Coverage of emergency after-hours ultrasound cases: survey of practices at U.S. Teaching hospitals

Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department

OBJECTIVES

The objective was to evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients.

METHODS

This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two physicians agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two physicians either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit or within 2 days by follow-up assessment.

RESULTS

A total of 387 lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (κ = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference = -1.7%; 95% confidence interval [CI] = -3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference = -2.8%; 95% CI = -9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference = 33.9%; 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference = 19.3%; 95% CI = -13.8% to 52.4%).

CONCLUSIONS

For clinically evident lesions, the addition of ultrasound (US) did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE.

What program directors think: results of the 2011 annual survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) conducts an annual survey to monitor and evaluate issues pertaining to radiology residents' educational experiences, work responsibilities, and benefits. Data are used to identify emerging trends and patterns of change to plan and provide resources that support radiology residency programs and their directors.

MATERIALS AND METHODS

The APDR Annual Survey Committee selected 59 items for an observational, cross-sectional study using a Web-based survey. Topics of interest included program director satisfaction, resident recruitment, social media, program requirements, curriculum, the new American Board of Radiology exam process, call, and residents-as-teachers programs. All active APDR members (n = 296) were invited to participate in survey between February 20 and March 11, 2011.

RESULTS

The response rate was 47% (140 of 296). Descriptive results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 59th annual meeting of the Association of University Radiologists.

CONCLUSIONS

Data generated by the annual survey enable the APDR to accrue data pertaining to residents' real-time educational experiences. In 2011, program directors were satisfied with their jobs but not convinced that competency-based program requirements had positive effect on residency training. Programs plan to use the Radiological Society of North America and American Association of Physicists in Medicine Web-based physics training modules. Most radiology programs do not have residents-as-teachers programs, nor do they plan to initiate them. During recruitment, programs use an applicant's location as a proxy for true interest in the program, and interest in the program is important for granting interviews and final ranking. Qualified international medical graduate applicants have access to radiology training in the United States and Canada. Almost half of radiology programs have in-house reading by attending radiologists with residents on call. Residency programs have been slow to embrace social media.

Use of emergency ultrasound in United States pediatric emergency medicine fellowship programs in 2011

OBJECTIVES

The purpose of this study was to evaluate the use of and training in emergency ultrasound (US) in pediatric emergency departments (EDs) with pediatric emergency medicine (EM) fellowship programs. We hypothesized that emergency US use and pediatric EM fellow training have become widespread and that more structured training is being offered.

METHODS

A survey instrument was sent via e-mail to all 69 United States pediatric EM fellowship directors or associate directors in the spring of 2011. We used descriptive summary statistics and χ(2) tests to determine characteristics associated with having a formal emergency US training program for pediatric EM fellows.

RESULTS

The survey response rate was 87% (60 of 69). Among responding programs, 40 (67%) resided within a children's hospital (versus general ED). Fifty-one (85%) were designated level 1 pediatric trauma centers. Fifty-seven programs (95%) endorsed the use of emergency US in their EDs. Fifty-three (88%) provided at least some emergency US training to fellows, and 42 (70%) offered a structured emergency US rotation. Training has existed for a median of 3 years (interquartile range, 2-4 years). Twenty-eight programs (67%) with emergency US rotations provided fellow training in the both a general ED as well as a pediatric ED. There were no hospital or program level factors statistically associated with having a formal training program for pediatric EM fellows.

CONCLUSIONS

As of 2011, nearly all pediatric EDs with pediatric EM fellowship programs use emergency US. Pediatric EM fellowship programs provide emergency US training to their fellows, with a structured rotation being offered by most of these programs.

A Pilot Study

Point-of-care sonography is a valuable tool used in medical practice. A free health clinic was the venue for the authors’ approach to hands-on training for medical and nursing students. Students were surveyed before and after the event regarding their experience and their ability to successfully perform six targeted sonographic skills. The primary outcome was the change presurvey to postsurvey in the students’ assessment of their ability to perform scans on patients and identify the anatomic structures in the six skill areas. An experienced sonographer monitored each scan and confirmed skill application. One hundred nineteen sonograms were performed. Most students (23/29) did not report competence in any of the six assessed skills prior to the study. On average, students developed competence in three of six skill areas. Before the study, 3 of 29 students (10%) reported being able to perform scans on patients and identify the major anatomic structures. After the study, 20 of 28 students (71%) reported that they could perform scans and identify these structures. This change was significant ( P < .0001, χ2).