Hand-carried echocardiography for assessment of left ventricular filling and ejection fraction in the surgical intensive care unit

Purpose

To better define the reliability of left ventricular ejection fraction (LVEF) and left ventricular filling, as determined by either hand-carried ultrasound (HCU) or formal transthoracic echocardiography (TTE), in the critically ill surgical patient.

Materials and Methods

Prospective cross-sectional study of 80 surgical intensive care unit patients with concomitant (<30 minutes apart) formal TTE and clinician-performed cardiac HCU. Visual estimates of LVEF and left ventricular filling (“underfilled” vs “normally filled”) were recorded, both by clinicians performing HCU and fellowship-trained echocardiographers.

Results

Bland-Altman plot analysis of LVEF estimates revealed good interobserver agreement between HCU and formal TTE (% LVEF mean bias, −2.2; with 95% limits of agreement, ±22.1). This was similar to agreement between independent echocardiography observers (% LVEF mean bias, 1.3; with 95% limits of agreement, ±21.0). However, assessments of left ventricular filling demonstrated only fair to moderate interobserver agreement (κ = 0.22-0.40). Of note, a greater percentage of the 5 standard acoustic windows were obtainable using formal TTE (72% vs 56%).

Conclusions

Formal TTE offers no advantage over HCU for determination of LVEF in critically ill surgical patients, even though the former allows for a more complete examination. However, estimations of left ventricular filling only demonstrate fair to moderate interrater agreement and thus should be interpreted with care when used as markers of volume responsiveness.     

Work of breathing during successful spontaneous breathing trial

Objective

The aim of this study was to evaluate the work of breathing (WOB) behavior during a 120-minute successful spontaneous breathing trial (SBT) with T-tube trial, and its predictive value for extubation outcome.

Design

A prospective cohort study.

Setting

2 medical-surgical intensive care units.

Patients

Fifty-one consecutive patients mechanically ventilated for more than 48 hours after a successful SBT were extubated based on the institutional protocol and followed for the occurrence of postextubation respiratory distress during 48 hours.

Measurements and Main Results

All cases were serially monitored during 120 minutes of SBT using the respiratory monitoring system Ventrak 1500 (Medical Novametrix Systems, Wallingford, CT). Successful extubation occurred in 38 (74.5%) of 51 of the sample. Respiratory and hemodynamic parameters, APACHE II score, sex, days on mechanical ventilation, and cause of respiratory failure were unable to predict extubation outcome. The WOB significantly increased during SBT in extubation failure patients (WOB at 1st minute 0.24 ± 0.06 J/L vs WOB at 120th minute = 0.39 ± 0.07 J/L; P < .01) when compared to successfully extubated patients (WOB at 1st minute 0.21 ± 0.08 J/L vs WOB at 120th minute = 0.24 ± 0.11 J/L; P = .12).The WOB variation was able to predict extubation outcome only after the 90th minute of SBT (extubation failure = 0.35 ± 0.08 J/L vs extubation success = 0.22 ± 0.11 J/L; P = .01).

Conclusion

An increase in the WOB could predict extubation failure during a T-tube trial of 120 minutes.     

An assessment of resuscitation quality in the television drama Emergency Room: Guideline non-compliance and low-quality cardiopulmonary resuscitation lead to a favorable outcome?

Objective

Two earlier studies found that outcome after cardiopulmonary resuscitation (CPR) in the television medical drama Emergency Room (ER) is not realistic. No study has yet evaluated CPR quality in ER.

Design

Retrospective analysis of CPR quality in episodes of ER.

Setting

Three independent board-certified emergency physicians trained in CPR and the American Heart Association (AHA) guidelines reviewed ER episodes in two 5-year time-frames (2001–2005 and 2005–2009). Congruency with the corresponding 2000 and 2005 AHA guidelines was determined for each CPR scene.

Patients

None.

Interventions

None.

Main outcome measures

To evaluate whether CPR is in agreement with the specific algorithms of the AHA guidelines. Fisher's exact test and Mann–Whitney-U-test were used to evaluate statistical significance (P < 0.05).

Results

A total of 136 on-screen cardiac arrests occurred in 174 episodes. Trauma was the leading cause of cardiac arrest (56.6%), which was witnessed in 80.1%. Return of spontaneous circulation occurred in 38.2%. Altogether, 19.1% of patients survived until ICU admission, and 5.1% were discharged alive.

Conclusions

Only one CPR scene was in agreement with the published AHA guidelines. However, low-quality CPR and non-compliance with the guidelines resulted in favorable outcomes.     

Reasons underlying interhospital transfers to an academic medical intensive care unit

Purpose

Interhospital critical care transfers are common, yet few studies address the underlying reasons for transfers. We examined clinician and patient/surrogate perceptions about interhospital transfers and assessed their agreement on these transfers.

Materials and methods

This is a mixed-mode survey of 3 major stakeholders in interhospital transfers to an academic medical intensive care unit from August 2007 to April 2008.

Results

Sixty-two hospitals transferred 138 patients during the study period. Response rates varied among stakeholders (accepting physician, 90%; referring physicians, 20%; patients/surrogates, 33%). All 3 groups frequently endorsed quality of care and need for a specific test/procedure as important. Referring hospital reputation and quality were rarely endorsed. Accepting physicians and patients/surrogates substantially agreed on the need for a specific test (κ = 0.70) and increased survival (κ = 0.78) but, otherwise, had fair to poor agreement. Referring physicians and patients/surrogates rarely agreed and sometimes disagreed greater than expected by chance (κ < 0). Physician pairs strongly agreed on the importance of accepting hospital experience (κ = 0.96) but agreed less on patient satisfaction at the referring hospital (κ = 0.37) and referring hospital reputation (κ = 0.35).

Conclusions

Stakeholders do not always agree on the reasons for critical care transfers. Efforts to improve communication are warranted to ensure informed patient choices.     

Benefits of simulation based training for neonatal resuscitation education: A systematic review

Background

Simulation-based training (SBT) is being more frequently recommended for neonatal resuscitation education (NRE). It is important to assess if SBT improves clinical outcomes as neonatal resuscitation aims to improve survival without long-term neurodevelopmental impairment. We aimed to assess the evidence supporting benefits of SBT in NRE.

Method

A systematic review was conducted using the Cochrane methodology. PubMed, Embase, PsycInfo and Cochrane databases were searched. Related abstracts were scanned and full texts of the potentially relevant articles were studied. Randomised controlled trials (RCT) and quasi-experimental studies with controls (non-RCT) assessing SBT for NRE were eligible for inclusion in the review.

Results

Four small studies [three RCT (n = 126) and one non-RCT (n = 60)] evaluated SBT for NRE. Participants included medical students (one RCT and one non-RCT), residents (one RCT) and nursing staff (one RCT). Outcomes included performance in a simulation scenario, theoretical knowledge, and confidence in leading a resuscitation scenario. One RCT favoured simulation [improved resuscitation score (p = 0.016), 2.31 more number of critical actions (p = 0.017) and decreased time to achieve resuscitation steps (p = <0.001)]. The remaining two RCTs and the non-RCT did not find any difference between SBT and alternate methods of instruction. None of the four studies reported clinical outcomes.

Conclusions

Evidence regarding benefits of SBT for NRE is limited. There are no data on clinical outcomes following SBT for NRE. Large RCTs assessing clinically important outcomes are required before SBT can be recommended widely for NRE.     

Low-dose (2-mSv) computed tomography for suspected appendicitis: Applicability in an emergency department

Objectives

To document the level of interobserver agreement and compare the diagnostic performances of emergency physicians and radiologists at interpreting low radiation CT images of acute appendicitis in adolescents and young adults.

Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule

Purpose

The aim of this present study was to compare the diagnostic accuracy and reproducibility of 2 clinical decision rules (the Ottawa Knee Rules [OKR] and Pittsburgh Decision Rules [PDR]) developed for selective use of x-rays in the evaluation of isolated knee trauma. Application of a decision rule leads to a more efficient evaluation of knee injuries and a reduction in health care costs. The diagnostic accuracy and reproducibility are compared in this study.

Methods

A cross-sectional interobserver study was conducted in the emergency department of an urban teaching hospital from October 2008 to July 2009. Two observer groups collected data on standardized case-report forms: emergency medicine residents and surgical residents. Standard knee radiographs were performed in each patient. Participants were patients 18 years and older with isolated knee injuries. Pooled sensitivity and specificity were compared using χ² statistics, and interobserver agreement was calculated by using κ statistics.

Results

Ninety injuries were assessed. Seven injuries concerned fractures (7.8%). For the OKR, the pooled sensitivity and specificity were 0.86 (95% confidence interval [CI], 0.57-0.96) and 0.27 (95% CI, 0.21-0.35), respectively. The PDR had a pooled sensitivity and specificity of 0.86 (95% CI, 0.57-0.96) and 0.51 (95% CI, 0.44-0.59). The PDR was significantly (P = .002) more specific. The κ values for the OKR and PDR were 0.51 (95% CI, 0.32-0.71) and 0.71 (95% CI, 0.57-0.86), respectively.

Conclusion

The PDR was found to be more specific than the OKR, with equal sensitivity. Interobserver agreement was moderate for the OKR and substantial for the PDR.     

Impact of addition of propofol to ED formulary

Study Objectives

Access to propofol remains a challenge for many emergency physicians. This report examines changes in patient care after the introduction of propofol to an emergency department formulary.

Methods

The Procedural Sedation in the Community Emergency Department registry is a prospective multicentered database of community emergency physician–directed procedural sedation cases. Medication selection and patient outcome were compared at a single Procedural Sedation in the Community Emergency Department registry study site before and after credentialing of emergency physicians for the use of propofol. Analysis was done through analysis of variance and χ² test.

Results

Over a 36-month period, 573 patients were entered into the registry from the single study site, 255 before and 318 after propofol introduction. The percentage of propofol use increased from 26% of procedural sedation cases in the first 3 months of availability to 69% in the final 3 months analyzed. Before propofol use, 46% of cases were completed with a single agent compared with after propofol use, in which 66% were completed with a single agent (P < .001). Complications decreased from 9% of patients before propofol use to 3% of patients after propofol use (P < .05), whereas sedation failures decreased from 5.1% to 4.1% (P < .02).

Conclusion

Granted access to propofol, emergency physicians will preferentially use this medication over prior procedural sedation agents with fewer procedural sedation complications and greater procedural success.     

The accuracy of adult limb radiograph interpretation by emergency nurse practitioners: A prospective comparative study

Background

One of the extensions to practice for the emergency nurse practitioner role is to appropriately order and interpret radiographs in the emergency department.

Objective

The aim of the study was to compare the accuracy in interpreting isolated adult limb radiographs between emergency nurse practitioners and emergency physicians.

Design

A prospective comparative study was undertaken.

Setting

Emergency department in a large metropolitan hospital.

Participants

200 adult patients with isolated limb injuries were consented.

Methods

Six emergency nurse practitioners and ten emergency physicians participated. One emergency physician and emergency nurse practitioner independently clinically assessed each patient, determined the need for radiograph and separately recorded their interpretation of the radiograph as either definite fracture, no fracture or possible fracture. A single consultant radiologist reviewed each radiograph and their interpretation was seen as the gold standard. The sensitivity and specificity of emergency physicians and emergency nurse practitioners were calculated. To measure the level of agreement between the two-clinician groups, the weighted Kappa statistic was used.

Results

The sensitivity for the emergency nurse practitioners was 91% and 88% for the emergency physicians. The specificity for the emergency nurse practitioners was 85% and for the emergency physicians 91%. The weighted Kappa on the presence of a fracture between the emergency nurse practitioners and emergency physicians was 0.83.

Conclusions

This study validates the clinical and diagnostic skills of emergency nurse practitioners assessed in the interpretation of isolated adult limb injury radiographs.     

Pediatric upper airway obstruction: Interobserver variability is the road to perdition

Purpose

The purposes of the study are to determine the interobserver variability in the clinical assessment of pediatric upper airway obstruction (UAO) and to explore how variability in assessment of UAO may contribute to risk factors and incidence of postextubation UAO.

Materials

This is a prospective trial in 2 tertiary care pediatric intensive care units. Bedside practitioners performed simultaneous, blinded UAO assessments on 112 children after endotracheal extubation.

Results

Agreement among respiratory therapists, pediatric intensive care nurses, and pediatric intensive care physicians was poor for cyanosis (κ = 0.01) and hypoxemia at rest (κ = 0.14) and fair for consciousness (κ = 0.27), air entry (κ = 0.32), hypoxemia with agitation (κ = 0.27), and pulsus paradoxus (κ = 0.23). When looking at “stridor” and “retractions,” defined using more than 2 grades of severity from the Westley Croup Score, the interrelater reliability was moderate (κ = 0.43 and κ = 0.47, respectively). This could be improved marginally by dichotomizing the presence or absence of stridor (κ = 0.54) or retractions (κ = 0.53). The overall incidence of UAO after extubation (stridor plus retractions) could range from 7% to 22%, depending on how many providers were required to agree.

Conclusions

Physical findings routinely used for UAO have poor interobserver reliability among bedside providers. This variability may contribute to inconsistent findings regarding incidence, risk factors, and therapies for postextubation UAO.     

Liver trauma diagnosis with contrast-enhanced ultrasound: interobserver variability between radiologist and emergency physician in an animal study

Objective

The purpose of our study was to evaluate interobserver variability between the radiologist and emergency physician in detecting blunt liver trauma by conventional and contrast-enhanced ultrasound (US) (CEUS).

Methods

We created 20 sites of blunt liver trauma in rabbits and performed conventional US and CEUS on the animals. A radiologist and an emergency physician independently evaluated the degree of liver trauma. Using contrast-enhanced computed tomography as a reference standard, the diagnostic performance of US and CEUS was calculated. Interobserver variability between radiologist and emergency physician was compared before and after contrast enhancement of US.

Results

Overall sensitivity and specificity for detecting liver trauma on conventional US, regardless of the degree of trauma, were 61.1% and 100% for the radiologist and 50% and 100% for the emergency physician. On CEUS, the sensitivity and specificity were 94.4% and 100% for both the radiologist and emergency physician. The interobserver agreement between emergency physician and radiologist increased from 0.867 to 0.955 after contrast enhancement on US.

Conclusions

Contrast-enhanced US may permit a more accurate diagnosis for liver trauma than conventional US by both the radiologist and emergency physician. Contrast-enhanced US may also reduce interobserver variability for this diagnosis.     

Serial measurements of f/VT can predict extubation failure in patients with f/VT ≤ 105?

Objective

To evaluate is serial measurements of respiratory rate (frequency to tidal volume, f/VT) may predict extubation failure (EF) from mechanical ventilation in patients following a successful spontaneous breathing trial (SBT) with first measurement of f/V_T ≤ 105.

Design

Prospective cohort study.

Setting

Two medical-surgical intensive care units.

Patients

Seventy-three patients ventilated for more than 48 hours after successful SBT were extubated and followed up for postextubation respiratory distress during 48 hours.

Results

Extubation failure occurred in 16 (21.9%) of 73 patients. Factors such as age, sex, Apache II score, days on mechanical ventilation, respiratory failure cause, and hemodynamic or ventilatory parameters did not predict EF. Patients were evaluated during 120 minutes of SBT, and f/V_T was measured at the 1st minute (f/V_T−1), 30th minute (f/V_T−30), and 120th minute (f/V_T−120). The f/V_T−30 increased as compared with f/V_T−1 (79 ± 24 vs 68 ± 30, P = .01) but did not differ from f/V_T−120 (79 ± 44 vs 81 ± 42, P = .79). The f/V_T−1 was lower in successful extubation (ES) as compared with EF patients (62 ± 29 vs 82 ± 15, P = .01), and this difference was unchanged during the trial (f/V_T−30: ES [63 ± 22] vs EF [85 ± 24], P = .02; and f/V_T−120: ES [65 ± 26] vs EF [88 ± 20], P = .01)].

Conclusions

Serial f/V_T measurements during 120 minutes of SBT were unable to detect EF in patients following a successful SBT with initial f/V_T lower than 105.     

Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan

Background

Across the globe, physicians in the emergency department (ED) are subject to violence by patients and visitors. This has been shown to have negative effects on patient care and physician performance.

Study Objectives

This study was conducted to determine the magnitude of the problem in a developing country, to examine the effects of ED violence on physician satisfaction and performance, and to identify underlying etiologies and potential solutions.

Methods and Setting

This nationwide cross-sectional study examined physicians-in-training (n = 675) in the EDs of nine major tertiary care hospitals in Pakistan.

Results

The study reveals a significant problem, with 76.9% of physicians facing verbal (65.0%) or physical (11.9%) abuse from patients or their caretakers in the previous 2 months. Male physicians were more likely than female physicians to be victims of such episodes (p < 0.05), as were physicians who had spent more than 60 h in the ED in the past 2 months (p < 0.0001). Reduced job satisfaction and a decline in the quality of job performance were reported by 40.7% and 44.3% of physicians, respectively. Junior trainee physicians were more likely to report impairment in job performance when compared to their senior colleagues (p = 0.014). Patients’ lack of education, overcrowding in the ED, and lack of coverage by security staff were identified as the major areas that need attention to address the problem.

Conclusion

This study provides further evidence of the global prevalence of the problem, with the first nationwide epidemiological study performed in a developing country.     

Intertester Agreement and Validity of Identifying Lumbar Pain Provocative Movement Patterns Using Active and Passive Accessory Movement Tests

Objective

The purpose of this study was to evaluate the interexaminer agreement and validity of active and passive pain provocation tests in the lumbar spine.

Methods

Two blinded raters examined 36 participants, 18 of whom were asymptomatic and 18 reported subacute nonspecific low back pain (LBP). Two types of pain provocation tests were performed: (1) physiological movements in single (flexion/extension) and, when necessary, combined planes and (2) passive accessory intervertebral movement tests of each lumbar vertebra in prone with the lumbar spine in neutral, flexion, and extension position.

Results

The interobserver agreement in both groups was good to excellent for the identification of flexion (κ = 0.87-1) or extension (κ = 0.65-0.74) as the most painful pattern of spinal movement. In healthy participants, 0% was identified as having a flexion provocative pattern and 8.8% were identified as having an extension provocative pattern. In the LBP group, 20% were identified as having a flexion provocative pattern vs 60% with an extension provocative pattern. The average interexaminer agreement for passive accessory intervertebral movement tests in both groups was moderate to excellent (κ = 0.42-0.83). The examiners showed good sensitivity (0.67-0.87) and specificity (0.82-0.85) to distinguish participants with LBP using this combined examination procedure.

Conclusion

The use of a combination of pain provocative tests was found to have acceptable interexaminer reliability and good validity in identifying the main pain provocative movement pattern and the lumbar segmental level of involvement. These pain provocation tests were able to distinguish participants with LBP from asymptomatic participants and may help clinicians in directing manual therapy treatment.     

Predicting Clinically Significant Changes in Motor and Functional Outcomes After Robot-Assisted Stroke Rehabilitation

Objective

To investigate the predictors of minimal clinically important changes on outcome measures after robot-assisted therapy (RT).

Design

Observational cohort study.

Setting

Outpatient rehabilitation clinics.

Participants

A cohort of outpatients with stroke (N=55).

Interventions

Patients with stroke received RT for 90 to 105min/d, 5d/wk, for 4 weeks.

Main Outcome Measures

Outcome measures, including the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL), were measured before and after the intervention. Potential predictors include age, sex, side of lesion, time since stroke onset, finger extension, Box and Block Test (BBT) score, and FMA distal score.

Results

Statistical analysis showed that the BBT score (odds ratio[OR]=1.06; P=.04) was a significant predictor of clinically important changes in the FMA. Being a woman (OR=3.9; P=.05) and BBT score (OR=1.07; P=.02) were the 2 significant predictors of clinically significant changes in the MAL amount of use subscale. The BBT score was the significant predictor of an increased probability of achieving clinically important changes in the MAL quality of movement subscale (OR=1.07; P=.02). The R² values for the 3 logistic regression models were low (.114−.272).

Conclusions

The results revealed that patients with stroke who had greater manual dexterity measured by the BBT appear to have a higher probability of achieving clinically significant motor and functional outcomes after RT. Further studies are needed to evaluate other potential predictors to improve the models and validate the findings.     

Neutral to positive views on the consequences of nurse prescribing: Results of a national survey among registered nurses,nurse specialists and physicians

Background

Over the last two decades, the number of countries where nurses are legally permitted to prescribe medication has grown considerably. A lack of peer support and/or objections by physicians can act as factors hampering nurse prescribing. Earlier research suggests that physicians are generally less supportive and more concerned about nurse prescribing than nurses are. However, direct comparisons between doctors’ and nurses’ views are scarce and are often based on small sample sizes.

Objectives

To gain insight into the views of Dutch registered nurses (RNs), nurse specialists (with a master's in Advanced Nursing Practice) and physicians on the consequences of nurse prescribing.

Design

Survey study.

Participants

Survey questionnaires were sent to national samples of RNs, nurse specialists and physicians.

Methods

The questionnaire addressed, among others, respondents’ general views on the consequences of nurse prescribing for the quality of care, the nursing and medical professions, and the relationship between the medical and nursing professions.

Results

The net response rate was 66.0% for RNs (n = 617), 28.3% for nurse specialists (n = 375) and 33.7% for physicians (n = 265). It was found that all groups agreed that nurse prescribing benefits nurses’ daily practice and the nursing profession. There were few concerns about negative consequences for physicians’ practice and the medical profession. Nurse specialists gave significantly (P < 0.05) more positive scores on most items than RNs and physicians. We found relatively little difference in views between RNs and physicians. It was only on issues surrounding the quality of care and patient safety that doctors showed more concerns, albeit mild, than RNs and nurse specialists.

Conclusions

RNs, nurse specialists and physicians generally hold neutral to moderately positive views on nurse prescribing. This is beneficial for the implementation and potential success of nurse prescribing in practice, as a lack of peer support and/or objections from physicians can be a hampering factor. However, concerns about the consequences of nurse prescribing for the quality of care and patient safety remain a point for attention, especially among physicians.     

Improvement of Upper Extremity Motor Control and Function After Home-Based Constraint Induced Therapy in Children With Unilateral Cerebral Palsy: Immediate and Long-Term Effects

Objective

To investigate the long-term effects of home-based constraint induced therapy (CIT) on motor control underlying functional change in children with unilateral cerebral palsy (CP).

Design

Randomized controlled trial.

Setting

Home based.

Participants

Children with unilateral CP (N=45; aged 6–12y) were randomly assigned to receive home-based CIT (n=23) or traditional rehabilitation (TR) (n=22).

Interventions

Both groups received a 4-week therapist-based intervention at home. The home-based CIT involved intensive functional training of the more affected upper extremity during which the less affected one was restrained. The TR involved functional unimanual and bimanual training.

Main Outcome Measures

All children underwent kinematic and clinical assessments at baseline, 4 weeks (posttreatment), and 3 and 6 months (follow-up). The reach-to-grasp kinematics were reaction time (RT), normalized movement time, normalized movement unit, peak velocity (PV), maximum grip aperture (MGA), and percentage of movement where MGA occurs. The clinical measures were the Peabody Developmental Motor Scales, Second Edition (PDMS-2), Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and Functional Independence Measure for children (WeeFIM).

Results

The home-based CIT group showed a shorter RT (P<.05) and normalized movement time (P<.01), smaller MGA (P=.006), and fewer normalized movement units (P=.014) in the reach-to-grasp movements at posttreatment and follow-up than the TR group. The home-based CIT group improved more on the PDMS-2 (P<.001) and WeeFIM (P<.01) in all posttreatment tests and on the BOTMP (P<.01) at follow-up than the TR group.

Conclusions

The home-based CIT induced better spatial and temporal efficiency (smoother movement, more efficient grasping, better movement preplanning and execution) for functional improvement up to 6 months after treatment than TR.     

Validity and Interobserver Reliability of Visual Observation to Assess Partial Weight-Bearing

Hurkmans HL, Bussmann JB, Benda E. Validity and interobserver reliability of visual observation to assess partial weight-bearing.

Objective

To determine the validity and interobserver reliability of visual observation to assess partial weight-bearing.

Design

Validation and interobserver reliability study.

Setting

University medical center.

Participants

Patients (N=10) with a total hip arthroplasty operated 1 to 12 months prior to the study referred by 10 physical therapists (5 experienced and 5 inexperienced in training patients in partial weight-bearing).

Interventions

Not applicable.

Main Outcome Measures

The amount of weight-bearing assessed by visual estimation (visual analog scale score) in percentage body weight (BW). Actual weight-bearing (percentage BW) as measured with the Pedar Mobile system. The mean difference (systematic error) between visual estimation and the Pedar system and the SD of the differences (random error) were determined by the limits of agreement (LOA) method with multiple observations per subject. The intraclass correlation coefficient (ICC) was calculated as a measure for the interobserver reliability.

Results

The mean difference ± SD between visual observation and the reference method was -9.5±20.1 percentage BW (95% confidence interval, -24.0 to 5.0 percentage BW) with LOA ranging from -49.8 to 30.8 percentage BW. The ICC was .57. The therapists' experience in partial weight-bearing training had no effect on the mean difference (P=.349) between the 2 methods.

Conclusions

Visual observation is not a valid and reliable method to assess partial weight-bearing.     

Staffing of the ED by non–emergency medicine-trained personnel: the VA experience

Study objective

VA (Veteran's Affairs) emergency departments (EDs) are generally staffed with physicians trained in internal medicine (IM), although recently, a movement has begun toward hiring emergency medicine (EM)-trained staff. At our institution, the ED is staffed by physicians of both specialties. This study examines the frequency of unscheduled return visits to the ED in an effort to compare the quality of emergency care given by physicians trained in IM and EM.

Methods

The record of all visits to a VA hospital ED during a 90-day period were examined, and all those visits resulting in a return ED visit within the 30 subsequent days were noted.

Results

The charts of 2891 consecutive ED patients were examined. The rate of revisits was significantly higher for the IM than for the EM-trained physicians (8.9% vs 5.5%, respectively; P < .001). The IM-trained physicians had a significantly higher rate of admissions upon revisit within 30 days than did the EM-trained physicians (3.5% vs 1.9%, respectively; P = .014). The IM-trained staff had lower initial hospitalization rates than the EM physicians (20% vs 43%, respectively; P < .0001).

Conclusions

The IM-trained physicians were less likely to hospitalize patients, although this can be partially explained by the lower acuity of patients during the hours that they covered. The IM-trained physicians were significantly more likely to have a patient return after discharge and also more likely to have a patient return in need of hospitalization. This may reflect a difference in training for the rapid diagnosis and risk stratification of ED patients.     

English Cross-Cultural Translation and Validation of the Neuromuscular Score: A System for Motor Function Classification in Patients With Neuromuscular Diseases

Objective

To develop and validate an English version of the Neuromuscular (NM)-Score, a classification for patients with NM diseases in each of the 3 motor function domains: D1, standing and transfers; D2, axial and proximal motor function; and D3, distal motor function.

Design

Validation survey.

Setting

Patients seen at a medical research center between June and September 2013.

Participants

Consecutive patients (N=42) aged 5 to 19 years with a confirmed or suspected diagnosis of congenital muscular dystrophy.

Interventions

Not applicable.

Main Outcome Measures

An English version of the NM-Score was developed by a 9-person expert panel that assessed its content validity and semantic equivalence. Its concurrent validity was tested against criterion standards (Brooke Scale, Motor Function Measure [MFM], activity limitations for patients with upper and/or lower limb impairments [ACTIVLIM], Jebsen Test, and myometry measurements). Informant agreement between patient/caregiver (P/C)-reported and medical doctor (MD)-reported NM scores was measured by weighted kappa.

Results

Significant correlation coefficients were found between NM scores and criterion standards. The highest correlations were found between NM-score D1 and MFM score D1 (ρ=−.944, P<.0001), ACTIVLIM (ρ=−.895, P<.0001), and hip abduction strength by myometry (ρ=−.811, P<.0001). Informant agreement between P/C-reported and MD-reported NM scores was high for D1 (κ=.801; 95% confidence interval [CI], .701–.914) but moderate for D2 (κ=.592; 95% CI, .412–.773) and D3 (κ=.485; 95% CI, .290–.680). Correlation coefficients between the NM scores and the criterion standards did not significantly differ between P/C-reported and MD-reported NM scores.

Conclusions

Patients and physicians completed the English NM-Score easily and accurately. The English version is a reliable and valid instrument that can be used in clinical practice and research to describe the functional abilities of patients with NM diseases.