Prospective Durability Testing of a Vascular Access Phantom

Introduction: We assessed the acoustic transmission, image quality, and vessel integrity of the Blue Phantom TM 2 Vessel Original Ultrasound Training Model with repeated use. Methods: The study consisted of two phases. During the first phase, a portion of the Blue Phantom TM rubber matrix (without a simulated vessel) was placed over a two-tiered echogenic structure and was repeatedly punctured with a hollow bore 18-gauge needle in a 1 cm 2 area. During the secon

Improving Initial Emergency Department Antibiotic Regimen Appropriateness for Patients Admitted to the Hospital with Pneumonia Using an Electronic Clinical Decision Support Tool

Distinguished MS Capstone Project 2015 Pneumonia (PNA) is defined as a pulmonary infection. PNA ideal antibiotic regimen (IAbxR) selection from the Emergency Department (ED) has been directly correlated to improved outcomes, reduced hospital length of stay, costs and secondary infections. The Christiana Care Health System Antibiotic Stewardship Program (CCHS-ASP) provides recommendations on initial ideal antibiotic regimen (IAbxR). Prior ED provider compliance with IAbxR is 55%. A key barrier to optimal performance of IAbxR selection is the vast potential for selection of multiple antibiotics through our EMR/CPOE, knowledge gaps by providers as to the IAbxR. Culture change using change management principles and tools including engagement of key stakeholders, data gathering, PDSA, and rapid cycle testing were employed for this quality project. The project team successfully addressed organizational behaviors, project barriers and organizational goals, culminating in the development and integration of an electronic ED PNA clinical decision support rule (ED-PNA-CDS) for IAbxR selection. Our primary outcome was the rate of IAbxR compliance with CCHS-ASP guidelines for adult patients admitted to the hospital through the ED for PNA. Results: The ED-PNA-CDS was launched for all ED providers at all ED locations on February 17, 2015. To date a total of 699 CDS activations have occurred with 183 activations for PNA. The ED-PNA-CDS opt out rate was 8.2% (15/183). Users completed the PNA specific CDS tool 91.8% of the time and 99.7% for all ED-PNA-CDS activations. The post project rate of IAbxR compliance is 90% (p = 0.002). In conclusion, our project, the development and integration of an electronic ED-PNA-CDS resulted in significant culture change by increasing IAbxR compliance from 55% to 90% for adult ED patients admitted with PNA. Other potential benefits may include improved clinical patient outcomes, broader institutional antibiotic stewardship, and improved financial performance for CCHS through the reduction in costs. Presentation: 39 minute

Unilateral papilledema: a case of optic neuritis diagnosed with bedside ocular sonography.

Optic neuritis is a demyelinating inflammatory condition that causes acute loss of vision, especially color vision, and eye pain. Magnetic resonance imaging and fundoscopy have traditionally aided the diagnosis of what largely remains a clinical diagnosis. We report a case of optic neuritis diagnosed in the emergency department with the aid of bedside ocular sonography. The pathophysiology, diagnosis and management of acute optic neuritis will be reviewed

Prospective Durability Testing of a Vascular Access Phantom

Introduction: We assessed the acoustic transmission, image quality, and vessel integrity of the Blue PhantomTM 2 Vessel Original Ultrasound Training Model with repeated use.Methods: The study consisted of two phases. During the first phase, a portion of the Blue PhantomTM rubber matrix (without a simulated vessel) was placed over a two-tiered echogenic structure and was repeatedly punctured with a hollow bore 18-gauge needle in a 1 cm2 area. During the second phase, a portion of the matrix with a simulated vessel was repeatedly punctured with another hollow bore 18-gauge needle. During both phases we obtained an ultrasound image using a high-frequency linear probe after every 100 needle punctures to assess the effect of repeated needle punctures on image quality, acoustic transmission, and simulated vessel integrity.Results: Testing on the rubber matrix alone (first phase) without a vessel demonstrated a gradual decrease in image quality and visualization of the proximal and distal portions of the target structure, but they remained visible after 1,000 needle punctures. The second phase demonstrated excellent acoustic transmission and image quality on both transverse and longitudinal images of the rubber matrix and simulated vessel after 1,000 needle punctures. The anterior and posterior vessel walls and needle tip were well visualized without any signs of vessel leakage on still images or with compression and power Doppler.Conclusion: The Blue PhantomTM 2 Vessel Original Ultrasound Training Model demonstrated excellent durability after 1,000 needle punctures in a 1- cm2 area. Based on the length of simulated vessel in each model, it should support over 25,000 simulated attempts at vascular access. [West J Emerg Med. 2010; 11(4):302-305.

Does the simple triage and rapid treatment method appropriately triage patients based on trauma injury severity score?

OBJECTIVES: To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS). DESIGN: Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the expert trainer. The colors and corresponding ISS were recorded. SETTING: Level I trauma center at a suburban tertiary care hospital. PATIENTS, PARTICIPANTS: One hundred charts of patients at least 65 years old who appear in Christiana Hospital\u27s Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included. MAIN OUTCOME MEASURE(S): Cohen\u27s Kappa score measures the level of agreement between the volunteer and expert reviewers. Pearson correlation determines the association between the START colors and mean ISS. RESULTS: The Cohen\u27s Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969. CONCLUSIONS: The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged red or black

ACR Appropriateness Criteria Head Trauma—Child

Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment