Dylan D. Cooper

Beating the Spread: Developing a Simulation Analog for Contagious Body Fluids.

Introduction Effective models simulating the spread of contagion from provider to other patients, visitors, and rooms in a physically simulated emergency department setting have not been reported, and the effect of personal protective equipment (PPE) on reducing such spread in a simulated emergency department environment has not been quantified. Methods We developed a physical model for the spread of an Ebola-like virus. The scenario involved 3 computerized mannequins. One case was a febrile patient after Ebola exposure. Four residents (group A) had only masks and gloves and were initially unaware of exposure history, whereas 4 residents (group C) had known exposure history and had full PPE present in the room. Infected mannequins and surrounding surfaces were coated with Glo Germ, a UV tracer. Fluorescence to UV light was recorded after each scenario. Both tracer groups were compared with a control group (group B) in which no tracer was used to account for background fluorescence. Results There was transfer of contagion to providers, other patients, nurse and family member confederates, and other treatment rooms. Half of group C used full PPE, and half used partial PPE. There were 3 contaminations in group C with full PPE use, 15 contaminations in group C with partial PPE, and 65 contaminations in group A. Conclusions The UV tracer seems to be a useful analog of contaminated bodily fluids because it spread easily and its spread decreased with the use of barrier methods. This model could be used in future studies to measure the effectiveness of different forms of PPE and to study the effectiveness of provider education on appropriately donning and doffing PPE.

Does Buffered Lidocaine Decrease the Pain of Local Infiltration

DATA SOURCES The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL) to June 2010, Ovid MEDLINE (1966 to June 2010), EMBASE (1988 to June 2010), Latin American and Caribbean Literature on Health Sciences Database (1982 to June 2010), CINAHL (1982 to June 2010), ISI Web of Science (1999 to June 2010), and abstracts of the meetings of the American Society of Anesthesiologists, without language restrictions. References of selected articles were searched, as well as http://www.controlled-trials.com, for relevant ongoing trials.

Effect of Socioeconomic Status Bias on Medical Student–Patient Interactions Using an Emergency Medicine Simulation

Implicit bias in clinical decision making has been shown to contribute to healthcare disparities and results in negative patient outcomes. Our objective was to develop a high‐fidelity simulation model for assessing the effect of socioeconomic status (SES) on medical student (MS) patient care.

Do α-Blockers Expedite Ureteral Stone Passage?

TUDY SELECTION ll randomized controlled trials on dult patients comparing a-blockers ith other pharmacotherapy or lacebo for ureteral stone passage ere reviewed. Inclusion criteria ere adult patients (>18 years), ymptoms of ureteral stone disease, ingle stone smaller than 10 mm by onfirmatory imaging (kidney, reter, and bladder radiograph; omputed tomography; intravenous yelography; or ultrasonography). xclusion criteria were evidence f urinary tract infection, ydronephrosis, and congenital bnormalities of the kidney or reter. Studies using a-blockers as n adjunct to surgery or lithotripsy ere also excluded. The primary utcome was stone clearance rate, ith secondary outcomes including tone expulsion time, pain scores,

Should I Use Lidocaine With Epinephrine in Digital Nerve Blocks

Of the 1,164 identified studies, only 4 met inclusion criteria for analysis, which included 167 patients. None of the studies were deemed to be high quality according to risk-of-bias analysis. Three studies used epinephrine with lidocaine concentration 1:100,000, whereas 1 used 1:200,000. Only 1 study reported prolonged anesthesia duration with epinephrine with lidocaine, and 2 studies demonstrated a reduction of bleeding during surgery. No studies reported any adverse events (eg, digital ischemia) in the lidocaine with epinephrine group. Commentary

Does Colchicine Improve Pain in an Acute Gout Flare

TUDY SELECTION he authors included all andomized controlled trials and ontrolled clinical trials on the enefits and harms of colchicine in dult patients with acute gout ares, identified by the presence f monosodium urate crystals in oint aspirate or patients fulfilling tandard criteria. The major utcomes included benefits, efined as 50% or greater eduction in pain at 12, 24, 36, or 8 hours; reduction of joint nflammation; and total number of dverse events.

Should children with acute asthma exacerbation receive inhaled anticholinergics

ATA SOURCES n this updated review, the authors dded to an initial search ofMEDLINE 1966 to April 2000), EMBASE (1980 o April 2000) and CINAHL (1982 to pril 2000), by including “all years” of he Cochrane Airways Group egister of Trials (searched April 18, 012). In addition, they searched the eference lists of relevant reviews and ontacted both the manufacturer of pratropiumbromide and researchers n the field of pediatric asthma.

Board 371 - Research Abstract A Comparison of Evaluation Metrics for High-Fidelity ACLS-Based Simulation Cases for PGY-1 and PGY-3 Level Emergency Medicine Residents: A Pilot Study (Submission #1012)

Introduction/Background High-fidelity simulation is increasingly being used as a medical educational assessment tool, especially in light of the Next Accreditation System (NAS), which commonly recommends the use of simulation to gather data for Emergency Medicine milestone assessment.1 Currently, there are no universally accepted metrics for evaluating clinician performance in the simulation environment. Furthermore, there is no baseline data characterizing the expected performance on specific cases according to training level. The objective of this pilot study is to develop a set of 6 ACLS-based cases and compare clinician performance using three different evaluation metrics A secondary objective is to compare case performance between PGY-1 and PGY-3 Emergency Medicine (EM) residents. Our hypothesis was that the metrics tested would demonstrate a difference in clinical performance between the two groups of learners, as they were interns just beginning residency and third years just prior to completion of residency. Methods Six cases with critical actions (CA) were developed by a multi-institutional EM faculty group. Each of the cases was piloted by 25 residents at the lead institution (13 PGY-1s during their first two months of internship and 12 PGY-3s during their last two months of residency). Learners participated as single providers in each case, completed all six cases in a randomized order and then received an individual debriefing for the entire session. Sessions were videotaped for independent review by two faculty observers. Data included the total number of CAs achieved, time-to each critical action (TCA) and a previously validated clinical performance evaluation (CPE) score.2 The CPE score is comprised of eight criteria, each with an 8-point possible score [8 being “excellent” and a 1 being “poor”]. The reported CPE scores are the average of the 8 values for each case that were then averaged for both reviewers. Descriptive statistics, Wilcoxon rank sum tests and repeated measures analyses of variance using generalized estimating equations are reported. Results For all of the cases, the mean proportion of CAs performed was 0.94 by the PGY-1s and 0.91 by the PGY-3s (p>0.05). For TCA, 11 CAs were analyzed and only two were found to have a significant difference: the PGY-1s had a time to second defibrillation attempt of 236 seconds compared with 291 seconds for the PGY-3s and the PGY-3s had a time to epinephrine ordered of 112 seconds compared to 164 for the PGY-1s (p<0.05). The overall mean CPE scores were 5.72 for PGY-1s and 6.38 for PGY-3s (p<0.05). The mean difference in CPE scores between the faculty observers was -0.39 (95%CI -0.55 - -0.23). Conclusion Of the three evaluation metrics tested, CPE showed a small but significant difference between training levels. Surprisingly, PGY-1 residents showed superior performance on certain metrics tested. Further studies are needed to define the optimal evaluation system for use in simulation education and optimal teaching strategies for retention of ACLS protocols. References 1. Beeson, M. The Emergency Medicine Milestone Project. http://www.acgme-nas.org/assets/pdf/Milestones/EmergencyMedicineMilestones.pdf. Accessed on July 17th, 2013. 2. Gordon J, Tancredi D, Binder W, Wilkerson W, Shaffer D: Assessment of a clinical performance evaluation tool for use in a simulator-based testing environment: A pilot study. Academic Medicine 2003;78(10 Suppl):S45-47. Disclosures None.

Board 259 Program Innovations Abstract A Novel Simulation Program to Train Paramedic Students in Safe EMS Patient Handoff (Submission #411)

Introduction/Background Emergency medical services (EMS) patient handoffs are a critical step in patient care and safety. Approximately 28 million such handoffs occur every year in the United States.1 Despite the importance of safe handoff to patient care, very little exists in formally accredited EMS or paramedic science education regarding the appropriate information to convey to hospital based patient care teams. While the effective use of simulation in paramedic education has been previously described,2,3 the essential step of patient handoff has been largely ignored. We developed and successfully implemented an interprofessional simulation program focused on safe patient handoff. Methods A focus group of emergency medicine faculty, nursing faculty and paramedic science educators came together to develop a program for teaching paramedic science students safe and effective handoffs. The selected educational tool for patient handoff was previously validated and contains the following information: Identification, Mechanism/medical complaint, Injuries/information relative to complaint, Signs/vitals including GCS, Treatment and trends, Allergies, Medications, Background history, and Other (IMIST-AMBO).4 Paramedic students received a didactic session on IMIST-AMBO and were then brought to the simulation center to practice communication and other patient management skills. The simulation began in the center’s Transport Room, featuring a decommissioned ambulance with a manikin representing a patient who had been in a high speed motor vehicle collision. After receiving initial “on scene” information from a confederate first-responder, teams of two paramedic students assumed care of the manikin for a 10 minute transport period. Upon arrival at the hospital, the students had to successfully unload the patient and transport him down the hall to a simulated emergency department room. Emergency medicine residents and nursing students, who until that point were blind to the use of paramedic students, were waiting in the room. The paramedic students transferred care to the team, communicating what they believed was pertinent information. The remainder of the case was completed with paramedic students providing additional assistance to the emergency department team. Following each case a structured debrief session was conducted featuring all members of the patient care team. The debriefing focused on communication issues as part of the patient handoff. All participants completed pre-session and post-session surveys regarding attitudes toward interprofessional communication and overall satisfaction with the simulation. Results: Conclusion A total of 12 paramedic students, 19 emergency medicine residents and 16 nursing students participated in the simulation. In the post-session survey, 44/47 participants (93.6%) agreed or strongly agreed that the in room experience was valuable for preparing them to work with other healthcare providers and 43/47 participants (91.5%) agreed or strongly agreed that the debriefing was valuable. Importantly, 44/47 participants (93.6%) agreed or strongly agreed that the experience enhanced their understanding of the importance of “clear, concise, and respectful” communication during paramedic-physician handoffs. Amongst the primary target audience of paramedic students, 100% agreed or strongly agreed with that statement. In open-ended feedback, paramedic students described the experience as “very beneficial” and noted that it seemed realistic. This model demonstrates an effective educational method for teaching safe patient handoff. Further studies more accurately quantifying the educational benefit will likely follow and have the potential to impact paramedic science education at other institutions. With the clear importance of safe and effective handoff in overall patient care, this could benefit our patients. Furthermore, safe patient transitions are not limited to paramedic-physician handoff in the emergency department and this simulation-based educational model could be easily adapted to provide training for multiple healthcare providers. References 1. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS ### ###, Washington, DC, 2012. Available at www.ems.go. 2. Boyle et al. “Contemporary simulation education for undergraduate paramedic students” Emerg Med J. 2007 Dec;24(12):854-7. 3. Leikin et al. “Simulation applications in emergency medical services” Dis Mon. 2011 Nov;57(11):723-33. 4. Ledema et al. “Design and trial of a new ambulance-to-emergency department handover protocol: ’IMIST-AMBO’.” BMJ Qual Saf. 2012 Aug;21(8):627-33. Disclosures None.