Solomon Behar

Disaster drill exercise documentation and management: are we drilling to standard?

INTRODUCTION Medical errors are known to occur even in a controlled setting with adequate resources. The few studies on mass-casualty events and disaster exercises suggest errors may be amplified in these situations. We hypothesized that both the documentation and medical care provided during a pediatric disaster drill would be substandard when compared with routine care at the same institution. METHODS Charts from the disaster exercise and matched charts from actual admitted patients were retrospectively reviewed for the presence of triage classification, allergies, weight, physical exam, vital signs, diagnosis, disposition time, disposition location, disposition instructions, and disposition vitals signs and for the appropriateness of diagnoses, medications, procedures, and disposition. Errors were quantified and classified into negligible, likely to cause temporary harm, or potential to cause admission or permanent harm. The drill charts were compared to actual charts by Fischers Exact Test. RESULTS Drill charts contained a significantly greater proportion of errors in regards to performance of procedures, administration of medication, and accuracy of diagnosis. Sixteen percent of these errors were judged as having the potential to cause permanent harm or admission. The exercise charts contained a significantly greater number of omissions in documentation in 9 of the 10 areas evaluated. DISCUSSION Both the documentation and the quality of care provided during our exercise were deficient when compared with conventional care. Opportunities allowing providers to clearly document pertinent information, and linking of this documentation to relevant prompts and algorithms may minimize this potential for error.

Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis

BACKGROUND Acute appendicitis is the most common cause of acute abdomen in pediatric emergency department (ED) visits, and right lower quadrant abdominal ultrasound (RLQUS) is a valuable diagnostic tool in the clinical approach. The utility of ultrasound in predicting perforation has not been well-defined. OBJECTIVES We sought to determine the sensitivity of RLQUS to identify perforation in pediatric patients with appendicitis. METHODS A chart review of all patients 3 to 21 years of age who received a radiographic work-up and who were ultimately diagnosed with perforated appendicitis between 2010 and 2013 at a pediatric ED was conducted. The final read for ultrasonography was compared to either the operative diagnosis, surgical pathology diagnosis, or further imaging results (if the patient was managed nonoperatively). Test characteristics were calculated for the identification of appendicitis and identification of perforation. RESULTS Of the 539 patients evaluated for appendicitis, 144 (26.7%) patients had appendicitis, and 40 of these (27.8%) were perforated. Thirty-nine had RLQUS performed as part of their evaluation. Of these, 28 had positive findings for appendicitis, and 9 were read as definite or possible perforated appendicitis. The sensitivity of RLQUS for the diagnosis of appendicitis in the group with perforation was 77.1% (95% confidence interval [CI], 59.4-89%) and the sensitivity for diagnosing a perforation was 23.1% (95% CI, 11.1-39.3%). CONCLUSION There was a low rate of detection of perforation by RLQUS in our pediatric population. If larger studies confirm this, additional imaging should be recommended in patients with a high suspicion of perforation and in whom a diagnosis of perforation would change management.

Flipping the Classroom in Medical Student Education: Does Priming Work?

Introduction The emergency medicine (EM) clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by “priming” the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing). Methods Twenty-minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for seven months and three days prior to the in-class session for eight months (in which both groups included both EM-bound and non-EM bound students). Results In the fifteen-month study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During ten months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In four months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format. Conclusion Immediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the EM rotation session increased when the students were EM-bound. Participation rates were not significantly different when given at two weeks versus three days.

Use of an emergency medical pictorial communication book during simulated disaster conditions

During disasters, the needs of victims outstrip available resources. Rapid assessment of patients must be performed; however, language barriers can be an impediment to efficient patient assessment, especially if interpreter resources are limited. Dependency on interpretive services requiring technology such a telephones, cell phones, and video conferencing may be inefficient, as they may be unavailable during disaster conditions. A low-tech, portable tool that aids in communication with non-English speakers would be beneficial. The medical emergency communication (MEC) book, developed at Childrens Hospital Los Angeles, has the potential to be a useful tool in this capacity. The goal of this pilot study was to compare the accuracy of a newly developed disaster-focused medical history obtained from Spanish-speaking patients or caregivers using the MEC book, compared to a control group with whom no book was used. Our hypothesis was that use of the MEC book improves accuracy of medical history taking between English-only speaking health care workers and Spanish-speaking patients better than a monolingual clinician trying to take a medical history without it. We anticipated a higher overall score in the group of subjects whose histories were taken using the MEC book than in the control group. Patient satisfaction with the MEC book also was measured.