Mary R. Mulcare

Third-year Medical Student Rotations in Emergency Medicine: A Survey of Current Practices

OBJECTIVES Exposure to emergency medicine (EM) is a crucial aspect of medical student education, yet one that is historically absent from third-year medical student training. There are limited data describing the existing third-year rotations. The goal of this study is to identify the content and structure of current EM rotations specific to third-year students. METHODS An institutional review board-approved survey of clerkship characteristics was designed by consensus opinion of clerkship directors (CDs). The survey was distributed to 32 CDs at institutions with known EM clerkships involving third-year students. RESULTS Twenty-three (72%) CDs responded to the survey. Sixty-five percent have rotations designed specifically for third-year students, of which 33% are required clerkships. Twenty-seven percent of rotations have prerequisite rotations; 37% of rotations include shifts in the pediatric ED. Clinical time averages four 8-hour shifts per week for 4 weeks; all rotations include weekly didactic time specific to third-year students. A wide variety of textbooks are used; some programs employ simulation labs. Two-thirds of the rotations have a required write-up or presentation; 53% include a final exam. Student evaluations are written and verbal. Most rotations receive more support from the EM departments than from the medical schools for physical space, administrative needs, and faculty time. Among those surveyed, students from institutions requiring a third-year EM rotation have a higher rate of application to EM residencies. CONCLUSIONS There is variability in the content and structure of existing third-year EM rotations, as well as in financial and administrative needs and support. These data can help to inform CDs and departments that are starting or modifying EM third-year rotations, as well as contribute to the development of curricula for such rotations.

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect

BACKGROUND Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patients home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. OBJECTIVE To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment. METHODS Five semi-structured focus groups with 27 EMS providers. RESULTS Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine. CONCLUSIONS EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology.

To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity.

Interrater agreement of emergency medicine milestone levels: resident self-evaluation vs clinical competency committee consensus

With the implementation of the Next Accreditation System (NAS), the Accreditation Council for Graduate Medical Education (ACGME) introduced 2 major paradigm shifts toward outcomes assessments: specialty-specific, competency-based milestones, and Clinical Competency Committees (CCC) [1]. As 1 of the 7 specialty “early adopters,” representatives from emergency medicine (EM) stakeholder organizations convened the EMMilestoneWorking Group, which developed and subsequently validated 23 milestones spanning the 6 core competencies [2,3]. In December 2013, 162 EM residency training programs reported their initial milestone data to the ACGME for 5806 residents, which represented the consensus evaluations made by their respective CCCs [4]. One of the resident-centric goals of themilestones is the provision of transparent expectations of performance to support better self-directed assessment and to more accurately assess plans for improvement and remediation [5]. Although the EM milestones have undergone validation byprogramdirectors and academic faculty, the extent towhich residents are able to accurately assess their own performance using the milestones framework has yet to be determined [3]. Therefore, the objective of this study is to understand the extent to which milestonebased resident self-assessments agree with assessments made by the CCC. We hypothesize that interrater agreement will be higher for milestones with quantifiable measures (ie, those pertaining to the patient care and medical knowledge core competencies) compared with milestones that relate more to resident behavior (ie, those pertaining to the professionalism and interpersonal/communication skills core competencies) and that overall agreement will improve between the midand end-of-year reporting periods.

A Novel Emergency Department-Based Telemedicine Program: How Do Older Patients Fare?

INTRODUCTION When we started using telemedicine to treat low acuity patients in the emergency department (ED), we assumed that this voluntary treatment pathway would primarily be used by younger patients. We were surprised to find that a significant portion of patients evaluated by telemedicine were older adults. MATERIALS AND METHODS We conducted a retrospective cohort study of quality assurance data. Adult ED patients at an urban academic medical center who had their care provided by telemedicine from July 2016 to September 2017 were included. We measured demographic characteristics, ED length of stay (LOS), triage severity score, X-ray orders placed, ED revisit within 72 h, need for change in treatment plan or admission on 72-h return, and patient satisfaction. RESULTS Of 1,592 patients evaluated, 18% were age 65 and older. Older patients were more likely to be evaluated for wound care and less likely to be evaluated for nontraumatic connective tissue illnesses. Older patients also had shorter median LOS (59 min vs. 63 min). Unplanned 72-h return (2% vs. 2%), likelihood to have a change in treatment on return (1% vs. 0.2%), and patient satisfaction were similar between age groups. The percentage of patients who returned in 72 h requiring admission were similar between age groups (0.4% vs. 0.1% p = 0.325). Sensitivity analysis with an age threshold at 75 years did not change primary results. CONCLUSION These findings suggest that among low acuity patients there are groups of older adults for whom an ED telemedicine evaluation can provide safe and effective medical care that is satisfactory to patients.

Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team

Background An ED visit provides a unique opportunity to identify elder abuse, which is common and has serious medical consequences. Despite this, emergency providers rarely recognise or report it. We have begun the design of an ED-based multidisciplinary consultation service to improve identification and provide comprehensive medical and forensic assessment and treatment for potential victims. Methods We qualitatively explored provider perspectives to inform intervention development. We conducted 15 semistructured focus groups with 101 providers, including emergency physicians, social workers, nurses, technologists, security, radiologists and psychiatrists at a large, urban academic medical centre. Focus groups were transcribed, and data were analysed to identify themes. Results Providers reported not routinely assessing for elder mistreatment and believed that they commonly missed it. They reported 10 reasons for this, including lack of knowledge or training, no time to conduct an evaluation, concern that identifying elder abuse would lead to additional work, and absence of a standardised response. Providers believed an ED-based consultation service would be frequently used and would increase identification, improve care and help ensure safety. They made 21 recommendations for a multidisciplinary team, including the importance of 24/7 availability, the value of a positive attitude in a consulting service and the importance of feedback to referring ED providers. Participants also highlighted that geriatric nurse practitioners may have ideal clinical and personal care training to contribute to the team. Conclusions An ED-based multidisciplinary consultation service has potential to impact care for elder abuse victims. Insights from providers will inform intervention development.

Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department

Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.

Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents

Introduction The use of direct oral anticoagulants (DOACs) such as rivaroxaban (Xarelto) is increasingly common. However, therapies for reversing anticoagulation in the event of hemorrhage are limited. This study investigates the ability of hemostatic agents to improve the coagulation of rivaroxaban-anticoagulated blood, as measured by rotational thromboelastometry (ROTEM). Hypothesis/Problem If a chitosan-based hemostatic agent (Celox), which works independently of the clotting cascade, is applied to rivaroxaban-anticoagulated blood, it should improve coagulation by decreasing clotting time (CT), decreasing clot formation time (CFT), and increasing maximum clot firmness (MCF). If a kaolin-based hemostatic agent (QuikClot Combat Gauze), which works primarily by augmenting the clotting cascade upstream of factor Xa (FXa), is applied to rivaroxaban-anticoagulated blood, it will not be effective at improving coagulation. METHODS Patients (age >18 years; non-pregnant) on rivaroxaban, presenting to the emergency department (ED) at two large, university-based medical centers, were recruited. Subjects (n=8) had blood drawn and analyzed using ROTEM with and without the presence of a kaolin-based and a chitosan-based hemostatic agent. The percentage of patients whose ROTEM parameters responded to the hemostatic agent and percent changes in coagulation parameters were calculated. RESULTS Data points analyzed included: CT, CFT, and MCF. Of the samples treated with a kaolin-based hemostatic agent, seven (87.5%) showed reductions in CT, eight (100.0%) showed reductions in CFT, and six (75.0%) showed increases in MCF. The average percent change in CT, CFT, and MCF for all patients was 32.5% (Standard Deviation [SD]: 286; Range:-75.3 to 740.7%); -66.0% (SD:14.4; Range: -91.4 to -44.1%); and 4.70% (SD: 6.10; Range: -4.8 to 15.1%), respectively. The corresponding median percent changes were -68.1%, -64.0%, and 5.2%. Of samples treated with a chitosan-based agent, six (75.0%) showed reductions in CT, three (37.5%) showed reductions in CFT, and five (62.5%) showed increases in MCF. The average percent changes for CT, CFT, and MCF for all patients were 165.0% (SD: 629; Range:-96.9 to 1718.5%); 139.0% (SD: 174; Range: -83.3 to 348.0%); and -8.38% (SD: 32.7; Range:-88.7 to 10.4%), respectively. The corresponding median percent changes were -53.7%, 141.8%, and 3.0%. CONCLUSIONS Rotational thromboelastometry detects changes in coagulation parameters caused by hemostatics applied to rivaroxaban-anticoagulated blood. These changes trended in the direction towards improved coagulability, suggesting that kaolin-based and chitosan-based hemostatics may be effective at improving coagulation in these patients. Bar J , David A , Khader T , Mulcare M , Tedeschi C . Assessing coagulation by rotational thromboelastometry (ROTEM) in rivaroxaban-anticoagulated blood using hemostatic agents. Prehosp Disaster Med. 2017;32(5):580-587.