RELIABILITY OF AND THE RELATIONSHIP BETWEEN ULTRASOUND MEASUREMENT AND THREE CLINICAL ASSESSMENTS OF HUMERAL TORSION

Purpose/Background:

Differences in humeral torsion have been observed between overhead athletes and non‐athletes. Although humeral torsion may be an adaptive process for athletic performance, it may be associated with injury. Methods for measuring humeral torsion have consisted of radiography, computer tomography, and ultrasound imaging. However, diagnostic imaging may be costly and not available to all clinicians. The implementation of clinical assessments may be an alternative way to measure humeral torsion. Before clinical measures can be recommended, these assessments need to be evaluated for validity and reliability of each test. The purpose of this study was to assess the intratester and intertester reliability of three clinical tests, intratester reliability of ultrasound measures, and the validity of each clinical test to ultrasound measures.

Methods

Thirty participants (male: 12, female: 18; age: 20±2 years; height: 174.24±9.35 cm; mass: 70.53±11.06 kg; body mass index: 23.13±2.47 kg/m²; years in sport: 9±4 years) with experience in overhead sports were assessed for humeral torsion, bilaterally. Humeral torsion was assessed using musculoskeletal ultrasound by a single assessor, and using three separate clinical assessments by two independent assessors. Clinical assessments included the angle of rotation during both the bicipital tuberosity palpation with the shoulder abducted at 90 degrees (Palp90) or 45 degrees (Palp45), and the angle of external rotation during horizontal adduction (HADD).

Results

Intratester reliability for the ultrasound measure was good (ICC=0.907), along with intratester reliability for both assessors across each clinical assessment (ICC''s > 0.769). Poor to moderate reliability was observed between assessors for each clinical assessment (ICC=0.256 Palp90, ICC=0.419 Palp45, ICC=0.243 HADD. Only the Palp90 measure had a fair but significant (r=0.326, p=0.011) relationship with ultrasound measures.

Conclusion

Individual assessors can achieve reliable ultrasound, bicipital tuberosity palpation and HADD values across multiple trials; however, these measures are not consistent between assessors. Additionally, only one clinical test had a fair but significant relationship with ultrasound measures. Improved testing procedures may be needed to increase between assessor reliability and strength of relationships to ultrasound measures. Current application of clinical assessments to measure humeral torsion is limited.

Level of Evidence:

3b; Grade of Recommendation C     

Effect of Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain

Objective

To study the immediate effects of interferential current stimulation (IFC) on shoulder pain and pain-free passive range of motion (PROM) of the shoulder in people with hemiplegic shoulder pain (HSP).

Design

Double-blind, placebo-controlled clinical trial.

Setting

Institutional physical therapy clinic, neurologic rehabilitation center.

Participants

A population-based sample of people with HSP (N=30) was recruited.

Intervention

Participants were divided into 2 groups—an IFC group and a placebo group—by using a match-paired method (age, sex, and Brunnstrom motor recovery stage). In the IFC group, participants received IFC for 20 minutes with an amplitude-modulated frequency at 100Hz in vector mode. The current intensity was increased until the participants felt a strong tingling sensation.

Main Outcome Measures

Pain intensity and pain-free PROM of the shoulder until the onset of pain were measured at baseline and immediately after treatment.

Results

Participants reported a greater reduction in pain during the most painful movement after treatment with IFC than with placebo (P<.05). The IFC group showed a greater improvement in posttreatment pain-free PROM than the placebo group in shoulder flexion (P<.01), abduction (P<.01), internal rotation (P<.01), and external rotation (P<.01).

Conclusions

This study provides evidence that IFC is effective for the relief of pain during movement and also increases the pain-free PROM of the shoulder in people with HSP.     

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.     

Pulsed Electromagnetic Field and Exercises in Patients With Shoulder Impingement Syndrome: A Randomized,Double-Blind,Placebo-Controlled Clinical Trial

Objective

To evaluate the effects of pulsed electromagnetic field (PEMF) and exercises in reducing pain and improving function and muscle strength in patients with shoulder impingement syndrome (SIS).

Design

Double-blind, randomized controlled trial with a 3-month posttreatment follow-up.

Setting

Outpatient rehabilitation of a public hospital.

Participants

Patients (N=56) between 40 and 60 years of age, with a diagnosis of SIS, were randomly assigned to receive active PEMF (n=26; mean age, 50.1y) or placebo PEMF (n=30; mean age, 50.8y).

Interventions

After 3 weeks of active or placebo PEMF, both groups performed the same program of exercises that focused on shoulder strengthening.

Main Outcome Measures

A visual analog scale, the University of California/Los Angeles shoulder rating scale, the Constant-Murley shoulder score, and handheld dynamometry for muscle strength were used as outcome measures at baseline (pretreatment), at 3 weeks (after active or placebo PEMF), at 9 weeks (postexercise), and at 3 months posttreatment.

Results

Patients in the active PEMF group had a higher level of function and less pain at all follow-up time frames compared with baseline (P<.05). However, the placebo PEMF group had increased function and reduced pain only at the 9-week and 3-month follow-ups (P<.05)—that is, after performing the associated exercises. For the shoulder dynamometry, the active PEMF group had increased strength for lateral rotation at 9 weeks (P<.05), and increased strength for medial rotation at 9 weeks and 3 months (both P<.05) when compared with baseline. There was no significant difference for shoulder strength in the placebo PEMF group (P>.05), as well as no significant differences (P>.05) for all outcome measures.

Conclusions

The combination of PEMF and shoulder exercises is effective in improving function and muscle strength and decreasing pain in patients with SIS. However, these results should be carefully interpreted because of the lack of differences between groups.     

Measurement of lower limb volume: Agreement between the vertically oriented perometer and a tape measure method

Objective

To investigate the agreement between lower limb volume measurements for the vertically oriented perometer and a tape measure method.

Design

Between-methods agreement and test–retest reliability study.

Setting

University setting.

Participants

Thirty university staff and students were recruited using convenience sampling with no participant drop-outs.

Interventions

All participants’ dominant lower limb volumes were measured using the vertically oriented perometer and a tape measure method.

Main outcome measures

The Bland–Altman difference plot was reported for determining the bias between the two methods and its 95% confidence interval. Test–retest reliability and the measurement error for the perometer method were determined using the ICC(2,1) model and within-subject standard deviation (s_w) respectively.

Results

There was a lack of agreement between the tape measure and perometer method. The Bland–Altman difference plot showed that the tape measure method overestimated limb volume by 157 ml compared to the perometer method. A 95% confidence interval of −834 ml to 519 ml was observed. The test–retest reliability of the perometer method was ICC(2,1) = 0.99. The measurement error of the perometer method was clinically acceptable (s_w = 121 ml).

Conclusions

There was a lack of agreement between the two methods investigated. Therefore the perometer and tape measure methods are not interchangeable. It is recommended that future validity and reliability studies for the vertically oriented perometer are conducted on clinical populations.     

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.     

Interobserver agreement rate of the spontaneous breathing trial

Purpose

During the mechanical ventilation weaning process, the spontaneous breathing trial (SBT) is the confirmatory test of patients' capability to breathe unassisted. However, the SBT interobserver agreement rate (its reliability) is unknown, and our objective was to evaluate it.

Materials and Methods

This is a prospective, multicentric and observational study. Patients were included when the SBT criteria were fulfilled. Two physicians and 2 respiratory therapists (RTs) rated each SBT. The SBT interobserver agreement was measured using κ statistic and also the percentage of agreement with its 95% credible interval (CrI) calculated by a Bayesian inference.

Results

Ninety-three distinct physicians and 91 distinct RTs rated 130 SBTs. The κ coefficient was 0.46 for physicians and 0.57 for RT, indicating a moderate interobserver agreement rate. The percentage of agreement was 87.7% between physicians (95% CrI, 81.0%-92.3%) and 86.2% between RT (95% CrI, 79.2%-91.1%). The physicians' and RT' percentage of agreement were not statistically different (P = .71).

Conclusions

The SBT interobserver agreement rate is only moderate for physicians and RT. The percentage of agreement between 2 different SBT observers is 79.2% to 92.3%. Therefore, a relevant percentage of patients will have different extubation decisions depending on the SBT observer.     

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.     

The feasibility of measuring joint angular velocity with a gyro-sensor

Arai T, Obuchi S, Shiba Y, Omuro K, Nakano C, Higashi T. The feasibility of measuring joint angular velocity with a gyro-sensor.

Objectives

To determine the reliability of an assessment of joint angular velocity using a gyro-sensor and to examine the relationship between ankle angular velocity and physical functions.

Design

Cross-sectional.

Setting

Kinesiology laboratory.

Participants

Twenty healthy young adults (mean age, 22.5y) and 113 community-dwelling older adults (mean age, 75.1y).

Interventions

Not applicable.

Main Outcome Measures

Maximal ankle joint velocity was measured using a gyro-sensor during heel-rising and jumping with knee extended. The intraclass correlation coefficient (ICC) was used to determine the intertester and intratester reliability. The Pearson correlation coefficient was used to examine the relationships between maximal ankle joint velocity and isometric muscle strength and isokinetic muscle power in young adults and also to examine the relationships between maximal ankle joint velocity and functional performance measurements such as walking time in older adults.

Results

High reliability was found for intertester (ICC=.96) and intratester reliability (ICC=.96). The data from the gyro-sensor highly correlated with muscle strength (r range, .62−.68; P<.01) and muscle power (r range, .45−.79; P range, .01−.05). In older subjects, mobility functions significantly correlated with the angular velocity of ankle plantarflexion.

Conclusions

Measurement of ankle angular velocity using a gyro-sensor is both reliable and feasible, with the results representing a significant correlation to muscle power and performance measurements.     

Delirium assessment using Confusion Assessment Method for the Intensive Care Unit in Chinese critically ill patients

Purpose

The aim of this study was to provide a method for delirium evaluation in simplified Chinese for patients speaking this language via validation of a translation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

Materials and Methods

Two phases were conducted including initial reliability testing (phase I) of the Attention Screening Exam (ASE) followed by reliability and validity testing of the CAM-ICU (phase II). To analyze the reliability of the ASE, each patient was assessed sequentially by ASE Visual and ASE Auditory. The patients were assessed by 2 nurse investigators using CAM-ICU and 1 neurologist using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition separately within 2 hours in the second phase.

Results

We found that the agreement between ASE Visual and ASE Auditory was high (κ = 0.83, P < .01, respectively). The educational level of the patients influenced the results of the inattention assessment, with the lower educational level of the patient yielding lower agreement on ASE. Even still, the κ consistencies were all above 0.61. The sensitivities of CAM-ICU were 91.8% and 93.4%, and the specificities were 90.8%and 87.7%, respectively. The interrater reliability of 2 nurse investigators was very high, with κ coefficient of 0.92 (P < .001).

Conclusions

This study affirmed the validity and reliability against reference raters using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition of a brief nursing-conducted method of diagnosing delirium in ICU patients who speak simplified Chinese using the CAM-ICU.     

The diagnosis of myocardial infarction in critically ill patients: An agreement study

Purpose

The aim of the study was to assess agreement among 4 intensivists in diagnosing myocardial infarction (MI) in critically ill patients based on screening electrocardiograms (ECGs) and cardiac troponin (cTn) levels.

Methods

Consecutive patients admitted to a medical-surgical intensive care unit (ICU) underwent systematic screening with 12-lead ECGs and cTn measurements throughout their ICU stay. Independently, 4 raters interpreted the ECGs assessing for changes indicative of ischemia and then classified each patient as to whether they met diagnostic criteria for MI based on the screening cTn measurements and ECG results. A priori, 2 raters were designated the primary adjudicators, and their consensus was used as the reference for the agreement statistics. Agreement on MI diagnosis was calculated for the 4 raters and expressed as raw agreement, κ (chance-corrected agreement) and ? (chance-independent agreement, calculated using pairs).

Results

Among 103 enrolled patients, 37 (35.9%) had MI according to the primary adjudicators. The raw agreement for diagnosing MI was 79% (substantial), κ was 0.24 (fair), and ? ranged from 0.12 to 0.73 (slight to substantial).

Conclusions

Diagnosing MI in the ICU remains a challenge due to variable agreement in 12-lead ECG interpretation. Such variation in practice may contribute to underrecognition of MI during critical illness.     

Initial interrater reliability for a novel measure of patient mobility in a cardiovascular intensive care unit

Purpose

The purpose of this study was to determine the interrater reliability of the Perme Intensive Care Unit Mobility Score.

Materials and methods

This was a prospective observational study. Data were collected from 20 patients admitted in a cardiovascular intensive care unit. The interrater reliability was tested using the intraclass correlation coefficient with 95% confidence interval and the Cohen κ coefficient of 0.9, using a 2-tailed α of .05 to provide a 90% power.

Results

The 15 items of the Perme ICU Mobility Score were individually analyzed. Interrater reliability (Cohen κ coefficient) for items 2, 3, 5, 6, 7, 8, 13, and 15 was 1.0000; for item 1, 0.8276; item 4, 0.8000; item 9, 0.6000; item 10, 0.7297; item 11, 0.7260; item 12, 0.7872; and item 14, 0.9048; the intraclass correlation coefficient (95% confidence interval) was 0.9880 (0.97743-0.99859).

Conclusions

The Perme ICU Mobility Score is a reliable tool to assess mobility status of patients admitted to the cardiovascular intensive care unit in a specific moment in time, which can be an important tool for research and clinical practice.     

Emergency Department Management of Shoulder Dystocia

Background

Precipitous obstetric deliveries can occur outside of the labor and delivery suite, often in the emergency department (ED). Shoulder dystocia is an obstetric emergency with significant risk of adverse outcome.

Objective

To review multiple techniques for managing a shoulder dystocia in the ED.

Discussion

We review various techniques and approaches for achieving delivery in the setting of shoulder dystocia. These include common maneuvers, controversial interventions, and interventions of last resort.

Conclusions

Emergency physicians should be familiar with multiple techniques for managing a shoulder dystocia to reduce the chances of fetal and maternal morbidity and mortality.     

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.     

The Reliability of Measuring Pain Distribution and Location Using Body Pain Diagrams in Patients With Acute Whiplash-Associated Disorders

Objective

The objective of this study was to measure the interexaminer reliability of scoring pain distribution using paper and electronic body pain diagrams in patients with acute whiplash-associated disorder and to assess the intermethod reliability of measuring pain distribution and location using paper and electronic diagrams.

Methods

We conducted an interexaminer reliability study on 80 participants recruited from a randomized controlled trial on the conservative management of acute grade I/II whiplash-associated disorder. Participants were assessed for inclusion/exclusion criteria by an experienced clinician. As part of the baseline assessment, participants independently completed paper and electronic pain diagrams. Diagrams were scored independently by 2 examiners using the body region method. Interexaminer and intermethod reliability was computed using intraclass correlation coefficients (ICCs) for pain distribution and κ coefficient for pain location. We used Bland-Altman plots to compute limits of agreement.

Results

The interexaminer reliability was ICC = 0.925 for paper and ICC = 0.997 for the electronic body pain diagram. The intermethod reliability for measuring pain distribution ranged from ICC = 0.63 to ICC = 0.93. For pain location, the intermethod reliability varied from κ = 0.23 (posterior neck) to κ = 0.90 (right side of the face).

Conclusions

We found good to excellent interexaminer reliability for scoring 2 versions of the body pain diagram. Pain distribution and pain location were reliably and consistently measured on body pain diagrams using paper and electronic methods; therefore, clinicians and researchers may choose either medium when using body pain diagrams.     

Nonsteroidal Anti-Inflammatory Drugs Versus Corticosteroid for Treatment of Shoulder Pain: A Systematic Review and Meta-Analysis

Objective

To compare the treatment efficacy between corticosteroid injection and nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with shoulder pain.

Data Sources

PubMed and EMBASE databases were searched from inception to January 2014. Reference lists of the retrieved studies were additionally scrutinized.

Study Selection

Randomized controlled trials (RCTs) comparing corticosteroid injection with NSAIDs for treatment of shoulder pain were included. The primary outcome was remission, and the secondary outcomes were pain relief and improvement of range of active abduction. Study selection was conducted by 2 researchers independently. Any disagreements were solved by discussion and confirmed by the third reviewer.

Data Extraction

Two reviewers independently conducted data extraction and the quality assessment. Data regarding patients, intervention, control, and outcomes were extracted from the included trials.

Data Synthesis

Six high-quality RCTs of 267 patients meeting the inclusion criteria were included. For an outcome of remission, NSAIDs were less effective than corticosteroid in 4 or 6 weeks (relative risk, .64; 95% confidence interval, .45–.92). NSAIDs did not significantly differ with corticosteroid in pain relief and improvement of range of active abduction.

Conclusions

Current meta-analysis suggests that NSAIDs are less effective than corticosteroid in achieving remission in patients with shoulder pain at 4 or 6 weeks after treatment. Considering the limited number of studies and small size of each trial, the results should be interpreted with caution, and more high-quality RCTs are encouraged.     

Interrater reliability of hemodynamic profiling of patients with heart failure in the ED

Objective

Hemodynamic profiling (HP) of patients with heart failure (HF) based on clinical assessment of central congestion and peripheral perfusion has been widely used by cardiologists to help guide therapy and determine prognosis but has never been tested or validated in the emergency department (ED). We hypothesized that the interrater reliability of HP in the ED would be good or greater than 0.6.

Methods

Study design. This was a prospective, observational study. Setting. It was conducted in an academic suburban ED with emergency medicine residency. Subjects. A convenience sample of patients presenting to the ED with suspected acute decompensated HF was enrolled. Measures. Demographic and clinical information was collected using standardized data collection forms. Two emergency medicine physicians (masked to each other) evaluated all patients and classified them into 1 of 4 hemodynamic categories based on the presence or absence of central congestion (wet or dry) and peripheral hypoperfusion (cold or warm): warm and dry, warm and wet, cold and dry, and cold and wet. B-type natriuretic peptide levels, objective test of cardiac function, and final cardiologist diagnoses were obtained. Data analysis. Interrater reliabilities for overall hemodynamic profile and individual elements of congestion and perfusion were calculated using κ coefficients.

Results

Sixty-eight patients were enrolled. Their mean age was 72 ± 14 years, 53% were female, and 78% were white. Of the patients, 79% had a final diagnosis of HF. Most patients (>60%) were considered wet and warm. Interrater agreement for HP was 64%, κ = 0.28 (95% confidence interval, 0.01-0.51). Interrater agreement was poor to fair for all elements of congestion and perfusion except peripheral edema (κ = 0.67) and a narrow pulse pressure (κ = 0.66).

Conclusions

Hemodynamic profiling of patients with HF by emergency physicians in the ED is not highly reliable. One in 5 patients thought to have HF in the ED did not have a final diagnosis of HF.     

The inaccuracy of determining overcrowding status by using the National ED Overcrowding Study Tool

Background

Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.

Objective

The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers’ perceptions of ED crowding.

Material and methods

This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.

Results

In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).

Conclusion

Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.     

Within-Day Test-Retest Reliability of the Timed Up & Go Test in Patients With Advanced Chronic Organ Failure

Objective

To investigate the within-day test-retest reliability of the Timed Up & Go (TUG) test in patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and chronic renal failure (CRF).

Design

Cross-sectional.

Setting

Patients' home environment.

Participants

Subjects (N=235, 64% men; median age, 70y [interquartile range, 61–77y]; median body mass index, 25.6kg/m² [interquartile range, 22.8–29.4kg/m²]) with advanced COPD (n=95), CHF (n=68), or CRF (n=72).

Interventions

Not applicable.

Main Outcome Measure

Time to complete the TUG test. Three trials were performed on the same day and by the same assessors. The intraclass correlation coefficient (ICC), kappa coefficient, standard error of measurement, and absolute and relative minimal detectable change (MDC) values were calculated.

Results

Good agreement was observed, in general, for both the total sample and subgroups (COPD, CHF, CRF), with ICC values ranging from .85 to .98, and kappa coefficients from .49 to 1.00. However, statistical improvement occurred in the total sample from the first to the second trial with large limits of agreement (mean difference, −.97s; 95% confidence interval, 3.00 to −4.94s; P<.01). The third trial added little or no information to the first 2 trials. For the total sample, a standard error of measurement value of approximately 1.6 seconds, an absolute value of MDC at the 95% confidence level (MDC_95%) of approximately 4.5 seconds, and a relative value of MDC at the 95% confidence level (MDC_95%%) of approximately 35% were found between the first 2 trials, with similar values found for the subgroups.

Conclusions

The TUG test is reliable in patients with advanced COPD, CHF, or CRF after 2 trials. Values of standard error of measurement and MDC may be used in daily clinical practice with these populations to define what is expected and what represents true change in repeated measures.     

An analysis of the introduction and efficacy of a novel training programme for ERC basic life support assessors

Aim

Existing ERC BLS/AED accreditation procedures allow BLS instructors to assess the capability of BLS/AED providers, without undergoing additional training as an assessor. The reliability of instructor-based assessment has been questioned. This study sought to determine the efficacy of a simple training programme for BLS/AED instructors aimed at standardising assessment decisions.

Methods

An Assessment Training Programme (ATP) which provides additional, assessment-focused tuition for BLS instructors was introduced. Eighteen ERC accredited instructors participated in the study. Nine received standard ERC training (instructors); nine received additional training through the ATP (assessors). The assessment of 73 students’ BLS/AED capabilities was carried out by an assessor, ERC instructor and ERC instructor trainer concurrently. Participants independently completed an ERC assessment form. Decisions for instructors and assessors were compared to the instructor trainers’ decisions; those not agreeing were deemed to be incorrect.

Results

Instructors (49.3%) had lower raw pass rates than assessors (67.1%) and instructor trainers (64.4%). There was a significant difference in overall decisions between instructors and instructor trainers (p = 0.035), and instructors and assessors (p = 0.015). There was no difference between assessors and instructor trainers (p = 0.824). Instructors were more prone to incorrectly failing candidates than assessors (sensitivities of 80.5% and 63.8% respectively, p = 0.077). AED-capability decisions were significantly different from instructor trainers in both the instructor (p = 0.007) and assessor groups (p = 0.031).

Conclusion

BLS instructors incorrectly fail candidates for reasons that should not normally constitute a true assessment failure. The ATP is an effective intervention to reduce false-failure rates and improve compliance with an experienced instructor trainer's decision. Consideration should be made to integrate such programmes into current BLS instructor accreditation procedures.