Best Oral Presentation

Does Frailty Defined by the SHARE Frailty Instrument Predict Adverse Outcomes After an ED Visit?

Scott T. Wilber1, Jennifer A. Frey1, Marissa N. Watson1, Scott A. Poland1, Alicia L. Bond1, Kirk A. Stiffler1

Summa Akron City Hospital Akron OH

BackgroundFrailty is a characterized by increased vulnerability to stressors including acute illness; frail patients are at increased risk of adverse outcomes. A commonly used frailty instrument requires measurement of gait speed, which is difficult in older emergency department (ED) patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) requires only grip strength and answering questions.ObjectivesThe objective was to determine the prevalence of frailty in older ED patients based on the SHARE-FI and the association between frailty and adverse 30-day outcomes.MethodsWe performed a prospective longitudinal study of patients ≥ 65 years in an urban community teaching ED. We excluded those who could not answer questions or perform measurements and those from nursing homes. We measured grip strength with a handheld dynamometer. Exhaustion, weight loss, slowness, and low activity were measured with the SHARE-FI questions. Frailty was determined with the SHARE-FI equations. The composite 30-day adverse primary outcome was death, functional decline, repeat ED or hospital admission, or nursing home admission. Secondary outcome was falls within 30 days. Data were analyzed using Stata and reported as means and proportions with 95% confidence intervals (CIs); associations were measured using Fisher's exact test (≤0.05). One-hundred patients provided an approximate 95% CI of ±10%.ResultsWe enrolled 107 patients: the mean age was 79 years, 50% were male, and 52% (56/107, 95% CI = 42%–62%) were dependent in one or more mobility-related activities of daily living at baseline. By SHARE-FI, 25% were nonfrail (27/107, 95% CI = 17%–35%), 36% prefrail (39/107, 95% CI = 27%–46%), and 38% frail (41/107, 95% CI = 29%–48%). Follow-up was obtained in 98/107 (92%). The composite outcome occurred in 50% (49/98, 95% CI = 40%–60%), including 19% of nonfrail, 44% of prefrail, and 78% of frail patients (p < 0.0001). A similar pattern was found for each individual outcome. Falls occurred in 0% of nonfrail, 6% of prefrail, and 21% of frail patients (p = 0.015).ConclusionFrailty is common in older ED patients and is significantly associated with adverse 30-day outcomes.

Best Poster Presentation

Assessment of Advanced Cardiac Life Support and Pediatric Advanced Life Support Competency by Emergency Medicine Residents Using a Simulation-based Curriculum

Michael J. McCrea1, Aaron M. Orqvist1, Kristina K. Burgard1

Mercy St. Vincent's Medical Center Toledo OH

BackgroundIn July 2010 our emergency medicine (EM) residency program began evaluating resident competency using a simulation-based curriculum. We first evaluated Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) competency.ObjectivesThe objective was to evaluate EM resident ACLS and PALS competency using high-fidelity human patient simulators.MethodsSimulation scenarios were written by faculty following the 2005 ACLS and PALS Guidelines. Each resident randomly selected a single ACLS scenario. Competency was determined by meeting all critical actions for each case. If a resident earned a “fail,” repeat evaluation was conducted after self-study and voluntary simulation practice. For repeat evaluations, residents were evaluated on three cases: pulseless arrest, tachycardia, and bradycardia. If failure occurred after a second evaluation, a required review session with faculty was scheduled before a final third evaluation of three cases. For PALS assessment, three cases were chosen for all evaluation attempts. After interim assessment, cases were revised to incorporate the 2010 ACLS and PALS updates and resident competency was reevaluated. Also, critical actions were revised with time-dependent performance measures to better simulate clinical performance.ResultsFor our initial ACLS competency evaluation, the final pass rate was 100% with a first-time pass rate of 78%. For PALS, the final pass rate was 93% with a first-time pass rate of 58%. Several themes emerged that resulted in failure: incorrect rhythm interpretation, differentiating a stable from an unstable patient, inability to perform electrical therapies, not supervising high-quality cardiopulmonary resuscitation, and incorrect pediatric weight-based medication dosing. An interventional curriculum was designed to address each of these deficiencies. However, first-time pass rate did not change with repeat competency evaluation for either ACLS (77%) or PALS (57%), but final pass rate remained at 100% for ACLS and increased to 100% for PALS.ConclusionOur initial evaluation revealed themes that prevented EM residents from demonstrating competency with ACLS and PALS in a simulation environment. A curriculum was designed and implemented to address these deficiencies that also incorporated the 2010 Guidelines updates. Repeat competency evaluation for ACLS and PALS showed no improvement in first-time competency pass rate, however. Additional education interventions will be developed to further improve resident competency with ACLS- and PALS-based care.

Best Student Presentation

Communication With Trauma Patients in Spinal Immobilization

Catherine A. Marco1, Stephanie Ritter1, Andrew Rudawsky1, Steven Nelson1, Matthew Jolly1

University of Toledo Toledo OH

BackgroundTrauma comprises approximately 34% of emergency department (ED) visits annually in the United States. Spinal immobilization can be a barrier to effective communication, including eye contact.ObjectivesThis study was undertaken to identify factors associated with patient satisfaction among ED patients who had been involved in acute trauma and were in spinal immobilization.MethodsThis prospective case cohort study was conducted at an urban trauma I ED. Eligible participants included consenting adult ED patients, age 18 and over, with acute trauma who were in spinal immobilization (cervical collar and backboard). Data collected included demographic information, communication in the ED, length of stay, disposition, and a survey regarding patient satisfaction of communication with health care providers. Health care providers and patients were blinded to the study objective and outcome measures.ResultsSeventy subjects were observed in the acute trauma resuscitation phase, and 64 subjects completed the patient satisfaction survey. Mechanisms of injury included motor vehicle accident (57%), fall (31%), and assault (7%). Among 667 observed communications with patients, only 20% of speakers introduced themselves, and 205 speakers used the patient's name. Sixteen percent of speakers oriented patients to trauma care. Most speakers addressed the patient from the side of the stretcher, above the patient's waist level (65%). Among 166 observed procedures, 72% of procedures were explained to the patient prior to the procedure. Most patients were highly satisfied with medical care (88% score of 4 or 5) and with communication (85%). A higher percentage of females (77%) had high anxiety compared to males (49%; p = 0.02).ConclusionAmong 70 patients with acute trauma in spinal immobilization, most were highly satisfied with medical care and communications. Deficiencies in ED communications included failure to address the patient by name, failure of the health care providers to introduce themselves, failures to orient the patient to trauma care, and failure to explain procedures. Satisfaction with care was associated with mechanism of injury. More females had higher anxiety compared to males.

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