Rodney Omron

Troponin Elevations Only Detected With a High-sensitivity Assay: Clinical Correlations and Prognostic Significance

OBJECTIVES With clinical use of high-sensitivity troponin I (hsTnI), more frequent troponin elevations will occur. However, the burden and implications of these elevations are not well understood. The authors quantified the prevalence of elevated hsTnI in patients presenting with possible acute coronary syndrome (ACS) who do not have elevated troponin with a current generation assay (cardiac troponin I [cTnI]) and determined the association of these newly detected elevations with a composite of all-cause mortality and subsequent cardiac hospitalization. METHODS This was a prospective observational study of 808 subjects evaluated for possible ACS and followed for up to 1 year. Troponin values were measured with hsTnI (Abbott Laboratories) and cTnI (Abbott and Beckman Coulter). Cardiac hospitalization was defined as hospitalization for ACS, revascularization, acute heart failure (AHF), or tachy/brady arrhythmia that occurred after the index emergency department (ED) visit or hospital discharge. RESULTS Forty subjects (5%) were diagnosed with ACS (26 myocardial infarction and 14 unstable angina). On the initial sample, the prevalence of elevated hsTnI among subjects with nonelevated cTnI was 9.2% using a gender-neutral cutoff (95% confidence interval [CI] = 7.1% to 11.4%) and 11.1% using a gender-specific cutoff (95% CI = 8.8% to 13.4%). Adjudicated diagnoses for subjects whose initial samples had elevated hsTnI but nonelevated cTnI (gender-neutral cutoff) were as follows: three (4.6%) ACS, 15 (23.1%) AHF, three (4.6%) volume overload etiology unclear/noncardiac, three (4.6%) cardiac (non-ACS), and 41 (63.1%) other. Of the 65 patients whose initial samples had hsTnI but nonelevated cTnI, eight developed cTnI elevation on subsequent serial sampling. After traditional cardiovascular risk factors and renal function were adjusted for, subjects with elevated initial hsTnI but nonelevated cTnI (initial and serial sampling) had a higher risk of all-cause mortality and subsequent cardiac hospitalization than subjects with both nonelevated hsTnI and nonelevated cTnI (hazard ratio [HR] = 1.91, 95% CI = 1.14 to 3.19). CONCLUSIONS On the initial sample, 9% to 11% of subjects without cTnI elevation had hsTnI elevation. Although the majority of the patients with these newly detected hsTnI elevations did not have ACS, they had a higher risk for all-cause mortality and subsequent cardiac hospitalization.

An Assessment Tool for the Placement of Ultrasound-Guided Peripheral Intravenous Access.

Background Ultrasound-guided peripheral intravenous line (USGPIV) placement is becoming an important tool in current clinical practice. Many residency programs utilize unstructured clinical observation to evaluate residents in this and other procedural skills. Simulation-based assessment permits educators to make objective, standardized observations, and may be ideal for assessment of important procedural competencies. Objective We created a simulation-based assessment tool for the skill of USGPIV placement. Methods A checklist tool was developed by a review of relevant literature and an expert review in accordance with established guidelines. Emergency medicine residents were recruited and surveyed on previous experience with USGPIV placement. Blinded, independent reviewers then utilized the checklist to assess residents as they made up to 3 attempts at USGPIV placement on a simulated pediatric arm. Results Of the 26 residents enrolled in our study, 26 participated (100%). A best attempt checklist score greater than or equal to 9 out of 10 correlated with expert performance (P < .001). Agreement between independent raters on first-attempt USGPIV placement score was determined by weighted kappa statistics to be 0.93 (95% CI 086-1.00). Conclusions The checklist assessment tool has acceptable interrater reliability and ability to distinguish performance at differing levels of competence. We propose this tool as a valuable component in the assessment of USGPIV access, and we hope this article serves as a roadmap for other educators to create similar assessment tools.

Do End-of-Rotation and End-of-Shift Assessments Inform Clinical Competency Committees’ (CCC) Decisions?

Introduction Clinical Competency Committees (CCC) require reliable, objective data to inform decisions regarding assignment of milestone proficiency levels, which must be reported to the Accreditation Council for Graduate Medical Education. After the development of two new assessment methods, the end-of-shift (EOS) assessment and the end-of-rotation (EOR) assessment, we sought to evaluate their performance. We report data on the concordance between these assessments, as well as how each informs the final proficiency level determined in biannual CCC meetings. We hypothesized that there would be a high concordance level between the two assessment methods, including concordance of both the EOS and EOR with the final proficiency level designation by the CCC. Methods The residency program is an urban academic four-year emergency medicine residency with 48 residents. After their shifts in the emergency department (ED), residents handed out EOS assessment forms asking about individual milestones from 15 subcompetencies to supervising physicians, as well as triggered electronic EOR-doctor (EORd) assessments to supervising doctors and EOR-nurse (EORn) to nurses they had worked with after each two-week ED block. EORd assessments contained the full proficiency level scale from 16 subcompetencies, while EORn assessments contained four subcompetencies. Data reports were generated after each six-month assessment period and data was aggregated. We calculated Spearman’s rank order correlations for correlations between assessment types and between assessments and final CCC proficiency levels. Results Over 24 months, 5,234 assessments were completed. The strongest correlations with CCC proficiency levels were the EORd for the immediate six-month assessment period prior (rs 0.71–0.84), and the CCC proficiency levels from the previous six-months (rs 0.83–0.92). EOS assessments had weaker correlations (rs 0.49 to 0.62), as did EORn (rs 0.4 to 0.73). Conclusion End-of-rotation assessments completed by supervising doctors are most highly correlated with final CCC proficiency level designations, while end-of-shift assessments and end-of-rotation assessments by nurses did not correlate strongly with final CCC proficiency levels, both with overestimation of levels noted. Every level of proficiency the CCC assigned appears to be highly correlated with the designated level in the immediate six-month period, perhaps implying CCC members are biased by previous level assignments.

The Diagnostic Performance Feedback “Calibration Gap”: Why Clinical Experience Alone Is Not Enough to Prevent Serious Diagnostic Errors

Medical diagnostic errors can be thought of as the bottom of the iceberg of patient safety—a hidden yet vast source of morbidity and mortality. According to the U.S. National Academy of Medicine, diagnostic errors represent a major public health problem likely to affect each of us in our lifetime. Diagnostic errors contribute to approximately 10% of deaths and 6% to 17% of hospital adverse events and are the leading cause of medical malpractice claims. Although typically multifactorial, the majority of diagnostic errors can be traced back to failures in bedside examination skills and clinical reasoning; knowledge and skill gaps appear to play important roles that have been underestimated in the context of an overemphasis on cognitive bias as a cause. A critical unanswered question for educational strategies to improve diagnosis is how diagnostic errors could remain so common, even with clinical presentations seen daily in clinical practice. In theory, accumulated clinical experience gained over time should be an “antidote” that gradually eliminates misdiagnosis, but experimental studies suggest that more years of experience does not necessarily confer greater diagnostic accuracy. Part of the problem is that feedback is essential for improved diagnostic performance, but is often lacking. For example, it has been shown that some short-term deaths after discharge from the emergency department (ED) likely reflect missed diagnoses of life-threatening illnesses. Unfortunately, such feedback rarely returns to individual ED clinicians, which prevents “recalibration” (i.e., adjusting one’s own mental models for diagnosis based on real-world accuracy in prior similar cases) that would otherwise improve diagnostic performance. In this article we argue that, absent systematic feedback, even years of sustained clinical practice may not produce the necessary experiential learning to prevent critical diagnostic errors, particularly for high-risk, low-frequency conditions. As a representative case, take the known public health problem of missed stroke in patients presenting with acute dizziness to the ED, where 45,000 to 75,000 strokes are missed at first contact each year and an estimated 10,000 to 25,000 serious preventable harms result from missed opportunities for early treatment. Dizziness and vertigo are common problems, accounting for approximately 3% of all ED

Optimizing Mastery Learning Environments: A New Approach to Deliberate Practice for Simulation-based Learning

Deliberate practice (DP) is a method of mastery learning widely used in healthcare education. Investigations into improved mastery learning environments are important as we move to competency‐based educational models. The objective of this pilot project is to create and test the feasibility of a simulation‐based learning methodology based on close adherence to the tenants of DP for the acquisition of mastery knowledge.

Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain

Introduction Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR). Methods We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. Results Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement. Conclusion Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.

Feedback in Medical Education: A Critical Appraisal

The objective was to review and critically appraise the medical education literature pertaining to feedback and highlight influential papers that inform our current understanding of the role of feedback in medical education.