Accuracy of emergency physicians\u27 self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial

BACKGROUND: Audit and feedback (AandF) has been used as a strategy to modify clinician behavior with moderate success. Although AandF is theorized to work by improving the accuracy of clinicians\u27 estimates of their own behavior, few interventions have included assessment of clinicians\u27 estimates at baseline to examine whether they account for intervention success or failure. We tested an AandF intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians\u27 baseline estimates of their own behavior compared to peers. METHODS: Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an AandF intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive AandF were shown a de-identified graph of the group\u27s baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. RESULTS: Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p \u3c 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. CONCLUSIONS: Our AandF intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After audit, it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention

Heart Failure in the Emergency Department: Treatment Impact and Short-Term Outcomes

Heart failure is now considered an emerging epidemic of the 21st century, affecting 5.7 million Americans and causing a $32.7 million strain on the healthcare system. Most admitted heart failure patients enter the hospital through the emergency department; however, there are not comprehensive established guidelines and treatment goals for emergency physicians. This retrospective chart abstraction study investigates the impact of ED treatment on HF patient outcomes to determine which treatment courses are most effective and efficient

Ultrasound-Guided Drainage for Pediatric Soft Tissue Abscesses Decreases Clinical Failure Rates Compared to Drainage Without Ultrasound: A Retrospective Study

OBJECTIVES: Soft tissue abscesses are common in the pediatric emergency department (ED). Ultrasound (US) can be used to both diagnose soft tissue abscesses as well as guide drainage. We hypothesized that clinical failure rates would be less in pediatric patients with suspected skin abscesses when evaluated with US. METHODS: We performed a retrospective review of suspected pediatric skin abscesses at 4 EDs over a 22-month period. Cases were identified through electronic medical record descriptions, discharge diagnoses, and US database records. Data on US use, findings, and outcomes were abstracted to an electronic database. Comparisons between groups included US versus non-US (primary outcome) as well as surgical drainage vs nonsurgical drainage (secondary outcome). RESULTS: A total of 377 patients were seen with concern for a potential skin abscess; 141 patients (37.4%) underwent US imaging during their visit, and 239 (63.4%) underwent incision and drainage (IandD) during their ED stay: 90 with US and 149 without. The failure rate for patients evaluated with US was significantly lower than that for those evaluated without US (4.4% versus 15.6%; P \u3c .005). Thirty-four (11.3%) of the 302 patients with a diagnosis of an abscess failed therapy: 19 (8.2%) after IandD and 15 (21.1%) after nonsurgical management. Failure after IandD was associated with a smaller abscess cavity on US imaging (17.2 versus 44.8 mm3 ; P \u3c .05). CONCLUSIONS: The use of US for patients with a suspected skin abscess was associated with a reduction in the amount of clinical failure rates after both surgical drainage and nonsurgical therapy. Ultrasound should be used when evaluating or treating patients with abscesses

Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial

STUDY OBJECTIVE: We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone. METHODS: We performed a prospective randomized clinical trial of patients presenting with a soft tissue abscess at a large, academic emergency department. Patients presenting with an uncomplicated soft tissue abscess requiring incision and drainage were eligible for enrollment and randomized to treatment with or without point-of-care ultrasonography. The diagnosis of an abscess was by physical examination, bedside ultrasonography, or both. Patients randomized to the point-of-care ultrasonography group had an incision and drainage performed with bedside ultrasonographic imaging of the abscess. Patients randomized to the non-point-of-care ultrasonography group had an incision and drainage performed with physical examination alone. Comparison between groups was by comparing means with 95% confidence intervals. The primary outcome was failure of therapy at 10 days, defined as a repeated incision and drainage, following a per-protocol analysis. Multivariate analysis was performed to control for study variables. Our study was designed to detect a clinically important difference between groups, which we defined as a 13% difference. RESULTS: A total of 125 patients were enrolled, 63 randomized to the point-of-care ultrasonography group and 62 to physical examination alone. After loss to follow-up and misallocation, 54 patients in the ultrasonography group and 53 in the physical examination alone group were analyzed. The overall failure rate for all patients enrolled in the study was 10.3%. Patients who were evaluated with ultrasonography were less likely to fail therapy and have repeated incision and drainage, with a difference between groups of 13.3% (95% confidence interval 0.0% to 19.4%). Abscess locations were predominantly torso (21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There was no difference in baseline characteristics between groups relative to abscess size, duration of symptoms before presentation, percentage with cellulitis, and treatment with antibiotics. CONCLUSION: Patients with soft tissue abscesses who were undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure compared with those treated without point-of-care ultrasonography

IQP - Mae Moh, Thailand - C08

In the past, the Electricity Generating Authority of Thailand (EGAT) was the cause of environmental disasters in which SO2 emissions soared, causing environmental and physical health problems in the surrounding areas of Mae Moh. Because of such problems, communication of pollution levels became an important objective for EGAT. We accomplished our goals of identifying EGAT's environmental communication strategies and residents' information needs through interviews with EGAT employees and residents of three Mae Moh villages. We conclude the report with communication guidelines for EGAT addressing the main barriers to communication - information accessibility, information comprehensibility, and trust - as well as further recommendations for EGAT regarding increased interaction with villagers

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax

OBJECTIVE: Ultrasound (US) has been shown to be effective at identifying a pneumothorax (PTX); however, the additional value of adding multiple views has not been studied. Single- and four-view protocols have both been described in the literature. The objective of this study was to compare the diagnostic accuracy of single-view versus four-view lung US to detect clinically significant PTX in trauma patients. METHODS: This was a randomized, prospective trial on trauma patients. Adult patients with acute traumatic injury undergoing computed tomography (CT) scan of the chest were eligible for enrollment. Patients were randomized to a single view or four views of each hemithorax prior to any imaging. USs were performed and interpreted by credentialed physicians using a 7.5-Mhz linear array transducer on a portable US machine with digital clips recorded for later review. Attending radiologist interpretation of the chest CT was reviewed for presence or absence of PTX with descriptions of small foci of air or minimal PTX categorized as clinically insignificant. RESULTS: A total of 260 patients were enrolled over a 2-year period. A total of 139 patients received a single view of each chest wall and 121 patients received four views. There were a total of 49 patients that had a PTX (19%), and 29 of these were clinically significant (11%). In diagnosis of any PTX, both single-view and four-view techniques showed poor sensitivity (54.2 and 68%) but high specificity (99 and 98%). For clinically significant PTX, single-view US demonstrated a sensitivity of 93% (95% confidence interval [CI] = 64.1% to 99.6%) and a specificity of 99.2% (95% CI = 95.5% to 99.9%), with sensitivity of 93.3% (95% CI = 66% to 99.7%) and specificity of 98% (95% CI = 92.1% to 99.7%) for four views. CONCLUSIONS: Single-view and four-view chest wall USs demonstrate comparable sensitivity and specificity for PTX. The additional time to obtain four views should be weighed against the absence of additional diagnostic yield over a single view when using US to identify a clinically significant PTX

A pilot study of prehospital antibiotics for severe sepsis

The primary aim of our investigation was to describe the safety and feasibility of a protocol for prehospital recognition of sepsis with hypotension and septic shock, drawing of blood cultures, and administration of intravenous (IV) antibiotics in an urban EMS service, thereby adding to the limited U.S. literature available on this subject and supporting the development of a large-scale randomized control trial (RCT). Primary feasibility measures included the frequency of allergic reactions, culture contamination, and paramedic adherence to the protocol in the prehospital environment