Objectives: The Residency Review Committee training requirements for emergency medicine residents (EM) are defined by consensus panels, with specific topics abstracted from lists of patient complaints and diagnostic codes. The relevance of specific curricular topics to actual practice has not been studied. We compared residency graduates’ self-assessed preparation during training to importance in practice for a variety of EM procedural skills.

Methods: We distributed a web-based survey to all graduates of the Denver Health Residency Program in EM over the past 10 years. The survey addressed: practice type and patient census; years of experience; additional procedural training beyond residency; and confidence, preparation, and importance in practice for 12 procedures (extensor tendon repair, transvenous pacing, lumbar puncture, applanation tonometry, arterial line placement, anoscopy, CT scan interpretation, diagnostic peritoneal lavage, slit lamp usage, ultrasonography, compartment pressure measurement and procedural sedation). For each skill, preparation and importance were measured on four-point Likert scales. We compared mean preparation and importance scores using paired sample t-tests, to identify areas of under- or over-preparation.

Results: Seventy-four residency graduates (59% of those eligible) completed the survey. There were significant discrepancies between importance in practice and preparation during residency for eight of the 12 skills. Under-preparation was significant for transvenous pacing, CT scan interpretation, slit lamp examinations and procedural sedation. Over-preparation was significant for extensor tendon repair, arterial line placement, peritoneal lavage and ultrasonography. There were strong correlations (r>0.3) between preparation during residency and confidence for 10 of the 12 procedural skills, suggesting a high degree of internal consistency for the survey.

Conclusions: Practicing emergency physicians may be uniquely qualified to identify areas of under- and over-preparation during residency training. There were significant discrepancies between importance in practice and preparation during residency for eight of 12 procedures. There was a strong correlation between confidence and preparation during residency for almost all procedural skills, re-enforcing the tenet that residency training is the primary locus of instruction for clinical procedures.

[WestJEM. 2009;10:152-156.]

Objective: An electronic emergency department information system (EDIS) can monitor the progress of a patient visit, facilitate computerized physician order entry, display test results and generate an electronic medical record. Ideally, use of an EDIS will increase overall emergency department (ED) efficiency. However, in academic settings where new interns rotate through the ED monthly, the “learning curve” experienced by the new EDIS user may slow down patient care. In this study, we measured the impact of the “intern learning curve” on patient length of stay (LOS).

Methods: We retrospectively analyzed one year of patient care data, generated by a comprehensive EDIS in a single, urban, university-affiliated ED. Intern rotations began on the 23rd of each month and ended on the 22nd of the next month. Interns received a 1.5-hour orientation to the EDIS prior to starting their rotation; none had prior experience using the electronic system. Mean LOS (± standard error of the mean) for all patients treated by an intern were calculated for each day of the month. Values for similar numerical days from each month were combined and averaged over the year resulting in 31 discrete mean LOS values. The mean LOS on the first day of the intern rotation was compared with the mean LOS on the last day, using Student’s t-test.

Results: During the study period 9,780 patients were cared for by interns; of these, 7,616 (78%) were discharged from the ED and 2,164 (22%) were admitted to the hospital. The mean LOS for all patients on all days was 267 ± 1.8 minutes. There was no difference between the LOS on the first day of the rotation (263±9 minutes) and the last day of the rotation (276 ± 11 minutes, p > 0.9). In a multiple linear regression model, the day of the intern rotation was not associated with patient LOS, even after adjusting for the number of patients treated by interns and total ED census (β = -0.34, p = 0.11).

Conclusion: In this academic ED, where there is complete intern “turnover” every month, there was no discernible impact of the EDIS “learning curve” on patient LOS. [West J Emerg Med. 2010; 11(4):329-332.]

Introduction: To describe the epidemiology and characteristics of emergency department (ED) visits by older adults for motor vehicle collisions (MVC) in the United States (U.S.).

Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS). Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years) and younger (18-64 years) MVC patients and calculated odds ratios (OR) and 95% confidence intervals (CIs) to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults.

Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6-8.3) visits per 1,000 for older adults and 16.4 (95% CI 14.0-18.8) visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46-9.36). Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86), have a high triage acuity (OR 1.56; 95% CI 0.77-3.14), or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42-2.23) as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8-19.2) of older MVC patients and 6.1% (95% CI 4.8-7.5) of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71-4.43), and admission to the ICU if hospitalized (OR 6.9, 95% CI 0.9-51.9), after adjustment for gender, race, ethnicity, and injury acuity. Markers of injury acuity studied included EMS arrival, high triage acuity category, ED imaging, and diagnosis of a head, spinal cord or internal injury.

Conclusion: Although ED visits after MVC for older adults are less common per capita, older adults are more commonly admitted to the hospital and ICU. Older MVC victims require significant ED resources in terms of diagnostic imaging as compared to younger MVC patients. As the U.S. population ages, and as older adults continue to drive, emergency departments (EDs) will have to allocate appropriate resources and develop diagnostic and treatment protocols to care for the increased volume of older adult MVC victims. [West J Emerg Med. 2013;14(6):576–581.]