Accuracy Of Emergency Physicians Research Articles

255 Are Certain PECARN Criteria Too Subjective to Be Accurate?

Study Objectives: The Pediatric Emergency Care Applied Research Network (PECARN) head injury criteria provides a 6-step algorithm which identifies pre-verbal pediatric patients (age < 2) at very low risk for clinically important traumatic brain injury (ciTBI), obviating the need for head CT (HCT). The efficacy of the algorithm depends on the accuracy of emergency physicians in appropriately characterizing patients. To maximize the reproducibility of the algorithm, the PECARN investigators only chose criterion with kappa values whose lower bound of the one-sided 95% confidence interval (CI) was 0.4, indicating at least moderate inter-rater reliability.

25 Emergency Physician Accuracy in Estimating Volume Responsive Shock Using the “CURVES” Questionnaire

25 Emergency Physician Accuracy in Estimating Volume Responsive Shock Using the “CURVES” Questionnaire

Accuracy of emergency physicians using ultrasound measurement of crown-rump length to estimate gestational age in pregnant females

Study objectiveThe objective of this study is to evaluate the accuracy of emergency providers (EPs) of various levels of training in determination of gestational age (GA) in pregnant patients using bedside ultrasound measurement of crown-rump length (CRL). MethodsWe conducted a prospective, cross-sectional, observational study of patients in obstetrical care at an urban county hospital. We enrolled a convenience sample of women at 6 to 14 weeks gestation as estimated by last menstrual period. Emergency providers used ultrasound to measure the CRL. Repeat CRL measurements were performed by either an obstetrical ultrasound technician or senior obstetrician and used as the criterion standard for true GA (TGA). ResultsOne hundred five patients were evaluated by 20 providers of various levels of training. The average time required to complete the CRL measurement was 85 seconds. When CRL measurements performed by EPs were compared with the TGAs, the average correlation was 0.935 (0.911-0.959). Using standard accepted variance for CRL measurements at different GAs according to the obstetrics literature (±3 days for 42-70 days and ±5 days for 70-90 days), correlation between EP ultrasound and measured TGA was 0.947 (0.927-0.967). ConclusionsEmergency providers can quickly and accurately determine GA in first-trimester pregnancies using bedside ultrasound to calculate the CRL. Emergency providers should consider using ultrasound to calculate the CRL in patients with first-trimester bleeding or pain because this estimated GA may serve as a valuable data point for the future care of that pregnancy.

312 Emergency Physician Accuracy in Estimating Volume Responsive Shock Using the “CURVES” Questionnaire

Excess fluid administration and inadequate or delayed fluid resuscitation carry increased morbidity and mortality. Intensive care unit studies have shown that approximately 50% of patients given fluid boluses were truly volume responsive when compared to dynamic changes in cardiac output or stroke volume. In ED patients with undifferentiated shock, emergency physician accuracy in estimating volume responsiveness when compared to dynamic changes in cardiac output or stroke volume is unknown. To assess emergency physician accuracy in estimating volume responsiveness in patients with shock. This is a pilot study analyzing patients from a prospective randomized controlled trial of fluid optimization in the ED (“EFFORT”-ED Flow-directed Fluid Optimization Resuscitation Trial; ClinicalTrials.gov ID: NCT01128413). The study is IRB approved with informed consent. Enrollment began in August, 2010 and continues at an urban, academic tertiary care medical center with 90,000 ED visits/year. Inclusion criteria are adults (≥ 18 years) with either of the following: hypotension (SBP ≤90 or mean arterial pressure ≤65) despite 20ml/kg fluids; vasopressor use; or lactate ≥ 2.5 mmol/L. Patients are randomized to receive IV fluids via 1 of 2 arms: 1) routine care per clinician discretion 2) fluid optimization with 500ml normal saline boluses if the cardiac index or stroke volume index increases ≥ 15% with passive leg raise testing (PLRT). Patients are monitored until ED departure or a maximum of 6 hours using continuous noninvasive cardiac output monitoring (Cheetah NICOM®). During this time, passive leg raise testing is performed immediately before and after each fluid bolus or at 30-minute intervals if on a locked or maintenance fluid rate. With each passive leg raise testing, a CURVES (CardiovascUlar Response and Volume Estimation in Shock) questionnaire is administered separately to attending and resident physicians caring for the patients. Clinicians are blinded to the results of the passive leg raise testing and NICOM® monitoring. The CURVES questionnaire is a newly developed 5-item survey for this study which queries clinicians for the patient's potential shock etiology and estimations of volume responsiveness at that point in time (ie, responsive or unresponsive to further fluid administration), intravascular volume status, and cardiac index. With each questionnaire, clinicians are given the current vital signs, total volume administered, urine output, and the option for bedside re-examination, lab review, or the use of any other modality used in their routine care (ie, ultrasound, CVP, Scv02). Descriptive statistical analysis was performed using Microsoft® Excel. 11/11 per protocol patients were analyzed. The median age was 58 years (range 20-90) with 27% female. A total of 79 passive leg raise testings and 118 CURVES were acquired. 50/79 (63.3%) passive leg raise testing demonstrated volume responsiveness changes in cardiac index or stroke volume index. Attending emergency physician accuracy in estimating volume responsiveness was 68% with a sensitivity of 89% and specificity of 32%. Resident accuracy was 41% with a sensitivity of 45% and specificity of 35%. This pilot study suggests that emergency physician accuracy in estimating volume responsiveness in the setting of shock is poor when compared to passive leg raise testing changes in cardiac index or stroke volume. Routine clinical estimations of volume responsiveness not guided by dynamic changes in cardiac index or stroke volume index may lead to inadequate or excess fluid administration. The impact of ED fluid administration guided by dynamic changes in cardiac index or stroke volume index on morbidity and mortality is unknown.

51 Accuracy of Emergency Physicians Using Ultrasound Measurement of Crown-Rump Length to Estimate Gestational Age in Pregnant Females

51 Accuracy of Emergency Physicians Using Ultrasound Measurement of Crown-Rump Length to Estimate Gestational Age in Pregnant Females

(A71) Prospective Evaluation of “Focused Assessment with Sonography for Trauma” Done by Emergency Physicians, and its Comparative Analysis with Radiologist's Performance

ObjectiveThe objective of this study was to determine the accuracy of emergency physicians in detecting free fluid in the abdomen when compared to radiologists during w primary survey of trauma victims by focused assessment with sonography for trauma (FAST) scan in the emergency department.MethodsThis prospective study was performed during a primary survey of the resuscitation of non-consecutive patients in the resuscitation bay. The study subjects included emergency physicians (EP) [one emergency medicine (EM) consultant, two EM residents, one orthopedic resident, and one surgical resident] who underwent training at a three-day workshop on emergency sonography and performed 10 supervised positive and negative scans for free fluid. The FAST scans were performed by the EPs and then by the radiology resident (RR). Both were blinded to each other's sonography findings. Computed tomography (CT) scan and laparatomy findings were used as gold standard. Results were compared between both groups. Intra-observer variability among EPs and level of agreement between EPs and RRs were assessed.ResultsOne hundred fifty scans performed by EPs and RRs were analyzed. The mean age of the patients was 28 [1–70] years. Out of 24 true positive patients, 18 underwent CT scan, and exploratory laparatomy was done in six patients. Intra-observer performance variation ranged from 87–97%. The sensitivity of FAST performed by EP and RR was 100%. The specificity of FAST by EPs was 95.4% vs. 98.4% by RRs. The level of agreement was 100%.ConclusionsThis study proves that FAST scan performed by EPs who are trained in short course of ultrasonography can be reliable and accurate when compared to a qualified radiologist.

Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure

IntroductionThe identification of diastolic heart failure (DHF) is important for determining the prognosis of congestive heart failure patients. This study attempted to determine the accuracy of emergency physicians who performed...

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women

Introduction Rapid and accurate determination of gestational age may be vital to the appropriate care of the critically ill pregnant patient. Before the use of emergency ultrasound, physical examination of fundal height (FH) in the nonverbal patient was considered the quickest method to estimate gestational age. We conducted a prospective, observational study of the performance of bedside sonography to determine gestational age. Methods We enrolled a convenience sample of women in their second or third trimester of pregnancy. Emergency physicians (EPs) made ultrasound measurements of fetal biparietal diameter (BPD) and femur length, followed by a measurement of FH. These measurements were compared with true gestational age (TGA), sonography by an ultrasound technician, and measurement of FH performed by an obstetrician. Main outcome measures were the average time needed to complete measurements; correlation coefficients between EP measurements and those made by an ultrasound technician, an obstetrician, and TGA, and overall accuracy to determine fetal age greater than 24 weeks. Results The average time to complete ultrasound measurements was less than 1 minute. When physician-performed measurements were compared with TGA, the correlation coefficients were 0.947 (0.926-0.968) for BPD, 0.957 (0.941-0.973) for femur length, and 0.712 (0.615-0.809) for FH. When determining fetal viability, EP's overall accuracy was 96% using ultrasound and 80% using FH. Conclusions With brief training, EPs can quickly and accurately determine gestational age using ultrasound, and these estimates may be more accurate than those obtained through physical examination. Emergency physicians should consider using ultrasound in emergent evaluation of pregnant patients who are unable to provide history.

Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis

To evaluate the accuracy of emergency physicians using bedside ultrasound to detect appendicitis (BUSA). Patients presenting to the emergency department with a clinical suspicion of appendicitis were prospectively enrolled and received a 5-min BUSA. Patients received routine work-up for acute appendicitis as deemed appropriate by the attending physician. Radiologists and consulting surgeons were blinded to BUSA results. The criterion standard for the presence or absence of acute appendicitis was the pathology report for patients who received appendectomies, and telephone follow-up for patients discharged home without surgical intervention. A total of 132 patients were enrolled. In 44 cases BUSA was positive. Of these, 37 had surgical pathology reports consistent with acute appendicitis, whereas seven did not have appendicitis. In 82 cases, BUSA was negative. Of these, 62 were determined not to have appendicitis, whereas 20 had appendicitis by pathology. Sensitivity for BUSA was 65% [95% confidence interval (CI) 52-76], specificity was 90% (95% CI 81-95), positive predictive value was 84% (95% CI 71-92), and negative predictive value was 76% (95% CI 65-84). The likelihood ratio of a positive BUSA was 6.4 (95% CI 3.1-13.2). Five patients discharged home with a diagnosis other than appendicitis were unable to be reached by telephone, and were excluded from data analysis. Our study gives insufficient evidence to support the use of bedside ultrasound by emergency physicians to rule out appendicitis. The high specificity in our study, however, suggests that with further training, BUSA may be useful to rule-in appendicitis in some patients.

Blunt chest trauma: utility of radiological evaluation and effect on treatment patterns

Minor chest wall trauma is a common complaint in the emergency department (ED) (Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib fractures in elderly patients: mortality and morbidity. Can J of Surgery 2002;45(1):43-6; Lee RB, Bass SM, Morris JA, Mackenzie EJ. Three or more rib fractures as an indicator for transfer to a level I trauma center. J Trauma 1990;30:689-94; Dubinsky I, Low A. Non–life-threatening blunt chest trauma: Appropriate investigation and treatment. Am J Emerg Med 1997;15(3):240-3). Up to 50% of rib fractures may be missed on standard x-ray (Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9; Palvanen M, Kannus P, Niemi S, Parkkari J. Hospital-treated minimal-trauma rib fractures in elderly Finns: long-term trends and projections for the future. Osteoperosis International). Little consensus exists among emergency physicians with respect to the workup of minor blunt chest trauma. The purpose of this study was to evaluate the accuracy of emergency physicians in interpreting rib radiographs and to determine if that interpretation resulted in any variance in treatment patterns. Our study is a retrospective study of 271 charts from a community-based teaching hospital from August 2000 to August 2002. Patients were excluded if they suffered major trauma. The treatment rendered was categorized. Categories included over-the-counter medication, nonsteroidal anti-inflammatory drugs, narcotics, and muscle relaxants. The overall χ 2 calculation showed no differences between the fractured group and the no fracture group ( P = .072). From this, it can be concluded that there were no between-group differences in drugs prescribed based on whether a fracture was diagnosed by the ED physician. Indicating that the interpretation of the rib series does not influence the physicians treatment plan.

Biliary ultrasonography for cholelithiasis: A retrospective analysis of the first two years of an emergency ultrasonography training program

Study objectives: Traditional diagnostic evaluation for patients presenting to the emergency department (ED) with right upper quadrant (RUQ) pain involves an ultrasonography performed by a sonographer and interpreted by a radiologist, which can result in long delays, higher costs, and patient dissatisfaction. Emergency physicians performing the initial RUQ ultrasonography to investigate for cholelithiasis can potentially shorten this evaluation. Previous studies in the emergency medicine literature report the accuracy of emergency physicians performing RUQ ultrasonography but have relatively small sample sizes. The study objective is to analyze the accuracy of bedside RUQ ultrasonography for evaluation of cholelithiasis by emergency physicians. Methods: A retrospective study was conducted on patients presenting to the ED who received a focused RUQ ultrasonography performed by an emergency medicine resident or attending physician between July 2001 and November 2003 in our urban, university, Level I trauma center. Physicians performing bedside ultrasonography were given various lectures on abdominal ultrasonography, including hands-on practice with quality assurance follow-up of videotaped scans. Emergency ultrasonographic examinations were performed using a 3.5-Mhz microconvex probe. All scans included in this study were reviewed by the quality assurance committee consisting of an emergency ultrasonography fellowship–trained attending physician and an emergency ultrasonography fellow. The quality assurance committee was blinded to the findings of the radiology ultrasonographs. Emergency ultrasonographic findings were limited to the presence or absence of gallstones. Three sets of comparisons were made: (1) emergency ultrasonographic findings versus the ED quality assurance committee's findings; (2) emergency ultrasonographic findings versus the radiology ultrasonographic findings; and (3) ED quality assurance committee's findings versus the radiology ultrasonographic findings. Results: Of a total of 1,577 emergency RUQ ultrasonographs during the study period, a total of 1,191 scans met inclusion criteria. Three hundred eighty-six scans were excluded because of documentation errors and poor image quality. Overall, 411 (35%) patients were confirmed to have gallstones, and 780 (65%) were without gallstones. Emergency resident interpretation had an 88% sensitivity, 97% specificity, and 93% accuracy when compared when compared with the ED quality assurance committee's findings. Of the 1,191 patients in the study, 429 (36%) patients also had a radiology ultrasonograph. From these, 257 (60%) patients were confirmed to have gallstones, and 172 (40%)patients were without gallstones. Compared with a radiology ultrasonograph as the criterion standard, emergency resident interpretation had an 88% sensitivity, 87% specificity, and 88% accuracy. When comparing the ED quality assurance committee's findings of this same subset against the radiology ultrasonograph (the criterion standard), the ED quality assurance committee was found to have a 91% sensitivity, 91% specificity, and 91% accuracy. Conclusion: Emergency bedside RUQ ultrasonography is an effective method of diagnosing cholelithiasis. Emergency physicians with a moderate amount of training have a high sensitivity and specificity for diagnosing cholelithiasis compared with radiology-performed ultrasonography. Furthermore, we demonstrate that review of recorded ultrasonographs from the ED by a fellowship-trained quality assurance committee can increase the accuracy of diagnosing cholelithiasis and serve as an important educational tool. These data add to a growing support for the use of bedside ultrasonography in the ED.

The Canadian C-Spine rule performs better than unstructured physician judgment

Study objective We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule. Methods This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the κ coefficient. Results During 18 months, 6,265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' κ for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule ( P<.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% ( P<.001) and specificity 53.9% versus 44.0% ( P<.001). Conclusion Interobserver agreement of unstructured clinical judgment for predicting clinically important cervical spine injury is only fair, and the sensitivity is unacceptably low. The Canadian C-Spine rule was better at detecting clinically important injuries with a sensitivity of 100%. Prospective validation has recently been completed and should permit widespread use of the Canadian C-Spine rule.

How accurate are emergency clinicians at interpreting noncontrast computed tomography for suspected renal colic?

To assess the accuracy of emergency physicians and trainees in the interpretation of noncontrast helical computed tomography (NCHCT) for suspected renal colic by examining the interrater reliability between emergency department (ED) clinicians and radiologists. Information was collected prospectively on all ED patients undergoing NCHCT for suspected renal colic over a 12-month period. Emergency physicians and trainees were asked to report the absence or presence of specific renal parameters (renal tract abnormality, calculus, hydroureter, hydronephrosis, perinephric stranding, and renal parenchymal edema) and nonrenal parameters (nonrenal abnormality, free gas, free fluid, and aortic diameter >3 cm). These reports were compared with the formal radiology report, which was used as the reference standard. The sensitivity, specificity, accuracy, and kappa coefficient were calculated for each of the parameters. Over the 12-month period, 212 patients underwent NCHCT for suspected renal colic, of whom 127 had both ED and formal radiological reporting. There was an excellent degree of interrater reliability between the ED clinicians and the radiologists (kappa > 0.75) for the presence of renal tract abnormality and renal tract calculus. There was intermediate interrater reliability (kappa 0.4-0.75) for nonrenal tract abnormalities, hydroureter, hydronephrosis, and perinephric stranding. Four patients had potentially significant nonrenal abnormalities missed by ED clinicians. Emergency clinicians are able to identify renal calculi with a high degree of accuracy but may miss important nonrenal abnormalities. Therefore, all patients without evidence of renal tract calculus on NCHCT must have early and appropriate follow-up.

Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians

The objectives of this study were to determine the accuracy of Emergency Physicians (EP) performing focused right upper quadrant (RUQ) ultrasound, to quantify how sonographic experience affects accuracy for gallbladder pathology, and to establish the time needed to complete a focused RUQ ultrasound. A convenience sample of patients with suspected gallbladder disease received a focused RUQ ultrasound by an EP. Sonographic findings, number of previous RUQ ultrasounds performed, and time for examination completion were recorded. Each patient then had a formal RUQ ultrasound by a sonographer blinded to the focused RUQ ultrasound results. Focused RUQ and formal ultrasound findings were compared, with the exception of the sonographic Murphy sign, which was compared to pathology reports. One hundred nine patients were enrolled. Fifty-one had gallstones. Forty-nine were detected by EPs, yielding a sensitivity of 96% [95% confidence interval (CI) .87-.99]. Of the 58 patients without gallstones, 51 were correctly diagnosed by EPs (specificity = 88%, 95% CI .77-.95). The sonographic Murphy sign was present during 54 emergency examinations, but in only 24 formal studies. When compared to pathology reports, the emergency sonographic Murphy sign had a sensitivity of 75% compared to the formal ultrasound sensitivity of 45% for acute cholecystitis. EPs were less accurate for other sonographic findings, and level of experience had little effect on sensitivity or specificity for detecting gallstones. Eighty-three percent of emergency studies were completed in less than 10 min. Gallstones are accurately detected by EPs in a timely fashion. Additionally, compared to the radiologist’s interpretation, the EP-detected sonographic Murphy sign was more sensitive for diagnosing acute cholecystitis.

A preliminary evaluation of emergency ultrasound in the setting of an emergency medicine training program

In this article we seek to evaluate the diagnostic accuracy of emergency physicians performing emergency ultrasonography in the setting of an emergency medicine training program. A prospective observational study was performed at an inner city Level I trauma center with an emergency medicine residency training program. From July 1994 to December 1996 a convenience sample of ultrasound exams was recorded. The diagnostic quality (“acceptable or technically limited”) was determined by a board-certified cardiologist or radiologist with fellowship training in ultrasonography. The emergency department interpretations were then compared to those of the blinded cardiologist or radiologist. Four hundred and fifty-six ultrasound examinations were videotaped and entered into the study; 408 (89%) of the studies performed were determined to be “acceptable.” The diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of these studies were as follows: cardiac, to rule out effusion (n = 67; 0.83, 0.98, 0.88, 0.98); transbdominal, to rule out abdominal aortic aneurysms (AAA), cholelithiasis, or free peritoneal fluid (n = 263; 0.91, 0.89, 0.88, 0.92); renal, to rule out hydronephrosis (n = 45; 0.94, 0.96, 0.94, 0.96); pelvic, to rule in intrauterine pregnancy (n = 33; 1.0, 0.90, 0.96, 1.0). The 48 “technically limited studies” included: 39 transabdominal (33 gallbladder, 1 abdominal aortic aneurysm, 5 free peritoneal fluid), 6 cardiac, 2 renal, and 1 pelvic ultrasound. This study suggests that emergency physicians with a minimal amount of training display acceptable technical skill and interpretive acumen in their approach to emergency ultrasonography.