affect their employment decisions. 68 Bedside Ultrasound versus Computed Tomography in. Diagnosing Renal Colic and Predictors of 30-Day Return Visits.
Research Forum Abstracts graduates. In 2013, a multi-organizational committee composed of the Council of Emergency Medicine Residency Directors (CORD), Society for Academic Emergency Medicine (SAEM), and ACEP published a minimum standard of US skills required for graduating emergency medicine residents. However, a national standard does not exist among emergency medicine residencies as to which US applications are taught, what standards residents are held to, and how residents perceive the quality of their training. Our objective was to determine the current status and extent of US teaching within emergency medicine residency programs. Methods: We performed a retrospective review of data obtained from a performance improvement project conducted by the Academy of Emergency Ultrasound, a section of SAEM. An email link of a Web-based survey tool was sent to the Ultrasound Coordinators (if present) or to Department Directors of all ACGME emergency medicine residency programs in the United States (n¼160). We requested that they forward the survey link to their residents. Additionally, at SAEM’s 2013 (Atlanta, GA) national conference, emergency medicine residents were given the survey in their welcome packet and were asked to place the responses in an anonymous collection box. The survey consisted of 23 questions regarding the extent and level of ultrasound exposure and comfort of the resident in teaching and performing specific ultrasound applications. Results: We obtained a total of 471 responses. Most residents were in their PGY 1 year (34.6%), came from academic or urban settings (72.8%, 84.0% respectively), with high volumes (62.5% saw >90,000 patients per year). Most residents have a required US rotation in their 1st year (70.9%). The majority had 4 dedicated weeks of US training (57.7%), while 10.45% had >4 weeks and 1.71% had just 1 week. Most residents have a formal ultrasound curriculum (98.0%) and lectures (97.0%); however, only 39.0% have a written US exam. Eighty-two percent of residents have US fellowship-trained faculty at their programs and 68.3% have US fellowship. A senior US elective is available at 78.4% of institutions and 31.7% of respondents plan on taking the elective. In a minority of institutions (15.4%) the resident is required to order a confirmatory study for the US exams they perform. When asked which US exams residents are most comfortable performing, the top five were: the FAST exam (99.1%), central venous access (96.3%), trans-abdominal pregnancy (86.6%), soft tissue (86.1%) and peripheral venous access (84.6%). The five exams that residents were least comfortable performing were: testicular torsion (84.4%), ovarian torsion (71.9%), ultrasound-guided nerve blocks (58.8%), trans-vaginal pregnancy (52.9%) and musculoskeletal (41.1%). In this survey, 26.9% were graduating residents. Of these graduating residents, 91.9% feel comfortable using US to make a diagnostic decision and 89.5% feel comfortable teaching clinician performed ultrasound applications. When considering employment, 87.7% of senior-reported that not having US would influence their decision to work there. Conclusion: There is variability in US teaching, resources, and resident comfort with exams across residency programs. Senior emergency medicine residents are comfortable using US to make diagnostic decisions and the availability of US may affect their employment decisions.
68
Bedside Ultrasound versus Computed Tomography in Diagnosing Renal Colic and Predictors of 30-Day Return Visits
Leo M, Langlois B, Mitchell P, Pare J, Linden J, Amanti C, Nam C, Monrose E, Libby B, Carmody K/Boston Medical Center, Boston, MA; New York University, New York, NY
Study Objectives: Computed tomography (CT) scans are commonly used to diagnose renal colic. Due to the prevalence and frequent recurrence of renal colic, the routine use of CT may increase health care costs and radiation exposure. Emergency physicians performed bedside ultrasound (US) may be a reliable alternative imaging modality. The objectives of this study were to determine if differences exist between emergency physician performed US and CT in identifying presence of hydronephrosis; to describe test characteristics of US in the diagnosis of renal colic; and to identify predictors of 30-day return visits in patients with renal colic. Methods: This was a prospective observational study of emergency department patients at an urban academic medical center from November 2010 to March 2014. Patients who presented with renal colic symptoms were screened for eligibility. Inclusion criteria were: non-contrast CT of the abdomen and pelvis, English-speaking, age > 21, and able to provide contact information for follow-up. Research assistants obtained consent and emergency physician co-investigators trained in US, blinded to CT results, performed US, and recorded presence or absence of hydronephrosis. A 30-day medical record review and follow-up phone call was completed to assess for return visits defined as: routine, intractable pain, urologic intervention, admission, or infection. We used McNemar’s test to compare bedside US and CT in the detection of hydronephrosis. Sensitivity, specificity, and positive and negative predictive values were calculated for US
Volume 64, no. 4s : October 2014
Table 1. Predictors of adverse return visit within 30 days; Multivariate analysis of patients with diagnosis of renal colic (n¼148) Predictors of adverse return visit within 30 days Covariates Sex (“Male” is reference) Race (“White” is reference) Black Hispanic Other (“No” or “none” is reference) Age 50 years High risk (hx of renal colic, recent urologic procedure, renal insufficiency, single kidney, transplant, DM, HIV, or PCKD) Sign of infection (fever, HR100, or WBC11 Creatinine1.1 Not done or not documented Blood on urinalysis Not done or not documented Nitrates or LE on urinalysis Stone size 5mm on CT scan N/A, stone not detected Hydronephrosis by ED ultrasound Mild Moderate or severe
OR (95% CI)
P value
1.72 (0.75, 3.94)
.20
1.44 (0.57, 3.61) 1.29 (0.50, 3.29) 1.67 (0.48, 5.81)
.80 .93 .60
1.39 (0.58, 3.35) 2.19 (1.07, 4.48)
.46 .03
0.45 (0.21, 0.97)
.04
1.86 0.46 0.77 1.22 0.85 1.36 1.20
(0.76, 4.56) (0.14, 1.50) (0.28, 2.14) (0.24, 6.24) (0.37, 1.97) (0.57, 3.26) (0.30, 3.77)
.04 .07 .42 .65 .70 .65 .96
1.62 (0.67, 3.90) 2.13 (0.80, 5.63)
.80 .25
DM, Diabetes Mellitus; HIV, human immunodeficiency virus; PCKD, polycystic kidney diease; LE, leukocyte esterase.
hydronephrosis in diagnosis of renal colic. Multivariate logistic regression was used to assess predictors of 30-day return visits. All data was analyzed using SAS 9.3. Results: We enrolled 316 subjects, (14 were dropped and 17 were lost to 30-day follow-up). A total of 302 subjects were included in the primary analysis. US and CT were not different in detecting hydronephrosis, 128 (42%) versus 118 (39%), P¼.14. US had high specificity (93%) and positive predictive value (93%) for the diagnosis of renal colic; sensitivity (68%), negative predictive value (68%). Predictors of 30-day return visits related to renal colic are reported in Table 1. High risk patients, sign of infection, and creatinine > 1.1 were significantly associated with 30-day returns. Conclusion: Emergency physician-performed bedside US and CT are similar in detection of hydronephrosis in patients with suspected renal colic. Our study suggests that US is a reliable first-line imaging modality for identifying renal colic. While other clinical factors were predictors of 30-day return visits, stones > 5 mm on CT and hydronephrosis on US do not seem to be predictive.
69
Does a History of Difficult Venous Access Mean the Patient Really Needs an Ultrasound-Guided IV?
Fields JM, Renzi N, McCarter K, Paziana K/Thomas Jefferson University, Philadelphia, PA
Study Objectives: Intravenous (IV) access is the most frequent emergency department (ED) procedure. Commonly, patients report a history of difficult venous access (DVA) or may not have visible or palpable veins on examination leading firstline ED providers to believe that traditional IV placement will fail and rescue vascular methods such as ultrasound-guided (USG) or extrajugular (EJ) IVs are indicated. The current study set out to determine the effect of a history of DVA, venous visibility and venous palpability on failure to establish an IV on the first attempt. Methods: This was a prospective observational study in an urban academic ED with an annual census of 45,000. Patients undergoing IV placement were consented and enrolled. Trained research associates collected data on patient demographics and history. For the history of DVA patients were asked if they had any history of being a “tough stick” (defined as a history of requiring multiple attempts at IV placement) or having to undergo any of the following rescue vascular access techniques: USGIV, EJ or central line (CL). Prior to any IV attempt, research associates asked the operator placing the IV if veins were visible (yes/no) and palpable (yes/no). The primary
Annals of Emergency Medicine S25
