Search

Objectives: The HEART score is a clinical decision tool that stratifies patients into categories of low, moderate, and high-risk of major adverse cardiac events in the emergency department (ED) but cannot identify underlying cardiovascular disease in patients without prior history. The presence of atherosclerosis can easily be detected at the bedside using carotid ultrasound. Plaque quantification is well established, and plaque composition can be assessed using ultrasound grayscale pixel distribution analysis. This study aimed to determine whether carotid plaque burden and/or composition correlated with risk of events and could improve the sensitivity of the HEART score in risk stratifying ED patients with chest pain., Methods: The HEART score was calculated based on history, electrocardiogram, age, risk factors, and initial troponin in patients presenting to the ED with chest pain (n = 321). Focused carotid ultrasound was performed, and maximum plaque height and total plaque area were used to determine plaque burden (quantity). Plaque composition (% blood, fat, muscle, fibrous, calcium-like tissue) was assessed by pixel distribution analysis., Results: Carotid plaque height and area increased with HEART score (p < 0.0001). Carotid plaque % fibrous and % calcium also increased with HEART score. The HEART score had a higher area under the curve (AUC = 0.84) in predicting 30-day events compared to the plaque variables alone (AUCs < 0.70). Integrating plaque quantity into the HEART score slightly increased test sensitivity (62-69%) for 30-day events and reclassified 11 moderate-risk participants to high-risk (score 7-10)., Conclusion: Plaque burden with advanced composition features (fibrous and calcium) was associated with increased HEART score. Integrating plaque assessment into the HEART score identified subclinical atherosclerosis in moderate-risk patients., (© 2024. The Author(s), under exclusive licence to the Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Emergency airway management requires the simultaneous coordination of clinical reasoning and therapeutic interventions in the complex and time-sensitive setting of emergency resuscitation. The cognitive demand associated with these situations is invariably high and must be taken into consideration when designing training programs for this core professional competency. The four-component instructional design model (4C/ID), based on cognitive load theory, was used to develop a 1-year longitudinal airway management curriculum for Emergency Medicine residents. The simulation-based curriculum was designed with the goal of facilitating the construction and automation of schemas by individual residents in preparation for the high cognitive demand associated with emergency airway management in the clinical environment., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background and Objective: Point-of-care focused vascular ultrasound (FOVUS), an assessment of carotid artery plaque, predicts coronary artery disease in outpatients referred for coronary angiography. Our primary objective was to determine the diagnostic accuracy of sonographer-performed FOVUS to predict major adverse cardiac events (MACE) within 30 days among patients with suspected cardiac ischemia in the emergency department (ED)., Methods: We conducted a prospective cohort study of patients with chest pain presenting to a tertiary care ED who had an electrocardiogram and cardiac troponin testing. The primary outcome was a composite of death, acute myocardial infarction, or re-vascularization at 30 days. A sonographer performed FOVUS scans in consenting eligible subjects. Emergency physicians, blinded to the sonographer FOVUS result, performed a second FOVUS on some subjects., Results: We recruited 326 subjects (age 62.1 ± 13.5 years; 166 (52%) men), 319 of whom completed an FOVUS scan by the sonographer. Of these, 198 (62%) had a positive FOVUS scan and 41 (13%) had a 30-day MACE. The sensitivity was 83% (95% CI 71-94%), specificity 41% (95% CI 36-47%), positive-likelihood ratio 1.41 (95% CI 1.19-1.68), and negative-likelihood ratio 0.41 (95% CI 0.23-0.75). Among 71 subjects also scanned by an emergency physician, the Kappa was 0.50 (95% CI 0.31-0.70), suggesting moderate agreement between sonographer and emergency physician on the determination of significant carotid plaque., Conclusions: The presence of carotid plaque on sonographer-performed FOVUS is associated with 30-day MACE in ED patients presenting with chest pain. The prognostic performance of FOVUS is not sufficient to support its use as a stand-alone risk stratification tool in the ED. Future work should investigate FOVUS in conjunction with validated clinical decision rules for chest pain and the impact of enhanced training and quality improvement in the conduct of FOVUS by emergency physicians., Registration: This study was registered at clinicaltrials.gov (NCT02947360)., (© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Ensuring the accuracy of unstructured clinical notes is critical for patient care, research, and quality improvement. Understanding how trainees learn to document these notes and the challenges they encounter are important steps to developing educational and informatics solutions.Authors conducted focus groups to gather the perspectives of 40 medical students (MS) and family and emergency medicine (EM) residents on recording clinical notes in the electronic medical record (EMR). Focus groups were audio recorded, transcribed, and thematically analyzed.Thematic analysis with a deductive approach revealed: a lack of formal education, a shift from information gathering to documenting clinical reasoning with seniority, and barriers to charting development, including variable preceptor expectations and EMR design constraints.Participating trainees report gaps in education around the documentation of notes in the EMR. Future work should explore opportunities to reduce gaps, including more formal education, the creation of specific competencies, and improvements to the EMR.

Background: Point-of-care ultrasound (POCUS) has been recognized as an essential skill across medicine. However, a lack of reliable and streamlined POCUS assessment tools with demonstrated validity remains a significant barrier to widespread clinical integration. The ultrasound competency assessment tool (UCAT) was derived to be a simple, entrustment-based competency assessment tool applicable to multiple POCUS applications. When used to assess a FAST, the UCAT demonstrated high internal consistency and moderate-to-excellent inter-rater reliability. The objective of this study was to validate the UCAT for assessment of a four-view transthoracic cardiac POCUS., Results: Twenty-two trainees performed a four-view transthoracic cardiac POCUS in a simulated environment while being assessed by two observers. When used to assess a four-view cardiac POCUS the UCAT retained its high internal consistency ([Formula: see text] and moderate-to-excellent inter-rater reliability (ICCs = 0.61-0.91; p's ≤ 0.01) across all domains. The regression analysis suggestion that level of training, previous number of focused cardiac ultrasound, previous number of total scans, self-rated entrustment, and intent to pursue certification statistically significantly predicted UCAT entrustment scores [F (5,16) = 4.06, p = 0.01; R 2  = 0.56]., Conclusion: This study confirms the UCAT is a valid assessment tool for four-view transthoracic cardiac POCUS. The findings from this work and previous studies on the UCAT demonstrate the utility and flexibility of the UCAT tool across multiple POCUS applications and present a promising way forward for POCUS competency assessment., (© 2021. The Author(s).)

Objectives: Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium., Design: Open-label feasibility study., Setting: An academic tertiary care Canadian ED (annual visits 60 000)., Participants: Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year., Intervention: A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders., Primary and Secondary Outcome Measures: The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968)., Results: Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications., Conclusion: Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT., Trial Registration Number: Clinicaltrials.gov #02892968., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Point-of-care ultrasound (POCUS) has become an integral diagnostic and interventional tool. Barriers to POCUS training persist, and it continues to remain heterogeneous across training programs. Structured POCUS assessment tools exist, but remain limited in their feasibility, acceptability, reliability, and validity; none of these tools are entrustment-based. The objective of this study was to derive a simple, entrustment-based POCUS competency assessment tool and pilot it in an assessment setting., Methods: This study was composed of two phases. First, a three-step modified Delphi design surveyed 60 members of the Canadian Association of Emergency Physicians Emergency Ultrasound Committee (EUC) to derive the anchors for the tool. Subsequently, the derived ultrasound competency assessment tool (UCAT) was used to assess trainee ( N  = 37) performance on a simulated FAST examination. The intraclass correlation (ICC) for inter-rater reliability and Cronbach's alpha for internal consistency were calculated. A statistical analysis was performed to compare the UCAT to other competency surrogates., Results: The three-round Delphi had 22, 26, and 26 responses from the EUC members. Consensus was reached, and anchors for the domains of preparation, image acquisition, image optimization, and clinical integration achieved approval rates between 92 and 96%. The UCAT pilot revealed excellent inter-rater reliability (with ICC values of 0.69-0.89; p   < 0.01) and high internal consistency (α = 0.91). While UCAT scores were not impacted by level of training, they were significantly impacted by the number of previous POCUS studies completed., Conclusions: We developed and successfully piloted the UCAT, an entrustment-based bedside POCUS competency assessment tool suitable for rapid deployment. The findings from this study indicate early validity evidence for the use of the UCAT as an assessment of trainee POCUS competence on FAST. The UCAT should be trialed in different populations performing several POCUS study types., (© 2020 by the Society for Academic Emergency Medicine.)

Objectives: We quantified the gaze fixation duration of resident and fellowship sonographers interpreting a prerecorded focused assessment with sonography in trauma (FAST). We hypothesized that all sonographers would fixate on each relevant anatomic relationship but that the duration of fixation would differ., Methods: We conducted a cross-sectional study collecting and analyzing the gaze fixations of a convenience sample of current resident and fellowship sonographers. All sonographers viewed a standardized FAST video, and their gaze fixations were recorded using a Tobii X3-120 eye-tracking bar. Gaze fixations over nine anatomic regions of interest (ROIs) were identified. These were assessed for normality and analyzed using the Wilcoxon rank sum test at an alpha of 0.05 and Bonferroni correction p value of <0.0034. The chi-square test and Pearson's correlation were performed to assess statistical association., Results: The gaze fixation recordings of 24 resident and eight fellowship sonographers were suitable for analysis. Fourteen of the 24 resident sonographers viewed all ROIs in the FAST, whereas all eight fellowship sonographers viewed each of the nine relevant ROIs. Five ROIs were identified over which at least one resident sonographer did not have a gaze fixation. No statistically significant difference was identified between groups. Resident sonographers gaze fixated over the left upper quadrant (LUQ) splenorenal interface for a median (interquartile range) of 10.64 (9.73-11.60) seconds. The fellowship group viewed the same ROI for 8.43 (6.64-8.95) seconds (p < 0.003). All participants viewed this ROI. No other ROIs had a statistical difference., Conclusion: Five ROIs were identified that were not visually interrogated by all resident sonographers. Only 14 of 24 resident sonographers visually interrogated every area in the FAST, whereas all fellowship sonographers interrogated every ROI. A statistically significant difference was found in gaze fixation duration between resident and fellowship sonographers in one ROI. Further study is required for gaze fixation assessment to become a tool for the interpretation component of point-of-care ultrasound., (© 2020 The Authors. AEM Education and Training published by Wiley Periodicals, Inc. on behalf of The Society for Academic Emergency Medicine.)

Objective: Our objectives were to identify educational interventions designed to equip medical students or residents with knowledge or skills related to various uses of electronic health records (EHRs), summarize and synthesize the results of formal evaluations of these initiatives, and compare the aims of these initiatives with the prescribed EHR-specific competencies for undergraduate and postgraduate medical education., Materials and Methods: We conducted a systematic review of the literature following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) guidelines. We searched for English-language, peer-reviewed studies across 6 databases using a combination of Medical Subject Headings and keywords. We summarized the quantitative and qualitative results of included studies and rated studies according to the Best Evidence in Medical Education system., Results: Our search yielded 619 citations, of which 11 studies were included. Seven studies involved medical students, 3 studies involved residents, and 1 study involved both groups. All interventions used a practical component involving entering information into a simulated or prototypical EHR. None of the interventions involved extracting, aggregating, or visualizing clinical data for panels of patients or specific populations., Discussion: This review reveals few high-quality initiatives focused on training learners to engage with EHRs for both individual patient care and population health improvement. In comparing these interventions with the broad set of electronic records competencies expected of matriculating physicians, critical gaps in undergraduate and postgraduate medical education remain., Conclusions: With the increasing adoption of EHRs and rise of competency-based medical education, educators should address the gaps in the training of future physicians to better prepare them to provide high quality care for their patients and communities., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

The development of small, user friendly, handheld ultrasound devices has stimulated the growth of cardiac point-of-care ultrasound (POCUS) for the purpose of rapid, bedside cardiac assessment. Medical schools have begun integrating cardiac POCUS into their curricula. In this review the authors summarize the variable approaches taken by several medical training programs with respect to duration of POCUS training, prerequisite knowledge, and methods of delivering these skills (including e-learning, hands-on training, and simulation). The authors also address issues related to the need for competency evaluation and the limitations of the technology itself. The studies reviewed suggest that undergraduate education is a viable point at which to introduce basic POCUS concepts., (Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)