Critical urologic skills and procedures in the emergency department.
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ABSTRACT:
SUBMITTER: Ramos-Fernandez MR
PROVIDER: S-EPMC5554872 | biostudies-other | 2013 Feb
REPOSITORIES: biostudies-other
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Project description:ImportanceLittle is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients' likelihood of a subsequent urologic intervention could inform decision-making in this population.ObjectivesTo examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention.Design, setting, and participantsThis retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018.Main outcomes and measuresThe main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up.ResultsA total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P < .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P < .001) compared with patients with all other insurance types.Conclusions and relevanceIn this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients.
| S-EPMC6902745 | biostudies-literature
Project description:BackgroundCritical appraisal of medical research is a valuable skill set that emergency physicians must learn in order to become competent clinicians. Despite the need for effective critical appraisal skills training, these skills have remained difficult to teach and assess. This study aimed to explore emergency physicians' perceptions of the barriers and motivations for learning critical appraisal skills in order to develop more successful critical appraisal training methods for Emergency Medicine (EM) residents.MethodsThis qualitative study involved in-depth, semi-structured interviews with emergency physicians interested in education and administration at an urban academic hospital. Transcribed interviews were descriptively coded by three main reviewers. A coding template was developed after coding an initial set of interviews and used to code the remaining transcripts. A thematic analysis of the codes was conducted to create a summary report which was given to the interviewees as part of a member checking process to further solidify themes.ResultsFourteen emergency physicians participated in the study. They described time limitations, perceived difficulty, and disinterest as major barriers to learning critical appraisal. Physicians noted patient care as well as professional identity goals of being a good educator or researcher as motivations for developing critical appraisal skills.ConclusionThere remain significant challenges to learning critical appraisal skills as well as an increasing need to build these skills during residency. Educational theories and a greater emphasis on professional identity formation during residency can be incorporated to create a more effective approach to teaching critical appraisal skills despite these barriers.
| S-EPMC9013089 | biostudies-literature
Project description:Transitioning from the pre-clinical environment to clerkships poses a challenge to students and educators alike. Students along with faculty developed the Clinical Reasoning Elective (CRE) to provide pre-clinical students exposure to patients in the emergency department and the opportunity to build illness scripts and practice clinical skills with longitudinal mentorship in a low-stakes environment before entering clerkships. It is a voluntary program. Each year, the CRE has received overwhelming positive feedback from students. The objective of this study is to determine if the CRE improved students' clinical skills and reported comfort in their skills.We examined the relationships between students' self-reported participation in the CRE and their individual scores on a comprehensive clinical assessment (CCA) at the end of the pre-clerkship period. A total of 178 students took the CCA exam in 2016. Of these, 113 participated in the CRE and 65 did not. Seven students who participated in CRE did not complete the exit survey and were omitted from analysis. We performed regression analysis and dichotomous (participants/nonparticipants) comparisons of means with t-tests. Survey of student reactions was collected.Participants completed an average of 10 sessions over the course of the program (range=1-20). Involvement in the CRE was associated with significantly increased scores on Abdominal History; Pulmonary Physical Exam; Overall History-Taking; Overall Communication; and Overall Physical Exam (p<0.05). Nearly all students (97%) reported that the program offered opportunities to enhance clinical skills, increased their comfort with patients, and better prepared them for their clinical years.There were measurable improvements in clinical skills performance for students who participated in CRE. As many schools seek to incorporate early clinical exposure to their curricula, this program provides a successful framework to provide meaningful clinical exposure to real patients that also shows objective benefits to students' clinical skills.
| S-EPMC5785190 | biostudies-literature
Project description:Around 42,000 children suffer from severe sepsis each year in the US alone, resulting in significant morbidity, mortality and billion dollar expenditures in the US healthcare system. Sepsis recognition is a clinical challenge in children. Biomarkers are needed to tailor appropriate antimicrobial therapies and improve risk stratification. The goal of this study was to determine if gene expression profiles from peripheral blood were associated with pathogen type and sepsis severity in children treated for suspected sepsis.
2020-01-01 | GSE119217 | GEO
Project description:BackgroundThe aim of this study was to assess nurses' self-reported confidence in their professional skills before and after an extensive Emergency Department (ED) reform in Kanta-Häme Central Hospital.MethodsEmergency nurses participated in transitional training commencing two years before the establishment of the new organization in 2007. Training was followed by weekly practical educational sessions in the new ED. During this process nurses improved their transition skills, defined house rules for the new clinic and improved their knowledge of new technology and instruments. The main processes involving critically ill ED patients were described and modelled with an electronic flow chart software.During the transitional training nurses compiled lists of practical skills and measures needed in the ED. These were updated after feedback from physicians in primary and secondary care and head physicians in Kanta-Häme Central Hospital. The final 189-item list comprised 15 different categories, each containing from 4 to 35 items. Based on the work described above, a questionnaire was developed to reflect ED nurses' skills in clinical measures but also to estimate the need for professional education and practical training. Nurses working in the ED were asked to fill the questionnaire in January 2007 (response rate 97%) and in January 2011 (response rate 98%).ResultsNurses' self-reported confidence in their professional skills improved significally in eight classes out of fifteen. These classes were cannulations, urinary catheterizations, patient monitoring, cardiac patients, equipment, triage and nurse practising, psychiatric patients as well as infection risk. Best results were noted in urinary catheterizations, patient monitoring and infection risk. When studying the group of nurses participating in both surveys in 2007 and 2011, improvements were observed in all fifteen categories. All but two of these changes were significant (p<0.05).ConclusionsDuring an extensive reform of emergency services, we noted a significant improvement in the professional skills of nurses. This improvement was especially consistent among nurses working in the ED during the whole transition process. Nurses' education and training program in the ED may be successfully put into practice when based on co-operation between nurses and physicians dedicated to emergency services.
| S-EPMC3599318 | biostudies-literature
Project description:Despite technical refinements in urologic oncologic surgery, complications are inevitable and often carry significant morbidity. Similar to oncologic surgery, reconstructive surgery has realized a paradigm shift from mainly open to an increasingly minimally invasive approach. Robotic assisted surgery has facilitated this transition as it mitigates some of the limitations of traditional laparoscopy. With continued technological advances in robotic technology along with improved training and experience, the breadth and complexity of cases expand annually. Few head to head trials exist and data is overall heterogeneous. Herein, we review and summarize the currently available literature describing robotic assisted reconstruction for complications following urologic oncologic procedures.
| S-EPMC8185667 | biostudies-literature
Project description:This study aimed to better understand differences in the total days' supply and fills of common opiates following urologic procedures. The Truven Health MarketScan® database was used to extract CPT codes from adults 18 years or older who underwent a urologic procedure with 90-day follow-up from 2012-2015 within the Austin-Round Rock, Texas metropolitan service area. A multivariate analysis and first hurdle modeling with a logistic outcome for any opiates was used to (1) assess differences in opioid prescribing patterns, (2) investigate opioid prescription outcomes, and (3) explore variability among opiate prescription patterns across seven urologic procedure categories. Among the 2312 patients who met the inclusion criteria, 23.7% received an opiate, with an average total day's supply of 6.20 (range 2.61-10.59). The proportion of patients receiving opiates varied significantly by procedure type (p = 0.028). Patients that had reconstructive procedures had the highest proportion of any opiates and the highest number of mean opiate prescriptions among the seven procedure categories (42% received opiates, p = 0.028, mean opiate prescriptions were 1.0 among all patients, p = 0.026). After adjustments, the multivariate analysis demonstrated that patients undergoing reconstructive procedures filled more opiate prescriptions (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.00-3.50, p = 0.05) compared to other subcategories. Of those that received opiates, reconstructive patients had a shorter time to fills (mean -18.4 days, CI -8.40 to -28.50, p < 0.001). Patients undergoing reconstructive procedures are prescribed and fill more opiates compared to other common urological procedures. The standardization and implementation of postoperative pain regimens may help curtail this variability.
| S-EPMC8911322 | biostudies-literature
Project description: Not available
| S-EPMC10487884 | biostudies-literature
Project description:ObjectiveIn response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider-staffed critical care step-down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations.MethodsWe compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre-CCSU period).ResultsThere were 31,418 critical care ED patient visits in the pre-CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre-CCSU period (∆1 [95% confidence interval (CI) = -2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆-4 [95% CI = -7.8, -0.2] minutes). 72-hour return ED visits also did not change overall (∆0% [95% CI = -0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = -0.05, -0.4]). CPT E&M billing increased for highest-level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]).ConclusionThis ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72-hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider-staffed solution to improvement in critical care in ED.
| S-EPMC7493497 | biostudies-literature
Project description:IntroductionBenefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM).MethodsWe conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel.ResultsThe data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted.ConclusionThis survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use.
| S-EPMC5226751 | biostudies-literature