Kerin A. Jones

White coat versus "sustained" borderline hypertension in Tecumseh, Michigan.

During a survey of young subjects not receiving treatment for hypertension in Tecumseh, Michigan, clinic and self-monitored blood pressures taken at home (14 readings in 7 days) were obtained in 737 subjects (387 men, 350 women, average age 31.5 years). Hypertension in the clinic was diagnosed if the clinic blood pressure exceeded 140 mm Hg systolic or 90 mm Hg diastolic. In the absence of firm criteria for what constitutes hypertension at home, subjects whose average home blood pressure was in the upper decile of the whole population were considered to have hypertension at home. By these criteria, 7.1% of the whole population had “white coat” hypertension (i.e., high clinic but not elevated home readings). The prevalence of “sustained” hypertension (i.e., high readings in the clinic and at home) was 5.1%. Subjects with white coat and sustained borderline hypertension in Tecumseh were very similar. Both groups showed, at previous examinations (at ages 5, 8, 21, and 23 years), significantly higher blood pressure readings than the normotensive subjects. As young adults (average age 333 years), the parents of both hypertensive groups had significantly higher blood pressure readings than the parents of normotensive subjects. Both hypertensive groups had faster heart rates, higher systemic vascular resistance, and higher minimal forearm vascular resistance. Both hypertensive groups were more overweight, had higher plasma triglycerides, insulin, and insulin/glucose ratios than normotensive subjects. The white coat hypertensive group also had lower values of high density lipoprotein than the normotensive group. White coat hypertension is a frequent condition. In regards to excessive risk of hypertension (past blood pressures, parental blood pressures, weight, and heart rate), excessive risk for atherosclerosis (triglycerides and insulin), and hemodynamic parameters (vascular resistance and minimal forearm resistance), the white coat and sustained hypertensive groups are similarly different from the normotensive group. These findings do not support the accepted practice of using home blood pressure determination to distinguish groups of borderline hypertensive subjects with a lesser or greater clinical problem.

Hyperkinetic borderline hypertension in Tecumseh, Michigan

Of 691 healthy (untreated) villagers of Tecumseh, Michigan (average age 32.6 years), 99 had a clinical blood pressure exceeding 140/90 mmHg. Thirty-seven per cent of these borderline hypertensives had increased heart rate, cardiac index, forearm blood flow and plasma norepinephrine. These subjects had elevated self-determined home blood pressure (average of 14 measurements). The present hyperkinetic borderlines had elevated blood pressure at 5, 8, 21 and 23 years of age and their parents also had higher blood pressure. The prevalence of high blood pressure in Tecumseh, its long history, elevated blood pressure readings outside the physicians office and family background of hypertension, suggests that the hyperkinetic state is a significant clinical condition. Previous studies on hospital-based populations proved that the hyperkinetic state is caused by an excessive autonomic drive. The association of the hyperkinetic state with elevated norepinephrine in this study suggests that a sympathetic hyperactivity is present in a large proportion of unselected subjects with mild blood pressure elevation.

The presence of a family witness impacts physician performance during simulated medical codes.

Objective:To determine whether the presence and behavior of a family witness to cardiopulmonary resuscitation (CPR) impacts critical actions performed by physicians. Design:This was a randomized comparison study of physicians’ performance during a simulated cardiac arrest with three different family witness states. Setting:This study was conducted at the Wayne State University Eugene Applebaum College of Pharmacy and Health Science’s Center for Healthcare Simulation. Subjects:Second-year and third-year emergency medicine (EM) residents from the Wayne State University Department of Emergency Medicine–affiliated residency programs and Michigan State University–affiliated EM residency programs. Intervention:Thirty teams comprised of one second-year and one third-year EM resident were randomly assigned to one of the three groups: 1) no family witness; 2) a nonobstructive “quiet” family witness; and 3) a family witness displaying an overt grief reaction. Measurements and Main Results:Each pair was assessed for time to critical actions (e.g., minutes to CPR and drug administration) and for resuscitation-based performance outcomes (e.g., number of shocks) during a simulated cardiac arrest. The time to critical events was similar across groups with respect to initiating CPR, attempting to intubate the patient, and pronouncing the death of the patient. However, the time to deliver the first defibrillation shock was longer for the overt reaction witness group (2.57 minutes) as compared with the quiet (1.77 minutes) and no family witness (1.67 minutes) groups. Additionally, fewer total shocks were delivered in the overt reaction witness groups (4.0 minutes) vs. the quiet (6.5 minutes) and no family witness groups (6.0 minutes). Conclusion:The presence of a family witness may have a significant impact on physicians’ ability to perform critical actions during simulated medical resuscitations. Further study is necessary to see if this effect crosses over into real clinical practice and if training ameliorates this effect.

Evaluation of a computer-based educational intervention to improve medical teamwork and performance during simulated patient resuscitations

Objectives:To determine the impact of a low-resource-demand, easily disseminated computer-based teamwork process training intervention on teamwork behaviors and patient care performance in code teams. Design:A randomized comparison trial of computer-based teamwork training versus placebo training was conducted from August 2010 through March 2011. Setting:This study was conducted at the simulation suite within the Kado Family Clinical Skills Center, Wayne State University School of Medicine. Participants:Participants (n = 231) were fourth-year medical students and first-, second-, and third-year emergency medicine residents at Wayne State University. Each participant was assigned to a team of four to six members (nteams = 45). Interventions:Teams were randomly assigned to receive either a 25-minute computer-based training module targeting appropriate resuscitation teamwork behaviors or a placebo training module. Measurements:Teamwork behaviors and patient care behaviors were video recorded during high-fidelity simulated patient resuscitations and coded by trained raters blinded to condition assignment and study hypotheses. Teamwork behavior items (e.g., “chest radiograph findings communicated to team” and “team member assists with intubation preparation”) were standardized before combining to create overall teamwork scores. Similarly, patient care items (“chest radiograph correctly interpreted”; “time to start of compressions”) were standardized before combining to create overall patient care scores. Subject matter expert reviews and pilot testing of scenario content, teamwork items, and patient care items provided evidence of content validity. Main Results:When controlling for team members’ medically relevant experience, teams in the training condition demonstrated better teamwork (F [1, 42] = 4.81, p < 0.05; &eegr;2p = 10%) and patient care (F [1, 42] = 4.66, p < 0.05; &eegr;2p = 10%) than did teams in the placebo condition. Conclusions:Computer-based team training positively impacts teamwork and patient care during simulated patient resuscitations. This low-resource team training intervention may help to address the dissemination and sustainability issues associated with larger, more costly team training programs.

A Simulation‐based Approach to Measuring Team Situational Awareness in Emergency Medicine: A Multicenter, Observational Study

OBJECTIVES Team situational awareness (TSA) is critical for effective teamwork and supports dynamic decision making in unpredictable, time-pressured situations. Simulation provides a platform for developing and assessing TSA, but these efforts are limited by suboptimal measurement approaches. The objective of this study was to develop and evaluate a novel approach to TSA measurement in interprofessional emergency medicine (EM) teams. METHODS We performed a multicenter, prospective, simulation-based observational study to evaluate an approach to TSA measurement. Interprofessional emergency medical teams, consisting of EM resident physicians, nurses, and medical students, were recruited from the University of Washington (Seattle, WA) and Wayne State University (Detroit, MI). Each team completed a simulated emergency resuscitation scenario. Immediately following the simulation, team members completed a TSA measure, a team perception of shared understanding measure, and a team leader effectiveness measure. Subject matter expert reviews and pilot testing of the TSA measure provided evidence of content and response process validity. Simulations were recorded and independently coded for team performance using a previously validated measure. The relationships between the TSA measure and other variables (team clinical performance, team perception of shared understanding, team leader effectiveness, and team experience) were explored. The TSA agreement metric was indexed by averaging the pairwise agreement for each dyad on a team and then averaging across dyads to yield agreement at the team level. For the team perception of shared understanding and team leadership effectiveness measures, individual team member scores were aggregated within a team to create a single team score. We computed descriptive statistics for all outcomes. We calculated Pearsons product-moment correlations to determine bivariate correlations between outcome variables with two-tailed significance testing (p < 0.05). RESULTS A total of 123 participants were recruited and formed three-person teams (n = 41 teams). All teams completed the assessment scenario and postsimulation measures. TSA agreement ranged from 0.19 to 0.9 and had a mean (±SD) of 0.61 (±0.17). TSA correlated with team clinical performance (p < 0.05) but did not correlate with team perception of shared understanding, team leader effectiveness, or team experience. CONCLUSIONS Team situational awareness supports adaptive teams and is critical for high reliability organizations such as healthcare systems. Simulation can provide a platform for research aimed at understanding and measuring TSA. This study provides a feasible method for simulation-based assessment of TSA in interdisciplinary teams that addresses prior measure limitations and is appropriate for use in highly dynamic, uncertain situations commonly encountered in emergency department systems. Future research is needed to understand the development of and interactions between individual-, team-, and system (distributed)-level cognitive processes.

1537The AHKER Study: Assessing HIV Knowledge of Emergency Residents

Background. Acute HIV infection, acute retroviral syndrome (ARVS), presents as a mononucleosis-like illness in up to two thirds of cases. 20% of people unknowingly infected with HIV are responsible for over 50% of new infections annually. A high index of suspicion is needed to screen for ARVS as there are no unique characteristics that distinguish it from other viral illnesses. We strive to determine Emergency Medicine residents’ practice behaviors for considering ARVS in the presentation of an acute viral illness. Methods. Two versions of an electronic survey was developed. Each had the same clinical vignette of a patient with symptoms suggestive of a viral illness; one version stated the patient’s homosexual orientation (Sexual Orientation Qualifier “SOQ”) while the other did not (No Qualifier “NQ”). The survey contained four sections including treatment options for the scenario, knowledge of ARVS symptoms, likelihood of ordering a rapid HIV test, and recommendations following a negative result. All U.S. based EM residency training programs were randomly assigned to receive one of the two versions of the survey. The survey link was sent to program directors with a request to forward it to their residents. Results. 703 responses (414 NQ; 289 SOQ) were received from 101/158 EM programs (63% from NQ and 64% from SOQ). Knowledge of homosexual orientation resulted in greater use of HIV testing (14.8 NQ vs 56.4% SOQ p<0.01). >85% of respondents correctly identified the most common symptoms of ARVS however <27% were likely to order a rapid HIV test on patients with these symptoms (Table). 76% of respondents recognized a repeat HIV test was needed following an initial negative rapid test.