Linda Spillane

National Growth in Simulation Training within Emergency Medicine Residency Programs, 2003-2008

OBJECTIVES The use of medical simulation has grown dramatically over the past decade, yet national data on the prevalence and growth of use among individual specialty training programs are lacking. The objectives of this study were to describe the current role of simulation training in emergency medicine (EM) residency programs and to quantify growth in use of the technology over the past 5 years. METHODS In follow-up of a 2006 study (2003 data), the authors distributed an updated survey to program directors (PDs) of all 179 EM residency programs operating in early 2008 (140 Accreditation Council on Graduate Medical Education [ACGME]-approved allopathic programs and 39 American Osteopathic Association [AOA]-accredited osteopathic programs). The brief survey borrowed from the prior instrument, was edited and revised, and then distributed at a national PDs meeting. Subsequent follow-up was conducted by e-mail and telephone. The survey concentrated on technology-enhanced simulation modalities beyond routine static trainers or standardized patient-actors (high-fidelity mannequin simulation, part-task/procedural simulation, and dynamic screen-based simulation). RESULTS A total of 134 EM residency programs completed the updated survey, yielding an overall response rate of 75%. A total of 122 (91%) use some form of simulation in their residency training. One-hundred fourteen (85%) specifically use mannequin-simulators, compared to 33 (29%) in 2003 (p < 0.001). Mannequin-simulators are now owned by 58 (43%) of the programs, whereas only 9 (8%) had primary responsibility for such equipment in 2003 (p < 0.001). Fifty-eight (43%) of the programs reported that annual resident simulation use now averages more than 10 hours per year. CONCLUSIONS Use of medical simulation has grown significantly in EM residency programs in the past 5 years and is now widespread among training programs across the country.

Frequent ED users: Patterns of use over time

The objective of this study was to examine the pattern of emergency department (ED) use by frequent ED users over time. This study was a retrospective study of adults with more than 10 visits to a university hospital ED from 8/90 through 7/91. ED visits of this cohort to all hospitals in the metropolitan area were followed for 3 years. Records were reviewed for the etiology of each patients ED visits. This cohort was comprised of 76 patients making 1,119 (1.9%) of the total 59,051 ED visits. Thirty-five of the 76 (46%) were frequent ED users in only the initial year. Thirteen of the 76 (17%) made more than 10 visits in all 4 years. The remainder had sporadic episodes of ED use. Thirty-five (46%) were evaluated at three or more EDs in years in which they were frequent users. Forty-two (55%) had a medical problem for the cause of the majority of their ED visits. Fifty-eight percent of patients making more than 10 visits in more than 1 year had psychiatric or substance abuse problems. The pattern of ED use in this cohort changed over time and was influenced by substance abuse and psychiatric problems. These data suggest that most patients do not remain frequent ED users over time.

Teaching Emergency Medicine Residents Evidence-Based Critical Appraisal Skills: A Controlled Trial

STUDY OBJECTIVES To compare the performance of an evidence-based medicine (EBM) approach and a traditional approach to teaching critical appraisal skills to emergency medicine residents. METHODS This was a prospective, case-controlled trial of 32 emergency medicine residents (16 control and 16 intervention). Intervention residents were exposed to a monthly, 1-hour journal club using an EBM approach to critical appraisal over the course of 1 year. Control residents were exposed to a traditional, unstructured journal club, also monthly. Both groups were given a factitious article to evaluate in an essay format before and after the 12-month study period. The Wilcoxon rank sum test was used to compare mean improvement in test scores for each group. RESULTS The mean improvement in test scores was 1.80 for the control group and 1.53 for the intervention group; these values were not significantly different (P =.90). The difference in mean change in test score between the 2 groups was.27 points. CONCLUSION Compared with a traditional approach, an EBM approach to teaching critical appraisal did not appear to improve the critical appraisal skills of emergency medicine residents. However, because of the small number of subjects studied, small differences in critical appraisal skill improvement cannot be ruled out.

The Status of Human Simulation Training in Emergency Medicine Residency Programs

Introduction: The objective of this study was to describe the availability and current use of high-fidelity mannequin-based simulation (HFMB) in emergency medicine (EM) training programs. Methods: A 12-item survey instrument was used to collect data on the status of human simulation training at the 126 approved EM residencies and the 30 accredited osteopathic EM residencies. Results: In all, 114 out of 156 programs completed the survey for a response rate of 73%. There are 54 (47%) EM training programs with HFMB simulators at their institution, 38 (33%) EM training programs with access to these HFMB simulators, and 33 (29%) EM training programs that have EM residents use HFMB simulators. The Department of Anesthesia manages the HFMB simulator at 19 (17%) institutions. EM manages the HFMB simulator at nine (8%) institutions. EM residents are using HFMB simulation every 1–2 weeks at three (8%) programs, every 1–4 months at 16 (42%) programs, yearly at nine (24%) programs, and not regularly at 10 (26%) programs. The simulation curriculum is described as “no formal curriculum” or “initial development” in 60% of programs. Conclusion: HFMB simulation technology has not been completely adopted by EM training programs even when it is available. Most EM training programs are using HFMB simulation less often than every month and curriculum development in EM training is still in the early phases.

Refractory Hypoglycemia from Ciprofloxacin and Glyburide Interaction

Patients taking multiple medications may suffer from unpredictable and complex drug–drug interactions resulting in significant morbidity and mortality. There are few reports in the literature of hypoglycemia with concurrent administration of an oral hyperglycemic agent and a fluoroquinolone antibiotic. We present a case of a diabetic patient taking glyburide who was prescribed ciprofloxacin and developed prolonged hypoglycemia, which persisted for over 24 hours. The mechanisms by which these agents interact to produce prolonged hypoglycemia are complex and probably multifactorial. Patients stabilized on glyburide who are started on a fluoroquinolone should have their glucose levels monitored closely.

Test ordering guidelines can alter ordering patterns in an academic emergency department

To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. No restrictions were placed on actual test ordering. The number of laboratory tests (total and individual) ordered per 100 patients decreased significantly after the educational program began for: total testing, CBC, and liver function test (LFT). In addition, declines during individual months for these tests were statistically significant. Prothrombin time and blood culture testing showed no significant decreases in test ordering frequency. Chemistry test ordering frequency showed statistically significant increases. Overall, approximately

The initial lateral cervical spine film for the athlete with a suspected neck injury: helmet and shoulder pads on or off?

50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.

Rhabdomyolysis associated with kava ingestion.

Plain radiographs remain the only reliable way to exclude cervical spine derangement during the initial Emergency Department (ED) evaluation of the athlete with a suspected neck injury. There have been no studies to evaluate whether the cervical spine can be adequately visualized when a helmet and shoulder pads remain on while the lateral cervical spine scout film is done in the ED trauma suite. The objective of our investigation was to determine whether a helmet and shoulder pads interfere with the assessment of the cervical spine on this initial ED radiographic evaluation.

Partnering in interprofessional education to design simulation programs to promote collaboration and patient safety.

We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage.

Acute encephalopathy with concurrent respiratory and metabolic disturbances in first known parenteral human administration of flunixin meglumine and acepromazine maleate.

Interprofessional education (IPE) using simulation strategies is a rewarding way to promote teamwork and interprofessional collaboration. The benefits of collaboration far outweigh the challenges that arise from differences in educational culture and scheduling logistics.