Pediatric Emergency Medicine Procedural Sedation Training: Consensus Educational Guidelines.

Assessment of Pediatric Emergency Medicine Fellow Competency in Procedural Sedation: An Adjunct to the Recently Published Pediatric Emergency Medicine Procedural Sedation Training: Consensus Educational Guidelines.

A Novel Task Trainer for Auricular Hematoma Repair.

Auricular hematoma drainage is a crucial skill that emergency medicine providers must be proficient in to prevent complications including permanent deformity of the ear. We aimed to develop and evaluate a cost-effective task trainer to allow emergency medicine (EM) residents to practice the key skills of auricular hematoma drainage and pressure dressing application.After creating a task trainer out of a bell pepper, we implemented this training during our EM simulation conference with a total of 20 PGY 1-3 EM residents. Prior to the simulation session, a survey of all 39 residents found a rated confidence level of auricular hematoma drainage as low on a five-point Likert scale (mean: 2.2 (standard deviation (SD): 1.08)). After the session, the 20 EM residents who participated were much more confident in their ability to perform this procedure (mean: 4.4 (SD: 0.6)).This low-cost, easy-to-create auricular hematoma drainage and repair task trainer was well received by our EM residents and led to an improved resident comfort level in performing this necessary EM procedure. This task trainer can be used by EM trainees of all levels as a tool to increase their skill and comfort level when performing the crucial procedure of auricular hematoma drainage and repair.

132 Faculty Procedural Skills in Academic Emergency Medicine: A Multisite Survey

Emergency physicians must be competent to perform numerous procedures. It is unclear if clinical practice alone is sufficient to maintain procedural skills, particularly for academic faculty who supervise trainees. Formal assessment of procedural skills beyond training is uncommon. There is a paucity of literature on faculty skills attrition or their preferences for skills maintenance. The faculty procedural skills (FPS) survey sought to determine faculty attitudes, beliefs and experience with procedures to inform programming aimed at skills maintenance. This was a multisite, cross-sectional study of emergency medicine (EM) and pediatric EM (PEM) physician faculty at five large US academic EM departments. Subjects were board certified or board eligible in EM or PEM and provided both clinical care and supervision of trainees. Subjects completed the FPS survey online which consisted of three sections: (1) respondent characteristics and experience performing and supervising EM procedures; (2) degree of confidence performing critical procedures; and (3) attitudes about skills attrition and learning preferences. Internal consistency of each survey section was calculated using Cronbach’s alpha. Items related to beliefs and attitudes were graded on a 5-point scale (strongly disagree to strongly agree), with higher values representing greater agreement. Response agreement (with 95% confidence interval [CI]) was calculated by combining “strongly disagree” with “disagree” and “strongly agree” with “agree” responses. A total of 186 faculty completed the survey (44% response rate). Scale reliability was good (Cronbach’s alpha performance = 0.82; supervision = 0.86; confidence = 0.85). All respondents agreed that ongoing procedural skills training is important for the clinical practice of EM. The majority of respondents agreed: that faculty should have opportunities to retrain for uncommon procedures (98%, 95% CI: ±2%); that skills attrition is a concerning problem (91%, 95% CI: ± 4.1%); that skills attrition is a patient safety issue (89%, 95% CI: ± 4.5%); that attrition was more likely in academic settings (93%, 95% CI: ± 3.7%); that faculty should be required to demonstrate procedural competence (83%, 95% CI: ± 5.4%). The majority of respondents (73%, 95% CI: ± 6.4%) personally experienced procedural skill attrition and a similar number (68%, 95% CI: ± 6.7%) observed it in peers. The most preferred method for skills maintenance was simulation (83%, 95% CI: ± 5.4%). The most preferred learning environment was in groups with peers (89%, 95% CI: ± 4.5%). A majority of faculty reported skills attrition, both personally and observed in peers. Respondents also overwhelmingly agreed they should be competent to perform procedures for which they are credentialed. These findings raise questions about the need for technical skill competency assessments for continued clinical practice. Faculty preferred simulation-based learning and peer environments for skills maintenance. Further study is needed to determine the attitudes, beliefs, and experiences of non-academic emergency physicians with procedural skills attrition.

Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative.

Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department. This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback. We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]). Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.

Developing a Novel, At-Home Procedure Curriculum for Fourth-Year Medical Students in Response to the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic provided our institution a unique opportunity to develop a new procedural curriculum for our fourth-year, emergency medicine-bound medical students. A significant portion of our ED’s fourth-year elective has traditionally been centered in our simulation center, using high-fidelity simulation models to practice important emergency medicine procedures. Due to the pandemic, the simulation center was unavailable for our use, and this new curriculum was created in an effort to fill this gap in procedural education.

The position of the head during treatment in the emergency room-an explorative analysis of immobilization of the cervical spine

Immobilization of the cervical spine is astandard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests. In the present study biomechanical motion data of the cervical spine of atest subject were analyzed. The test subject was placed in asupine position on amobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing acervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out apredetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, amotion score was calculated that can represent the motion of the cervical spine. When the test subject's head was positioned on astandard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination. The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with acervical collar and ahead rest. The application of acervical collar and the positioning on the concave pillow may achieve agood immobilization of the cervical spine in trauma patients in the early trauma phase.

Lung Ultrasound in Neonatology to diagnose a Pneumothorax (part one): Evidence - Time for a New Standard Protocol

Lung ultrasound is a well-studied diagnostic procedure in emergency medicine. Over the last several years, international research groups have investigated the role of lung ultrasound to evaluate neonatal respiratory diseases. Specific diagnostic algorithms and key features of a neonatal pneumothorax have been released. Compared to X-ray examination, lung ultrasound has many advantages, such as faster diagnostic time, lack of exposure to ionizing radiation, and excellent sensitivity and specificity. Thus, lung ultrasound contributes to the improvement of medical healthcare in the neonatal intensive care unit. We consider the use of lung ultrasound as a new standard procedure to diagnose a pneumothorax in neonatology.

Expert consensus on emergency medicine procedure optimization guided by routine prevention and control strategy for COVID-19

The outbreak of coronavirus disease 2019 (COVID-19) was declared a global public health emergency on 31 January 2020. Emergency medicine procedures in Emergency Department should be optimized to cope with the current COVID-19 pandemic by providing subspecialty services, reducing the spread of nosocomial infections, and promoting its capabilities to handle emerging diseases. Thus, the Chinese Society of Emergency Medicine and Wuhan Society of Emergency Medicine drafted this consensus together to address concerns of medical staffs who work in Emergency Department. Based on in-depth review of COVID-19 diagnosis and treatment plans, literatures, as well as management approval, this consensus proposes recommendations for improving the rationalization and efficiency of emergency processes, reducing the risk of nosocomial infections, preventing hospital viral transmission, and ensuring patient safety.

Intern Orthopedic Rotation Versus Emergency Medicine Procedure Month: Which one Derives More Opportunity?

INTRODUCTIONThe American College of Graduate Medical Education (ACGME) defines 18 “key procedures” as requirements in emergency medicine (EM) residency programs. The post-graduate year-1 (PGY-1) curriculum provides an early foundation for EM trainees to gain procedural experience, but traditional PGY-1 rotations may not provide robust procedural opportunities. Our objective was to replace a traditional orthopedic rotation with a 4-week rotation that emphasized EM procedure acquisition and comprehension. Although all residents met ACGME procedural requirements before the curricular modification, the purpose of this month was to increase overall procedure numbers. The block contained dedicated procedure shifts in the emergency department as well as an asynchronous, self-directed learning course. We sought to compare the number of procedures performed by PGY-1 residents during their orthopedic rotation (the year before implementation), to the number of procedures performed during their procedure rotation (the year after implementation).METHODSThe total number of procedures performed and logged by PGY-1 residents during the traditional orthopedic rotation (during the year prior to implementation of the new procedure rotation) were compared to the total number of procedures by the first class to undergo the new procedure rotation the following year. Thirty resident logs were reviewed (15 per class). Data were analyzed using SAS NPAR1WAY; Z < 0.05 was considered significant.RESULTSWhen compared to the orthopedic rotation, the procedure rotation had statistically significant higher numbers of procedures per resident (22, standard deviation [SD] 12, vs 11.4, SD 7.6; Z = 0.0177). A wide variety of nonorthopedic procedures accounted for the increased numbers, (13.6, SD 10.3, vs 0.9, SD 0.9; Z < 0.001). While the average number of orthopedic procedures was slightly less on the procedure rotation, there was no statistical difference (orthopedic rotation 10.13, procedure rotation 8.26; Z = 0.4605). Notably, fewer procedures were performed when 2 residents were on the procedure rotation at the same time (21 vs 10.1).CONCLUSIONThis analysis demonstrated a larger number and a wider variety of procedures performed by PGY-1 residents during a dedicated procedure rotation compared to a traditional orthopedic rotation. Furthermore, exposure to orthopedic procedures did not decline significantly. Limitations of the study include a modest number of subjects. Data may be limited by the consistency of procedure logging by individual residents. Further studies may assess procedural competency after PGY-1 year of training.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-hcycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or≥1year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Regulatory Challenges to Emergency Medicine Procedural Sedation

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.