CJEM Articles: emergency medicine

Objective: We sought to evaluate the time to antibiotics for emergency department (ED) patients meeting criteria for severe sepsis before and after the implementation of an ED sepsis protocol. Compliance with published guidelines for time to antibiotics and initial empiric therapy in sepsis was also assessed.

Methods: A retrospective chart review was conducted. Emergency department patient encounters with International Classification of Diseases codes related to severe infections were screened during a 3-month period before and after the implementation of a sepsis protocol. Encounters meeting criteria for severe sepsis were further assessed. The time to ini­tiation of antibiotics was determined as well as the initial choice of antimicrobial therapy based on the presumed source of infection.

Results: We reviewed 213 unique ED patient encounters meeting criteria for severe sepsis. Analysis of the period before implementation showed a median time from the time criteria for severe sepsis were met to delivery of antibiotics of 163 minutes (95% confidence interval [CI] 124 to 210 min). Analysis of the period after implementation of the protocol revealed a median time of 79 minutes (95% CI 64 to 94 min), representing an overall reduction of 84 minutes (95% CI 42 to 126 min). Before the implementation of the protocol, 47% of patients received correct antibiotic coverage for the presumed source of infection in compliance with locally published guidelines. After the initiation of the protocol, 73% received appropriate initial antibiotics, for an overall improvement of 26%.

Conclusion: A guideline-based ED sepsis protocol for the evaluation and treatment of the septic patient appears to improve the time to administration of antibiotics as well as the appropriateness of initial antibiotic therapy in patients with severe sepsis.

The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulation’s unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule.

Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.

A mentor is a person who takes a special interest in the professional development of a junior colleague and provides guidance and support. Mentoring can be beneficial for students, residents, junior colleagues and researchers and can be very rewarding for the physician who provides this guidance. Although mentoring is a well recognized topic in academic medicine, relatively little has been written about mentoring in emergency medicine (EM). Consequently, we conducted a literature review on mentoring in EM and present our findings in this paper. We discuss different models of mentoring, factors that foster the development of strong mentor ship programs, the responsibilities of mentors and mentees, and issues specific to mentorship of female, minority and research physicians. We also present several case scenarios as a basis for recommendations for teachers and learners in EM.

Objective: Training in practical aspects of disaster medicine is often impossible, and simulation may offer an educational opportunity superior to traditional didactic methods. We sought to determine whether exposure to an electronic simulation tool would improve the ability of medical students to manage a simulated disaster. Methods: We stratified 22 students by year of education and randomly assigned 50% from each category to form the intervention group, with the remaining 50% forming the control group. Both groups received the same didactic training sessions. The intervention group received additional disaster medicine training on a patient simulator (disastermed.ca), and the control group spent equal time on the simulator in a nondisaster setting. We compared markers of patient flow during a simulated disaster, including mean differences in time and number of patients to reach triage, bed assignment, patient assessment and disposition. In addition, we compared triage accuracy and scores on a structured command and control instrument. We collected data on the students' evaluations of the course for secondary purposes. Results: Participants in the intervention group triaged their patients more quickly than participants in the control group (mean difference 43 s, 99.5% confidence interval [CI] 12 to 75 s). The score of performance indicators on a standardized scale was also significantly higher in the intervention group (18/18) when compared with the control group (8/18) (p < 0.001). All students indicated that they preferred the simulation based curriculum to a lecture based curriculum. When asked to rate the exercise overall, both groups gave a median score of 8 on a 10 point modified Likert scale. Conclusion: Participation in an electronic disaster simulation using the disastermed.ca software package appears to increase the speed at which medical students triage simulated patients and increase their score on a structured command and control performance indicator instrument. Participants indicated that the simulation based curriculum in disaster medicine is preferable to a lecture based curriculum. Overall student satisfaction with the simulation based curriculum was high.