Table 1
Block schedule for the 2018–19 CPEM academic year. ACLS: Advanced Cardiac Life Support; ECG: electrocardiogram; ATLS: Advanced Trauma Life Support; FAST: Focused Assessment with Sonography in Trauma; PALS: Pediatric Advanced Life Support; NIHSS: National Institutes of Health Stroke Scale.
| MONTH | TOPIC | KEY SKILLS AND PROCEDURES |
|---|---|---|
| July | Cardiovascular | ACLS, echocardiogram, ECG, pericardiocentesis, central venous catheter placement, ultrasound-guided intravenous line placement, ankle-brachial indices, pulsus paradoxus |
| August | Pulmonary | Intubation, mechanical ventilation, non-invasive positive pressure ventilation, arterial blood gas, chest tube/needle decompression, thoracentesis, lung ultrasound |
| September | Trauma | ATLS, FAST/e-FAST |
| October | Orthopedics, Immunology, Rheumatology, Dermatology | Arthrocentesis, laceration repair, wound care, incision and drainage, procedural sedation, nerve blocks, splinting, joint reduction, soft tissue/musculoskeletal ultrasound, x-ray interpretation |
| November | Renal, Genitourinary, Gynecology | Foley placement, renal/bladder/pelvic ultrasound, lab interpretation (electrolytes) |
| December | Obstetrics, Pediatrics | PALS, emergency delivery, intraosseous line placement, pediatric lumbar puncture, pediatric intravenous access, obstetrical and pediatric ultrasound, pediatric x-ray interpretation |
| January | Gastroenterology | Nasogastric tube placement, paracentesis, abdominal ultrasound |
| February | Neurology | NIHSS, lumbar puncture |
| March | Ophthalmology, Otorhinolaryngology | Slit lamp exam, foreign body removal, peritonsillar abscess drainage, nasal packing, lateral canthotomy, dental block, eye ultrasound |
| April | Hematology, Oncology, Endocrinology | Lab interpretation (hematology and coagulation studies, endocrinology studies) |
| May | Psychiatry, Toxicology | Pharmacology, ECG interpretation |
| June | Infectious Diseases | Antibiotic stewardship, review of ultrasound and procedures |
Table 2
Clinical metrics and outcomes used pre-/post-CPEM implementation. Patients at risk for cardiovascular disease/acute coronary syndrome, sepsis, respiratory disease, and trauma were identified using these parameters and metrics based on prior studies and measures of high-quality emergency care in international guidelines and standards. ECG: electrocardiogram; FAST: Focused Assessment with Sonography in Trauma.
| POPULATION | METRIC | |
|---|---|---|
| All | Mortality | |
| All | Length of stay (LOS) | |
| All | Time-to-evaluation | |
| Risk for Cardiovascular Disease/Acute Coronary Syndrome | Patients ≥40 | Rate of ECG and troponin ordering as well as repeat testing [1920212223] |
| Risk for Sepsis | Patients with a shock index of >0.9 and fever (100.4°F) [192425] | Rate of lactate and blood culture ordering[192425] |
| Risk for Respiratory Disease | Patients with hypoxia (pulse oximetry saturation ≤92%) [1926] | Rate of chest x-ray ordering |
| Risk for Intra-Abdominal Trauma | Patients with chief complaint including trauma, assault, injury, or fall | Rate of FAST exam completion [1927] |
Table 3
Clinical outcomes and metrics pre- and post-CPEM. Two sample proportion tests and two sample t-tests were used to compare years. ECG: electrocardiogram; FAST: Focused Assessment with Sonography in Trauma. *Point-of-care ultrasound (i.e., the FAST exam) was not being performed in IHHN in 2017.
| 2017 | 2019 | p-VALUE | ||
|---|---|---|---|---|
| Population Total | 55,213 | 71,224 | NA | |
| Mean Age (years) | 38.84 (SD 16.94) | 37.99 (SD 16.61) | p < 0.0001 | |
| Sex (F:M) | 0.83:1(25,051 females) | 0.94:1(34,469 females) | p < 0.0001 | |
| Acuity Level(Level P1-P5) | 2.72 (SD 0.70) | 2.85 (SD 0.79) | p < 0.0001 | |
| Mortality | 109 deaths(20/10,000 patients) | 136 deaths(19/10,000 patients) | p = 0.7397 | |
| Length of Stay (hh:mm) | 06:33 (SD 05:40) | 08:21 (SD 06:58) | p < 0.0001 | |
| Time-to-Evaluation (hh:mm) | 00:49 (SD 01:13) | 01:02 (SD 01:23) | p < 0.0001 | |
| Risk for Cardiovascular Disease/Acute Coronary Syndrome | Total at Risk (% of Total Population) | 23,797 (43%) | 28,608 (40%) | p < 0.0001 |
| ECG (% of Total at Risk) | 6,500 (27%) | 8,056 (28%) | p = 0.0314 | |
| Repeat ECG (% of Total with ECG) | 925 (14%) | 1,291 (16%) | p = 0.0027 | |
| Troponin (% of Total at Risk) | 3,155 (13%) | 4,419 (15%) | p < 0.0001 | |
| Repeat Troponin (% of Total with Troponin) | 64 (2%) | 266 (6%) | p < 0.0001 | |
| Risk for Sepsis | Total at Risk (% of Total Population) | 3,872 (7%) | 3,666 (5%) | p < 0.0001 |
| Blood Cultures (% of Total at Risk) | 403 (10%) | 894 (24%) | p < 0.0001 | |
| Lactate (% of Total at Risk) | 117 (3%) | 301 (8%) | p < 0.0001 | |
| Blood Cultures and Lactate (% of Total at Risk) | 58 (1%) | 114 (3%) | p < 0.0001 | |
| Risk for Respiratory Disease | Total at Risk (% of Total Population) | 1,682 (3%) | 2,023 (3%) | p < 0.0001 |
| Chest X-ray (% of Total at Risk) | 953 (57%) | 1,250 (62%) | p = 0.0015 | |
| Risk for Intra-abdominal Trauma | Total at Risk (% of Total Population) | NA* | 2,587 (4%) | NA |
| FAST Exam (% of Total at Risk) | 214 (8%) |
Table 4
Comparison of populations, outcomes, and metrics of CPEM graduates versus other trainees. Two sample proportion tests and two sample t-tests were used to compare cohorts. ECG: electrocardiogram; FAST: Focused Assessment with Sonography in Trauma.
| CPEM | OTHER TRAINEES | p-VALUE | ||
|---|---|---|---|---|
| Population Total | 12,394 | 20,242 | NA | |
| Mean Age (years) | 39.39 (SD 16.83) | 39.52 (SD 17.20) | p = 0.5088 | |
| Sex (F:M) | 0.85:1(5699 female) | 0.88:1(9478 female) | p = 0.1391 | |
| Acuity Level(Level P1-P5) | 2.74 (SD 0.78) | 2.63 (SD 0.79) | p < 0.0001 | |
| Mortality | 32 deaths(26/10,000 patients) | 71 deaths(35/10,000 patients) | p = 0.1478 | |
| Length of Stay (hh:mm) | 06:35 (SD 04:11) | 05:46 (SD 04:38) | p < 0.0001 | |
| Time-to-Evaluation (hh:mm) | 01:06 (SD 01:15) | 01:12 (SD 01:25) | p < 0.0001 | |
| Risk for Cardiovascular Disease/Acute Coronary Syndrome | Total at Risk (% of Total Population) | 5,547 (45%) | 9,054 (45%) | p = 0.9624 |
| ECG (% of Total at Risk) | 1,691 (30%) | 3,249 (36%) | p < 0.0001 | |
| Repeat ECG (% of Total with ECG) | 240 (14%) | 545 (17%) | p = 0.0185 | |
| Troponin (% of Total at Risk) | 903 (16%) | 1,852 (20%) | p < 0.0001 | |
| Repeat Troponin (% of Total with Troponin) | 58 (6%) | 108 (6%) | p = 0.5402 | |
| Risk for Sepsis | Total at Risk (% of Total Population) | 739 (6%) | 1,371 (7%) | p = 0.0039 |
| Blood Cultures (% of Total at Risk) | 140 (19%) | 354 (26%) | p = 0.0004 | |
| Lactate (% of Total at Risk) | 69 (9%) | 135 (10%) | p = 0.7054 | |
| Blood Cultures and Lactate (% of Total at Risk) | 22 (3%) | 52 (4%) | p = 0.3311 | |
| Risk for Respiratory Disease | Total at Risk (% of Total Population) | 483 (4%) | 935 (5%) | p = 0.0019 |
| Chest X-ray (% of Total at Risk) | 283 (59%) | 588 (63%) | p = 0.1153 | |
| Risk for Intra-abdominal Trauma | Total at Risk (% of Total Population) | 517 (4%) | 949 (5%) | p = 0.0287 |
| FAST Exam (% of Total at Risk) | 90 (17%) | 178 (19%) | p = 0.5233 |
Table 5
Comparison of populations, outcomes, and metrics of CPEM graduates versus non-trainees. Two sample proportion tests and two sample t-tests were used to compare the cohorts. ECG: electrocardiogram; FAST: Focused Assessment with Sonography in Trauma.
| CPEM | NON-TRAINEES | p-VALUE | ||
|---|---|---|---|---|
| Population Total | 12,394 | 31,811 | N/A | |
| Mean Age (years) | 39.39 (SD 16.83) | 36.70 (SD 16.16) | p < 0.0001 | |
| Sex (F:M) | 0.85:1(5,699 female) | 1.24:117,334 (female) | p < 0.0001 | |
| Acuity Level (Level P1-P5) | 2.74 (SD 0.78) | 2.82 (SD 0.68) | p < 0.0001 | |
| Mortality | 32 deaths (26/10,000 patients) | 33 deaths(10/10,000 patients) | p = 0.0001 | |
| Length of Stay (hh:mm) | 06:35 (SD 04:11) | 06:50 (SD 05:40) | p < 0.0001 | |
| Time-to-Evaluation (hh:mm) | 01:06 (SD 01:15) | 01:04 (SD 01:25) | p = 0.0662 | |
| Risk for Cardiovascular Disease/Acute Coronary Syndrome | Total at Risk (% of Total Population) | 5,547 (45%) | 11,351 (36%) | p < 0.0001 |
| ECG (% of Total at Risk) | 1,691 (30%) | 3,105 (27%) | p < 0.0001 | |
| Repeat ECG (% of Total with ECG) | 240 (14%) | 503 (16%) | p = 0.0665 | |
| Troponin (% of Total at Risk) | 903 (16%) | 1,660 (15%) | p = 0.0049 | |
| Repeat Troponin (% of Total with Troponin) | 58 (6%) | 98 (6%) | p = 0.5993 | |
| Risk for Sepsis | Total at Risk (% of Total Population) | 739 (6%) | 1539 (5%) | p < 0.0001 |
| Blood Cultures (% of Total at Risk) | 140 (19%) | 400 (26%) | p = 0.0002 | |
| Lactate (% of Total at Risk) | 69 (9%) | 97 (6%) | p = 0.0091 | |
| Blood Cultures and Lactate (% of Total at Risk) | 22 (3%) | 40 (3%) | p = 0.5239 | |
| Risk for Respiratory Disease | Total at Risk (% of Total Population) | 483 (4%) | 593 (2%) | p < 0.0001 |
| Chest X-ray (% of Total at Risk) | 283 (59%) | 379 (63%) | p = 0.744 | |
| Risk for Intra-abdominal Trauma | Total at Risk (% of Total Population) | 517 (4%) | 1,042 (3%) | p < 0.0001 |
| FAST Exam (% of Total at Risk) | 90 (17%) | 58 (7%) | p < 0.0001 |
Table 6
Relative risk of death with age, sex, and acuity as covariates using multinomial logistic regression.
| PRE- AND POST-IMPLEMENTATION OF CPEM | |||
|---|---|---|---|
| Risk of Year (2019, relative to 2017) | 0.587 | 0.452–0.763 | p < 0.0001 |
| PHYSICIAN GROUP ANALYSIS | |||
| Risk of CPEM Graduates versus Other Trainees | 0.844 | 0.553–1.289 | p = 0.432 |
| Risk of CPEM Graduates versus Non-Trainees | 1.298 | 0.783–2.154 | p = 0.312 |