CAEP/ACMU 2000 Scientific Abstracts: 33-36

CAEP Abstracts

CJEM 2001;2(3):169-187

033 Computer-Assisted Instruction of Carpal Bone Radiograph Interpretation.
Westendorp MW, McGraw RC, Pickett W. Queen's University, Kingston, Ont.

OBJECTIVE: To develop a computer-assisted self-directed training module to teach carpal bone radiograph interpretation to clinical clerks, and to evaluate the efficacy of the module as a teaching tool.
METHODS: Using commercially available authoring software, we developed a computer program designed to teach carpal bone radiograph interpretation. The program was made available on existing computer workstations and for downloading to personal computers over the World Wide Web. Following an 8-month period where the module was a mandatory component of the clerkship rotation in Emergency Medicine, we recruited a convenience sample of 36 students that included pre-clerkship students, clinical clerks, and residents. We used an OSCE (objective structured clinical exam) format to measure skill in carpal bone radiograph interpretation. We wanted to compare the scores of the clinical clerks who had completed the module with the scores of students from various levels of medical education who had not. RESULTS: The median score (out of 7) for a group of clerks who completed the module was 5 (n = 10). The median score for a group made up of clerks who did not complete the module and residents with no specific training in carpal bone radiograph interpretation was 2 (n = 7). The Mann­Whitney Test showed a statistically significant difference in performance between the two groups as measured by mean ranked scores (Mann­Whitney U = 8.50, p = 0.008). The median score for emergency medicine residents, who have specific training in carpal bone radiograph interpretation was 6 (n = 9). There was no statistically significant difference in mean ranked scores between them and the clerks who completed the module (Mann­Whitney U = 25.00, p = 0.092). CONCLUSIONS: We have developed a computer-assisted self-directed training module to teach carpal bone radiograph interpretation and it appears to be an effective teaching tool.
Key words: radiography, medical education

034 Evaluating the Impact of an Advanced Paramedic Educational Intervention on the Cancelled Call Rate and Paramedic Documentation of Capacity Assessment: A Before and After Observational Study.
Riley J, Burgess R, Schwartz B. Division of Prehospital Care, Sunnybrook & Women's College Health Sciences Centre, University of Toronto, and Toronto Ambulance Service, Toronto, Ont.

OBJECTIVES: To compare the rates of cancelled calls, paramedic documentation of capacity and signature acquisition on the refusal section of the Ambulance Call Report (ACR), before, immediately after and 1 year post an educational intervention.
METHODS: ACRs were reviewed for all Advanced Life Support (ALS) calls occurring during the three periods of interest. The number of patient initiated cancellations was compared for each period. Paramedic compliance with documentation of capacity and signature obtainment was determined from a consecutively extracted sample of every fourth call report, to a total of 75, from each period. Reviewers were blinded to the study period and accuracy was measured using 20% double data entry. The intervention was a 1.5-hour module on the assessment and documentation of capacity. A chi-square test of significance was applied for all comparisons. RESULTS: The total number of ACRs was 7,744 before the intervention, 7,444 immediately after and 7,604 one year later. The proportion of cancelled calls prior to the intervention (0.090; 95% confidence interval [CI] 0.084­0.097) decreased significantly in the periods immediately after (0.021; 95% CI 0.017­0.024) p < 0.01 and 1 year later (0.066; 95% CI 0.061­0.072) p < 0.01. There was no change in documentation rate for capacity in the three periods (1/75, 0/75, 0/75) p = 0.366, and no change in the rate of signature acquisition (64/75, 64/75, 59/75) p = 0.453. The error rate for data entry was 0.74%. CONCLUSIONS: An educational module directed at improving paramedic assessment and documentation of capacity in patients refusing transport resulted in a significant reduction in the number of cancelled calls immediately after and 1 year following the intervention. There was no improvement in the rate of capacity documentation on the ACR or in signature acquisition.
Key words: emergency medical services, documentation

035 Factors Associated with Field Pronouncement and Futile Resuscitation of Out-of-Hospital Cardiac Arrest Patients.
De Maio VJ, Stiell IG, Wells GA, Spaite DW, Martin M, O'Brien J-A, for the OPALS Study Group. Clinical Epidemiology Unit, University of Ottawa, Ottawa.

OBJECTIVES: Many EMS programs have adopted termination of resuscitation policies for cardiac arrest in response to research establishing the futility of transport after unsuccessful advanced life support (ALS) measures in the field. This study evaluated out-of-hospital termination practices and determined predictors of unsuccessful resuscitation, as part of the Ontario Prehospital Advanced Life Support (OPALS) Study.
METHODS: This prospective cohort study included all adult, cardiac etiology, out-of-hospital cardiac arrest cases within 11 communities with established field pronouncement policies and prehospital ALS care. Case definitions followed the Utstein style. Univariate (chi-square and t-test) and stepwise logistic regression (LR) analyses identified factors associated with field termination and overall non-survival to hospital discharge. RESULTS: From 1995 to 1999, there were 978 (52%) field terminations among the 1,875 cases treated. Survival was 5.0% overall. LR analysis found factors independently associated with field pronouncement and their odds ratios (95% CI): age >80 years 1.8 (1.4­2.3), unwitnessed arrest 2.2 (1.8­2.7), no citizen CPR 1.3 (1.0­1.8), non-VF/VT rhythm 3.1 (2.5­3.9), and successful intubation 1.5 (1.1­2.0). Non-survival was independently associated with: age >80 years 3.0 (1.2­7.7), unwitnessed arrest 4.3 (2.2­8.3), defibrillation response interval >8 minutes 8.5 (1.2­62.3), non-VF/VT rhythm 9.4 (4.7­18.8), and successful intubation 2.0 (1.1­3.7). CONCLUSION: This study demonstrates that field termination occurs frequently for unwitnessed arrests in elderly patients with non-VF/VT rhythms. Factors associated with futile resuscitation are age >80 years, unwitnessed arrest, defibrillation response interval >8 minutes, non-VF/VT rhythm, and successful intubation and could form the basis for evidence-based EMS field termination guidelines.
Key words: resuscitation

036 Analysis of Pre-Hospital Transport of Head-Injured Patients After Regionalization of Neurosurgery Resources.
Holmen C, Sosnowski T, Latoszek K, Dow D, Rowe BH. University of Alberta, Edmonton, Alta.

OBJECTIVES: The objectives of this study were to determine the factors (e.g., paramedic, system, or patient) associated with initial transport to a non-NS Emergency Department (ED), following regionalization of NS services.
METHODS: A retrospective chart review was performed 6 months following NS regionalization. All charts of patients secondarily transferred to the NS service from January 1996 to November 1998 were examined. The EMS consisted of 5 acute care EDs, all with CT scanners, and 1 designated NS ED. EMS guidelines mandated transport of possible head injured (HI) patients to the NS centre if GCS was <14 or Prehospital Index >4 (using mechanism of injury). Charts were accessed from the Regional Trauma Program and EMS electronic databases. Charts and ambulance reports were matched, and reviewed independently by two researchers to determine reasons for the original transport to the non-NS site.
RESULTS: 91 charts were identified and 82 (90%) patients fulfilled criteria for transfer to the NS centre due to HI. There was a bimodal age distribution: 38% were 30­49 years old and 29% were 60­79 years old. 70 patients were male (85%) and only 6 (7%) were pediatric. In 17 cases (21%) there was no history of head trauma. In 28 (34%), alcohol intoxication was documented, and 11% admitted to chronic alcohol abuse. Triage guidelines were followed in all but 5 (6%) cases. NS consultation was delayed by 6.5 hours by a second transfer. Following transfer, all patients were admitted, 25 (30%) underwent craniotomy and 18 (22%) died. The most common (35%) final diagnosis was subdural hematoma. CONCLUSION: Few inappropriate pre-hospital decisions were identified, and patient factors appeared most commonly responsible for secondary HI transfer to a NS centre in this EMS. However, long delays and serious outcomes were identified, and this suggests a re-evaluation of NS screening criteria may reduce these inappropriate transports.
Key words: emergency medical services, trauma system, traumatic brain injury