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Introduction: Chest pain is a common reason for ambulance transport. Acute coronary syndrome (ACS) and pulmonary embolism (PE) risk assessments, such as history, electrocardiogram, age, risk factors (HEAR); Emergency Department Assessment of Chest Pain Score (EDACS); Pulmonary Embolism Rule-out Criteria (PERC); and revised Geneva score, are well validated for emergency department (ED) use but have not been translated to the prehospital setting. The objectives of this study were to evaluate the 1) prehospital completion rate and 2) inter-rater reliability of chest pain risk assessments. Methods: We conducted a prospective observational cohort study in two emergency medical services (EMS) agencies (April 18, 2018 – January 2, 2019). Adults with acute, non-traumatic chest pain without ST-elevation myocardial infarction or unstable vital signs were accrued. Paramedics were trained to use the HEAR, EDACS, PERC, and revised Geneva score assessments. A subset of patients (a priori goal of N = 250) also had the four risk assessments completed by their treating clinicians in the ED, who were blinded to the EMS risk assessments. Outcomes were 1) risk assessments completion rate and 2) inter-rater reliability between EMS and ED assessments. An a priori goal for completion rate was set as >75%. We computed kappa with corresponding 95% confidence intervals (CI) for each risk assessment as a measure of inter-rater reliability. Acceptable agreement was defined a priori as kappa ≥ 0.60. Results: During the study period, 837 patients with acute chest pain were accrued. The median age was 54 years, interquartile range 43-66, with 53% female and 51% Black. Completion rates for each risk assessment were above goal: the HEAR score was completed on 95.1% (796/837), EDACS on 92.0% (770/837), PERC on 89.4% (748/837), and revised Geneva score on 90.7% (759/837) of patients. We assessed agreement in a subgroup of 260 patients. The HEAR score had a kappa of 0.51 (95% CI, 0.41- 0.61); EDACS was 0.60 (95% CI, 0.49-0.72); PERC was 0.71 (95% CI, 0.61-0.81); and revised Geneva score was 0.51 (95% CI, 0.39-0.62). Conclusion: The completion rate of risk assessments for ACS and PE was high for prehospital field personnel. The PERC and EDACS both demonstrated acceptable agreement between paramedics and clinicians in the ED, although assessments with better agreement are likely needed.

Author(s): Alley, William D.; Burns, Cynthia; Hartman, Nicholas D.; Askew, Kim; Mahler, Simon A. | Abstract: Introduction: Chest pain is a common chief complaint among patients presenting to health systems and often leads to complex and intensive evaluations. While these patients are often cared for by a multidisciplinary team (primary care, emergency medicine, and cardiology), medical students usually learn about the care of these patients in a fragmented, single-specialty paradigm. The present and future care of patients with chest pain is multidisciplinary, and the education of medical students on the subject should be as well. Our objective was to evaluate the effectiveness of a multidisciplinary, problem-based learning workshop to teach third-year medical students about risk assessment for patients presenting with chest pain, specifically focusing on acute coronary syndromes. Methods: To create an educational experience consistent with multidisciplinary team-based care, we designed a multidisciplinary, problem-based learning workshop to provide medical students with an understanding of how patients with chest pain are cared for in a systems-based manner to improve outcomes. Participants included third-year medical students (n=219) at a single, tertiary care, academic medical center. Knowledge acquisition was tested in a pre-/post-retention test study design. Results: Following the workshop, students achieved a 19.7% (95% confidence interval [CI] [17.3-22.2%]) absolute increase in scores on post-testing as compared to pre-testing. In addition, students maintained an 11.1% (95% CI [7.2-15.0%]) increase on a retention test vs. the pre-test. Conclusion: A multidisciplinary, problem-based learning workshop is an effective method of producing lasting gains in student knowledge about chest pain risk stratification.

Introduction: Emergency department (ED) crowding negatively impacts patient care quality and efficiency. To reduce crowding many EDs use a physician-in-triage (PIT) process. However, few studies have evaluated the effect of a PIT processes on resident education. Our objective was to determine the impact of a PIT process implementation on resident education within the ED of an academic medical center. Methods: We performed a prospective cross-sectional study for a 10-week period from March to June 2011, during operationally historic trended peak patient volume and arrival periods. Emergency medicine residents (three-year program) and faculty, blinded to the research objectives, were asked to evaluate the educational quality of each shift using a 5-point Likert scale. Residents and faculty also completed a questionnaire at the end of the study period assessing the perceived impact of the PIT process on resident education, patient care, satisfaction, and throughput. We compared resident and attending data using Mann-Whitney U tests. Results: During the study period, 54 residents and attendings worked clinically during the PIT process with 78% completing questionnaires related to the study. Attendings and residents indicated “no impact” of the PIT process on resident education [median Likert score of 3.0, inter-quartile range (IQR): 2-4]. There was no difference in attending and resident perceptions (p-value =0.18). Both groups perceived patient satisfaction to be “positively impacted” [4.0, IQR:2-4 for attendings vs 4.0,IQR:1-5 for residents, p-value =0.75]. Residents perceived more improvement in patient throughput to than attendings [3.5, IQR:3-4 for attendings vs 4.0, IQR:3-5 for residents, p-value =0.006]. Perceived impact on differential diagnosis generation was negative in both groups [2.0, IQR:1-3 vs 2.5, IQR:1-5, p-value = 0.42]. The impact of PIT on selection of diagnostic studies and medical decision making was negative for attendings and neutral for residents: [(2.0, IQR:1-3 vs 3.0,IQR:1-4, p-value =0.10) and (2.0, IQR:1-4 vs 3.0, IQR:1-5, p-value =0.14 respectively]. Conclusion: Implementation of a PIT process at an academic medical center was not associated with a negative (or positive) perceived impact on resident education. However, attendings and residents felt that differential diagnosis development was negatively impacted. Attendings also felt diagnostic test selection and medical decision-making learning were negatively impacted by the PIT process. [West J Emerg Med. 2014;15(7):–0.]

Introduction: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload. Methods: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated. Results: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9–77.3) and 62 mm (95% CI 49.3–75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74–0.86) for both CR techniques and 0.81 (95% CI 0.72–0.87) for supine CR and 0.80 (95% CI 0.69–0.87) for erect CR, respectively. Conclusion: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used. [West J Emerg Med. 2011;12(4):426–432.]