Timeliness of Care for Injured Patients Initially Seen at Freestanding Emergency Departments: A Pilot Quality Improvement Project.
centers; delay; freestanding emergency department; golden hour; impact; injured patients; interfacility transfer; level I trauma center; mortality; Trauma; trauma patients; urgent care
BACKGROUND: The impact of freestanding emergency departments (FSEDs) on timeliness of care for trauma patients is not well understood. This quality improvement project had 2 objectives: (1) to determine whether significant delays in definitive care existed among trauma patients initially seen at FSEDs compared with those initially seen at other outlying sites prior to transfer to a level I trauma center; and (2) to determine the feasibility of identifying differences in time-to-definitive care and emergency department length of stay (ED LOS) based on initial treatment location. METHODS: Trauma registry data from January 1, 2017, through December 31, 2017, from a verified level I trauma center were analyzed by location of initial presentation. Appropriate statistical tests are used to make comparisons across transport groups. RESULTS: Patients initially seen at non-FSEDs experienced ED LOS that were, on average, 24.5 minutes greater than patients seen initially at FSEDs, although the difference was not statistically significant (P = .3112). Several challenges were identified in the feasibility analysis that will inform the design for a larger study including large quantities of missing time stamp data and potential selection bias. Prospective solutions were identified. CONCLUSION: This project found that there were not significant differences in ED LOS for injured patients presenting initially to FSEDs or other non-FSED facilities, suggesting that timeliness of care was similar across location types.
Birmingham Lauren E; Richner Gwendolyn; Moran Mary; Hatridge Kindra M; George Richard L
Quality management in health care
2020
2020-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
journalArticle
<a href="http://doi.org/10.1097/QMH.0000000000000252" target="_blank" rel="noreferrer noopener">10.1097/QMH.0000000000000252</a>
Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall.
*Delayed intracranial hemorrhage; *Elderly; *Fall; *Head injury; *Intracranial hemorrhage; 80 and over; Accidental Falls/*statistics & numerical data; Aged; Anticoagulants/administration & dosage/*adverse effects; Combination; Drug Therapy; Female; Humans; Intracranial Hemorrhages/diagnostic imaging/*etiology; Male; Platelet Aggregation Inhibitors/administration & dosage/*adverse effects; Retrospective Studies; Tomography; X-Ray Computed
BACKGROUND: Falls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy. METHODS: Data from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (\textgreater/=65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported. RESULTS: Data on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications. CONCLUSIONS: Universal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.
Mann Nolan; Welch Kellen; Martin Andrew; Subichin Michael; Wietecha Katherine; Birmingham Lauren E; Marchand Tiffany D; George Richard L
BMC emergency medicine
2018
2018-08
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1186/s12873-018-0179-0" target="_blank" rel="noreferrer noopener">10.1186/s12873-018-0179-0</a>
Development, Validation, and Implementation of a Medical Judgment Metric.
clinical judgment; decision making; medical judgment; simulation
Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss's Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen's Kappa 0.851 to 0.880). Discussion: The MJM demonstrated preliminary evidence of reliability and validity.
Ahmed Rami A; McCarroll Michele L; Schwartz Alan; Gothard M David; Atkinson S Scott; Hughes Patrick G; Cepeda Brito Jose Ramon; Assad Lori; Myers Jerry G; George Richard L
MDM policy & practice
2017
2017-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/2381468317715262" target="_blank" rel="noreferrer noopener">10.1177/2381468317715262</a>
Pediatric Trauma Boot Camp: A Simulation Curriculum and Pilot Study.
Trauma is a leading cause of morbidity and mortality in infants and children worldwide. Trauma education is one of the most commonly reported deficiencies in pediatric emergency medicine (PEM) training. In this study, we describe the creation of a pediatric trauma boot camp in which trainees' basic knowledge, level of confidence, teamwork, and communication skills are assessed. The primary goal of this pilot study was to create a simulation-based pediatric trauma curriculum for PEM fellows and emergency medicine residents utilizing Kern's curricular conceptual framework. This was a pilot, prospective, single cohort, exploratory, observational study utilizing survey methodology and a convenience sample. The curriculum consisted of a two-day experience that included confidence surveys, a cognitive multiple-choice questionnaire, and formative and summative simulation scenarios. At the conclusion of this intensive simulation-based trauma boot camp participants reported increased confidence and demonstrated significant improvement in the basic knowledge and performance of the management of pediatric trauma cases in a simulated environment.
Khobrani Ahmad; Patel Nirali H; George Richard L; McNinch Neil L; Ahmed Rami A
Emergency medicine international
2018
2018
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1155/2018/7982315" target="_blank" rel="noreferrer noopener">10.1155/2018/7982315</a>
Medical judgement analogue studies with applications to spaceflight crew medical officer.
Astronaut Health; Clinical Judgement; Decision-making; Medical Judgement; Simulation
Background: The National Aeronautics and Space Administration (NASA) developed plans for potential emergency conditions from the Exploration Medical Conditions List. In an effort to mitigate conditions on the Exploration Medical Conditions List, NASA implemented a crew medical officer (CMO) designation for eligible astronauts. This pilot study aims to add knowledge that could be used in the Integrated Medical Model. Methods: An analogue population was recruited for two categories: administrative physicians (AP) representing the physician CMOs and technical professionals (TP) representing the non-physician CMOs. Participants completed four medical simulations focused on abdominal pain: cholecystitis (CH) and renal colic (RC) and chest pain: cardiac ischaemia (STEMI; ST-segment elevation myocardial infarction) and pneumothorax (PX). The Medical Judgment Metric (MJM) was used to evaluate medical decision making. Results: There were no significant differences between the AP and TP groups in age, gender, race, ethnicity, education and baseline heart rate. Significant differences were noted in MJM average rater scores in AP versus TP in CH: 13.0 (+/-2.25), 4.5 (+/-0.48), p=\textless0.001; RC: 12.3 (+/-2.66), 4.8 (+/-0.94); STEMI: 12.1 (+/-3.33), 4.9 (+/-0.56); and PX: 13.5 (+/-2.53), 5.3 (+/-1.01), respectively. Discussion: There could be a positive effect on crew health risk by having a physician CMO. The MJM demonstrated the ability to quantify medical judgement between the two analogue groups of spaceflight CMOs. Future studies should incorporate the MJM in a larger analogue population study to assess the medical risk for spaceflight crewmembers.
McCarroll Michele L; Ahmed Rami A; Schwartz Alan; Gothard Michael David; Atkinson Steven Scott; Hughes Patrick; Brito Jose Cepeda; Assad Lori; Myers Jerry; George Richard L
BMJ simulation & technology enhanced learning
2017
2017-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1136/bmjstel-2017-000210" target="_blank" rel="noreferrer noopener">10.1136/bmjstel-2017-000210</a>
The Role of Negative Affect on Headache-Related Disability Following Traumatic Physical Injury.
Acute Disease – Etiology; ACUTE diseases; acute physical injury; Adult; Anxiety Disorders; ANXIETY disorders; Arousal; AROUSAL (Physiology); avoidance; Avoidance (Psychology); AVOIDANCE (Psychology); Chronic Pain; CHRONIC pain; Depression; Early Intervention; EARLY medical intervention; HEADACHE; Headache – Etiology; headache-related disability; Health Status; HEALTH status indicators; Human; hyperarousal; INJURY complications; Linear Regression; LONGITUDINAL method; MENTAL depression; negative affect; Nonexperimental Studies; OBSERVATION (Scientific method); Post-Traumatic; POST-traumatic stress disorder; Prospective Studies; PTSD symptoms; REGRESSION analysis; Secondary Analysis; SECONDARY analysis; Stress Disorders; Trauma – Complications
OBJECTIVE: Acute postinjury negative affect (NA) may contribute to headache pain following physical injury. Early psychiatric-headache comorbidity conveys increased vulnerability to chronic headache-related disability and impairment. Yet, it is unknown whether NA is involved in the transition to chronic headache related-disability after injury. This prospective observational study examined the role of acute postinjury NA on subacute and chronic headache-related disability above and beyond nonpsychiatric factors. METHODS: Eighty adult survivors of single-incident traumatic physical injury were assessed for negative affect (NA): a composite of depression and anxiety symptoms, and symptoms of posttraumatic stress disorder (PTSS) during the acute 2-week postinjury phase. NA was examined as the primary predictor of subacute (6-week) and chronic (3-month) headache-related disability; secondary analyses examined whether the individual NA components differentially impacted the outcomes. RESULTS: Hierarchical linear regression confirmed NA as a unique predictor of subacute (Cohen's f (2) = 0.130; P = .005) and chronic headache related-disability (Cohen's f (2) = 0.160; P = .004) beyond demographic and injury-related factors (sex, prior headaches, and closed head injury). Upon further analysis, PTSS uniquely predicted greater subacute (Cohen's f (2) = 0.105; P = .012) and chronic headache-related disability (Cohen's f (2) = 0.103; P = .022) above and beyond demographic and injury-related factors, depression, and anxiety. Avoidance was a robust predictor of subacute headache impairment (explaining 15% of the variance) and hyperarousal was a robust predictor of chronic headache impairment (10% of the variance). CONCLUSION: Although NA consistently predicted headache-related disability, PTSS alone was a unique predictor above and beyond nonpsychiatric factors, depression, and anxiety. These results are suggestive that early treatment of acute postinjury PTSS may correlate with reductions in disability and negative physical health sequelae associated with PTSS and chronic headache.
Pacella Maria L; Hruska Bryce; George Richard L; Delahanty Douglas L
Headache
2018
2018-03
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1111/head.13233" target="_blank" rel="noreferrer noopener">10.1111/head.13233</a>
In situ simulation to assess workplace attitudes and effectiveness in a new facility.
*Attitude of Health Personnel; *Patient Simulation; Adult; Emergency Service; Hospital/*organization & administration; Hospitals; Humans; Inservice Training/methods; Patient Care Team/*organization & administration; Patient Safety/*standards; Self Efficacy; Teaching/organization & administration; Trauma Centers/*organization & administration; Workforce
INTRODUCTION: In situ simulation within new facilities holds the promise of identifying latent safety threats. The aim of this study was to identify if in situ simulation can also impact important employee perceptions and attitudes. METHODS: In the current study, health care professionals of an adult, urban, community teaching hospital level 1 trauma center participated in simulated scenarios in a new emergency department. Before and after the simulated scenarios, participants provided responses to the variables regarding their ability to work in the new facility and other work-related variables. RESULTS: Significant increases in communication (P = 0.05), facility clinical readiness (P \textless 0.05), self-efficacy (P \textless 0.01), trauma readiness (P \textless 0.01), and work space satisfaction (P \textless 0.05) were found from presimulation to postsimulation. The results also demonstrated a significant decrease from presimulation to postsimulation with performance beliefs (P \textless 0.001). Finally, cardiac readiness did not reveal a significant change from presimulation to postsimulation. DISCUSSION: In situ simulation exercises before practicing clinically in a new facility can both increase familiarity with new clinical environments and impact important organizational outcomes. Thus, simulation in a new work space can influence factors important to employees, organizations, and patients.
Gardner Aimee King; Ahmed Rami A; George Richard L; Frey Jennifer A
Simulation in healthcare : journal of the Society for Simulation in Healthcare
2013
2013-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/SIH.0b013e31829f7347" target="_blank" rel="noreferrer noopener">10.1097/SIH.0b013e31829f7347</a>
Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population.
Aged; Anticoagulants – Therapeutic Use – In Old Age; Chi Square Test; Descriptive Statistics; Guideline Adherence; Human; Intracranial Hemorrhage – Diagnosis – In Old Age; Logistic Regression; Midwestern United States; Platelet Aggregation Inhibitors – Therapeutic Use – In Old Age; Quality Improvement; Record Review; Tomography; Trauma – Therapy – In Old Age; X-Ray Computed – In Old Age
PURPOSE: Geriatric trauma patients taking preinjury anticoagulant or antiplatelet (ACAP) medications are at greater risk for delayed intracranial hemorrhage (DICH), a rare but potentially life-threatening condition. Routine repeat head computed tomography (RRHCT) scans can identify DICH. Our objective was to decrease the rate of missed RRHCT in a level 1 Midwest trauma center geriatric minor trauma population on preinjury ACAP medications. OBJECTIVE: The objective of the quality improvement project was to identify the root cause of the missed RRHCTs and to implement a comprehensive solution to reduce rates of missed RRHCTs. METHODS: Medical records from before and after the intervention were evaluated. Frequencies and percentages were calculated. In addition, chi and logistic regression were utilized. The Lean Six Sigma (LSS) DMAIC (Define, Measure, Analyze, Improve, and Control) process was used to drive process improvement. RESULTS: At baseline, 15% (41 of 267) of RRHCTs were missed. After solution implementation, missed RRHCTs dropped to 4% (2 of 50). Of the 2 that were missed, zero were clinically inappropriate misses, making the postimplementation rate effectively 0%. CONCLUSION: The LSS DMAIC process helped health care professional to facilitate improved adherence to the department's practice guideline with respect to RRHCT. Adherence with this guideline can help providers identify patients with DICH, a potentially life-threatening condition.
Birmingham Lauren E; Sedorovich Ashley; Mann Nolan; George Richard L
Quality management in health care
2018
2018-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/QMH.0000000000000186" target="_blank" rel="noreferrer noopener">10.1097/QMH.0000000000000186</a>
Current challenges in dedifferentiated fat cells research.
*adult stem cells; *Biomedical Research; *Cell Dedifferentiation; *culture purity; *dedifferentiated fat cells; *dedifferentiation; *surface marker; Adipocytes/*cytology; Animals; Cells; Cultured; Humans; Phenotype
Dedifferentiated fat cells show great promises as a novel cell source for stem cell research. It has many advantages when used for cell-based therapeutics including abundance, pluripotency, and safety. However, there are many obstacles researchers need to overcome to make the next big move in DFAT cells research. In this review, we summarize the current main challenges in DFAT cells research including cell culture purity, phenotypic properties, and dedifferentiation mechanisms. The common methods to produce DFAT cells as well as the cell purity issue during DFAT cell production have been introduced. Current approaches to improve DFAT cell purity have been discussed. The phenotypic profile of DFAT cells have been listed and compared with other stem cells. Further studies on elucidating the underlying dedifferentiation mechanisms will dramatically advance DFAT cell research.
Shah Mickey; George Richard L; Evancho-Chapman M Michelle; Zhang Ge
Organogenesis
2016
2016-07
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1080/15476278.2016.1197461" target="_blank" rel="noreferrer noopener">10.1080/15476278.2016.1197461</a>
The utility of hair cortisol concentrations in the prediction of PTSD symptoms following traumatic physical injury.
*Acute physical injury; *Avoidance; *Hair cortisol concentrations; *Numbing; *PTSD; *PTSD symptoms; 80 and over; Adult; Aged; Biological Markers; Female; Hair Analysis; Hair/*chemistry; Human; Humans; Hydrocortisone; Hydrocortisone/*analysis; Male; Middle Aged; Midwestern United States; Post-Traumatic – Risk Factors; Post-Traumatic/*diagnosis/*etiology; Prospective Studies; Regression; Retrospective Design; Retrospective Studies; Risk Factors; Saliva; Stress Disorders; Trauma Centers – Midwestern United States; Wounds and Injuries/*complications
RATIONALE: Although cortisol alterations have been associated with posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS), the direction of association is mixed. Cortisol which is measured in blood, saliva, or urine is subject to transient factors that may confound results. Recent advances in cortisol sampling techniques provide novel opportunities to address these inconsistencies. Hair cortisol sampling is a non-invasive method for the retrospective assessment of long-term integrated cortisol, yet its utility at predicting PTSS has not been assessed in acute injury victims. OBJECTIVE: The aim of this prospective study was to examine whether higher levels of hair cortisol concentrations (HCC) were associated with increases in PTSS following traumatic physical injury. METHOD: From January 2012 to May 2013, injury victims admitted to a level-1 Midwestern trauma center were recruited during their routine trauma clinic appointment within 30-days post-injury. Thirty participants had sufficient hair length to obtain 3-cm hair samples for cortisol assay. These participants completed PTSS assessments in relation to their recent injury at both the baseline and follow-up assessments (within 30- and 60-days post-injury, respectively). RESULTS: Hierarchical regression analyses - which controlled for baseline PTSS, age, and sex - revealed that higher HCC predicted significant increases in overall PTSS at follow-up. Higher HCC also predicted increases in the avoidance/numbing subscale symptoms of PTSS. Dividing the avoidance symptoms and numbing symptoms into two separate clusters (consistent with the 4-factor DSM-5 model of PTSD) revealed that HCC was only marginally associated with numbing, but not with avoidance symptoms. CONCLUSION: Hair sampling is a feasible method for assessing integrated cortisol levels soon after traumatic physical injury. This study suggests that elevated HCC may serve as a biomarker of risk for the development of posttraumatic symptomatology, and identifies specific symptoms that may be targeted for intervention in those with high HCC in the aftermath of injury.
Pacella Maria L; Hruska Bryce; Steudte-Schmiedgen Susann; George Richard L; Delahanty Douglas L
Social science & medicine (1982)
2017
2017-02
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.socscimed.2016.12.046" target="_blank" rel="noreferrer noopener">10.1016/j.socscimed.2016.12.046</a>
The relationship between confidence and competence in the development of surgical skills.
*Clinical Competence; *Education; *Self Efficacy; Adult; competence; confidence; Data Collection; Education; General Surgery/*education; Humans; Medical; medical students; Medical/*psychology; Patient Care; Practice-Based Learning and Improvement; Students; surgical education; surgical skills; Systems-Based Practice; Undergraduate; Video Recording
BACKGROUND: Confidence is a crucial trait of any physician, but its development and relationship to proficiency are still unknown. This study aimed to evaluate the relationship between confidence and competency of medical students undergoing basic surgical skills training. METHODS: Medical students completed confidence surveys before and after participating in an introductory workshop across 2 samples. Performance was assessed via video recordings and compared with pretraining and posttraining confidence levels. RESULTS: Overall, 150 students completed the workshop over 2 years and were evaluated for competency. Most students (88%) reported improved confidence after training. Younger medical students exhibited lower pretraining confidence scores but were just as likely to achieve competence after training. There was no association between pretraining confidence and competence, but confidence was associated with demonstrated competence after training (p \textless 0.001). CONCLUSIONS: Most students reported improved confidence after a surgical skills workshop. Confidence was associated with competency only after training. Future training should investigate this relationship on nonnovice samples and identify training methods that can capitalize on these findings.
Clanton Jesse; Gardner Aimee; Cheung Maureen; Mellert Logan; Evancho-Chapman Michelle; George Richard L
Journal of surgical education
2014
2014-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.jsurg.2013.08.009" target="_blank" rel="noreferrer noopener">10.1016/j.jsurg.2013.08.009</a>
Telepresent Focused Assessment With Sonography for Trauma Examination Training Versus Traditional Training for Medical Students: A Simulation-Based Pilot Study.
*Students; *Videoconferencing; Adult; Clinical Competence/*statistics & numerical data; Curriculum; Debriefing Assessment for Simulation in Healthcare; education; Female; Focused Assessment with Sonography of Trauma/*methods; Humans; Male; Medical; Pilot Projects; remote telementored ultrasound; Simulation Training/*methods; teledebriefing; telementor; telepresence; telesonography; Ultrasonics/*education; Young Adult
OBJECTIVES: Telepresent education is becoming an important modality in medical education, as it provides a means for instructors to lead education sessions via videoconferencing technologies. This study aimed to compare the effectiveness of telepresent ultrasound training versus traditional in-person ultrasound training. METHODS: Medical student cohorts were educated by either traditional in-person instruction or telementoring on how to perform a focused assessment with sonography for trauma (FAST) examination. Effectiveness was evaluated by pre- and post-multiple-choice tests (knowledge), confidence surveys, and summative simulation scenarios (hands-on FAST simulation). Formative simulation scenario debriefings were evaluated by each student using the Debriefing Assessment for Simulation in Healthcare student version (DASH-SV). RESULTS: Each method of instruction had significant increases in knowledge, confidence, and hands-on FAST simulation performance (P \textless .05). The collective increase in knowledge was greater for the in-person group, whereas the improvement in FAST examination performance during simulations was greater for the telementored group. Confidence gains were comparable between the groups. The DASH-SV scores were significantly higher for the in-person group for each criterion; however, both methods were deemed effective via median scoring. CONCLUSIONS: Telepresent education is a viable option for teaching the FAST examination to medical students.
Poland Scott; Frey Jennifer A; Khobrani Ahmad; Ondrejka Jason E; Ruhlin Michael U; George Richard L; Gothard M David; Ahmed Rami A
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
2018
2018-08
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1002/jum.14551" target="_blank" rel="noreferrer noopener">10.1002/jum.14551</a>