Simulation: the new teaching tool.
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Clinical Competence↗
Biomedical subjects
Richard L Lammers
Publications and source records attributed to Richard L Lammers.
Competence of new emergency medicine residents in the performance of lumbar punctures.
BACKGROUND: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. OBJECTIVE: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. METHODS: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. RESULTS: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4-26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7-28) in 14.3 minutes (range: 3-22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0-10), but only 40% of those who did so were supervised by an attending during their first attempt. CONCLUSIONS: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance.
Attitude of Health Personnel↗
Prediction of traumatic wound infection with a neural network-derived decision model.
The objective of this study was to develop and validate a decision model, using an artificial neural network, that predicts infection in uncomplicated, traumatic, sutured wounds. The study was a prospective, cohort study of all patients presenting to the emergency department of a county teaching hospital with uncomplicated wounds that required suturing. In evaluating and treating wounds, emergency medicine (EM) faculty and residents, resident physicians in primary-care specialties, and supervised medical students on EM clerkships followed a standardized wound-management protocol. Clinicians estimated the likelihood of subsequent infection using a 5-point scale. Wound healing was followed until sutures were removed. Wound outcome data were collected by medical personnel blinded to the initial prediction. Student's t-tests and Pearson's chi-square statistic were used to identify independent predictors that served as input variables. Wound infection was the single output variable. Neural network analysis was used to assign weights to input variables and derive a decision equation. A total of 1,142 wounds were analyzed in the study. The overall infection rate was 7.2%. The most predictive factors for wound infection were wound location, wound age, depth, configuration, contamination, and patient age. To derive a decision equation for the model, the network was trained on data from half of the subjects and tested on the remainder. When used as a diagnostic test for wound infection, the decision model had a sensitivity of 70%, as compared to 54% for physicians, and a specificity of 76%, as compared to 78% for physicians. We conclude that through the use of combinations of 7 clinical variables available at the time of initial wound management, a neural network-derived decision model may be used to identify uncomplicated, traumatic wounds at higher risk for infection.
Adolescent↗
The effect of a new emergency medicine residency program on patient length of stay in a community hospital emergency department.
OBJECTIVES: It is not clear how emergency medicine residents affect emergency department (ED) efficiency. The objective of this study was to determine whether a new emergency medicine residency program affected the length of stay (LOS) of patients in a community hospital ED. METHODS: A before-and-after observational study was conducted during a one-year period prior to, and for three years after, the start of a new residency. An additional year's worth of data were collected during the fifth year after the residency started. Patients were excluded if their LOS was less than 30 minutes and they were admitted directly to the hospital. Explanatory variables included scheduled resident and student hours/day; scheduled faculty hours/day; nursing plus clerk hours/day; patients/day; ambulances/day; and admissions/day. The data were analyzed using descriptive and correlation statistics and regression analysis. RESULTS: Average patient LOS prior to the residency was 122.9 minutes. During the first year of residency, it was 126.6 minutes; second year, 129.9 minutes; third year, 158.9 minutes; and fifth year, 162.4 minutes. There was a positive correlation between LOS and third-postgraduate-year resident (PGY-3) hours (rho = 0.43), and between LOS and PGY-3 hours/patients/day (rho = 0.42). All other correlations were poor (rho < 0.4). CONCLUSIONS: In this ED, there was a weak, positive correlation between ED patient length of stay and the presence of PGY-3 emergency medicine residents.
Analysis of Variance↗