Just in Time Training (JiTT) is an educational concept that has been easily adapted for EM. Interesting, this educational strategy originates from inventory management. To them, JiTT means: right material, right time, right place, in the exact amount. In educational terms, this means: right educational modality, given to the learner at the right time, at the right location, and exactly the amount needed.
According to mindtools.com, the benefits of JiTT include:
- Low Inventory
- Low Wastage
- High Quality Production
- High Customer Responsiveness
To translate this to educational philosophy:
- Not having to create a ton of educational material
- Low wastage of your time as the educator and your learners’ time
- High quality of delivery of educational material
- Real time engagement of your learners!
How is this put into use?
Right Educational Modality
- Your learner is about to do a central line on an intubated patient. Before they begin the procedure, you both pull up NEJM video vignette on IJ central placement.
- The charge nurse gets notification of a pedestrian struck patient arriving in 15 minutes not intubated. You pull out the manikin head that is stored in the department and quickly review airway anatomy with your resident.
- Your second year resident is about to start an ICU rotation. Prior to starting on Day 1, they are required to watch a 10 minute learning module that was created to review sepsis protocol.
JiTT should be used sparingly. It is not meant to replace traditional learning didactics such as lecture and board review. But it can be used right before the start of an important procedure, or before the start of a difficult rotation as listed in the above examples.
JiTT is perfect to be done by the computer station prior to entering a patient’s room for a procedure. Or it can be done via internet modules from home.
Time and attention is valuable, and very short in supply! The goal of JiTT is to deliver hard impacting educational content in a short amount of time. Greatest amount of educational delivery in a short amount of time. Bam! Educational Gold!
As you can see from above examples, JiTT is the perfect combination of andragogy adult learning theories and asynchronous learning. It also allows educators the option of creativity. You can access great collaborative educational material to be used for your learners in the philosophy of FOAM. Or you can create your own educational material such as practice intubation carts, learning podcasts for your department, or low fidelity models for high risk procedures such as cricothyroidotomy.
Small sample listing of resources that can be used for JiTT in no particular order:
- Right material
- Right time
- Right place
- In the exact amount
Please share successful methods of JiTT that you have used in the past!
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Did you know that there is a section in the Annals of Emergency Medicine that is written by EM residents only? As Annals’ Resident Fellow, I wanted to share a great writing and publishing opportunity with my fellow residents. Many of the residents who have published in this series have gone on to do great things in EM as faculty members.
The Residents’ Perspective section is now in its 16th year. The purpose of the column is to create a forum for the discussion and analysis of topics affecting trainees in EM. They were written as informative instructional pieces, educational research, referenced position papers, or uniquely resident perspectives on current EM topics.
Examples of previous articles
- Meguerdichian DA, Heiner JD, Younggren BN. Emergency medicine simulation: a resident’s perspective. Ann Emerg Med. 2012 Jul;60(1):121-6.
- Morton MJ, Korley FK. Head computed tomography use in the emergency department for mild traumatic brain injury: integrating evidence into practice for the resident physician. Ann Emerg Med. 2012 Sep;60(3):361-7.
- Jones CW, Platts-Mills TF. Understanding commonly encountered limitations in clinical research: an emergency medicine resident’s perspective. Ann Emerg Med. 2012 May;59(5):425-431.e11.
- Reiter DA, Lakoff DJ, Trueger NS, Shah KH. Individual interactive instruction: an innovative enhancement to resident education. Ann Emerg Med. 2013 Jan;61(1):110-3.
- Medlej K, Lewiss R. I’m an emergency medicine resident with a special interest in ultrasonography: should I take a certification examination? Ann Emerg Med. 2011 Nov;58(5):490-3.
- Taira BR. Public health interventions in the emergency department: one resident’s perspective. Ann Emerg Med. 2013 Mar;61(3):326-9.
If you are a current resident in EM and have an idea that you would like to discuss in the Residents’ Perspective section, I’d like invite you to submit an abstract (limit 300 words, double-spaced) outlining the background and significance of the topic to EM residents. Those with novel content will be invited to submit a full manuscript for peer review. The deadline is rolling, and all manuscripts will undergo the same peer review process as all other submissions to Annals.
More information for authors
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Multi-detector computed tomographic pulmonary angiography (CTPA) allows for better visualization of peripheral pulmonary arteries allowing for diagnosis of small peripheral emboli limited to the subsegmental pulmonary arteries. Interestingly as these SSPE’s get diagnosed more and more, two questions come to mind:
- What is the prognostic utility of diagnosing SSPEs?
- What is the morbidity and mortality of SSPEs compared to more proximal PEs?
A recent study in 2013 Blood looked at these questions.
Cohorts for this study? 
- 116/748 (15.5%) of patients had diagnosis of isolated SSPE
- 632/748 (84.5%) of patients had diagnosis of segmental or more proximal PE
- 2,980 patients had PE ruled out by clinical probability and a normal (D-Dimer or CTPA)
Cumulative risk for recurrent venous thromboembolism (VTE) at 3 months? 
- SSPE = 3.6%
- Segmental and More Proximal PE = 2.5%
- PE Ruled-Out at Baseline = 1.1%
- Of note: There was a 99.9% follow-up rate of patients
- SSPE vs Segmental and More Proximal PE did not meet statistical significance
Percentage of patients with bleeding complications associated with treatment of PE? 
- SSPE = 1.7%
- Segmental and More Proximal PE = 1.6%
- SSPE vs Segmental and More Proximal PE did not meet statistical significance
Cumulative mortality risk associated with each cohort? 
- SSPE = 10.7%
- Segmental and More Proximal PE = 6.5%
- PE excluded = 5.4%
- SSPE vs Segmental and More Proximal PE did not meet statistical significance
What were the limitations of the study? 
- Independent radiologists were not used to confirm the diagnosis of SSPE in majority of cases
- The definition of SSPE included both single and multiple SSPEs
- The absolute incidences of recurrent VTE, bleeding complications, and mortality were small
- An underpowered study to detect small changes in outcomes (i.e. SSPE vs Segmental and Proximal PE did not meet statistical significance)
Take Home Points
- SSPE has a similar rate of recurrent VTE at 3 months, bleeding complications from treatment, and mortality when compared to segmental and proximal PEs (no statistical significance among the 3 outcome measures).
- Should we question the conflicting data by Weiner et al stating: “ We have increased the incidence of PE diagnosis with CTPA ,but not changed the mortality risk”? 
P.L. den Exter, J. van Es, F.A. Klok, L.J. Kroft, M.J.H.A. Kruip, P.W. Kamphuisen, H.R. Büller, and M.V. Huisman, "Risk profile and clinical outcome of symptomatic subsegmental acute pulmonary embolism.", Blood, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23736701
R.S. Wiener, L.M. Schwartz, and S. Woloshin, "Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.", Archives of internal medicine, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21555660
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Health-care associated pneumonia (HCAP) is the term used to describe patients presenting with pneumonia who may be at higher risk of multi-drug resistant (MDR) pathogens than other patients presenting from the community due to recent contact with the health care system. What are the criteria for HCAP?
Criteria for HCAP 
- Hospitalization for 2 days or more in the preceding 90 days
- Residence in a nursing home or extended care facility
- Home infusion therapy (including antibiotics and chemo)
- Chronic dialysis within 30 days
- Home wound care
The Seemingly Well-Appearing HCAP Patient
When a patient hits your ED with symptoms consistent with pneumonia and meets criteria for HCAP, you most likely reach for vancomycin plus a broad-spectrum, anti-pseudomonal beta-lactam such as piperacillin/tazobactam. Perhaps you even add on a second gram-negative agent such as a fluoroquinolone or aminoglycoside if you are closely following the old 2005 ATS pneumonia guidelines . In an era where antimicrobial stewardship is becoming increasingly essential to prevent further development of drug resistance, do we need to be hitting all of these seemingly well HCAP patients with ‘gorillacillin?’ A new study in Clinical Infectious Diseases says maybe not .
In this Japanese multicenter, prospective study, the authors attempted to identify low-risk patients with HCAP who might fare just as well with a less aggressive antibiotic regimen such as that for community-acquired pneumonia (CAP). The study took into account criteria for HCAP in conjunction with risk factors for harboring MDR pathogens.
Risk Factors for Multi-drug Resistant Pathogens
- Antimicrobial therapy in preceding 90 days
- Current (recent) hospitalization of 5 days or more
- Poor functional status
- Immunosuppressive disease and/or therapy
Can patients with HCAP with non-severe illness (i.e., not requiring intubation or ICU admission) and <2 risk factors for MDR be deemed as “low risk” and thus can be treated with CAP therapy (respiratory fluoroquinolone or beta-lactam plus macrolide) instead of HCAP guideline-concordant therapy (anti-pseudomonal beta-lactam plus fluoroquinolone or aminoglycoside plus vancomycin or linezolid)?
Following this modified treatment approach where HCAP patients are divided into high-risk (HCAP regimen) versus low-risk (CAP regimen), only 50% received broad-spectrum coverage, yet 93% of regimens were appropriate for the identified pathogen! Of note, atypical organisms were also identified in 10% of the patients with HCAP, which is an interesting finding since empiric HCAP treatment (without the inclusion of a fluoroquinolone) does not cover atypical organisms.
Even more recent data…
A separate group evaluated a retrospective cohort comparing HCAP patients treated with CAP regimens versus HCAP regimens. They found NO increase in clinical cure rates in patients that received HCAP guideline-concordant regimens .
Take home points
- Until the updated guidelines for the management of hospital-acquired and HCAP are released (IDSA’s projected publication is summer 2015), consider using CAP treatment for non-severely ill HCAP patients with < 2 risk factors for MDR pathogens.
- Although CAP treatment regimens provide a narrower spectrum therapy, they do add atypical organism coverage that most HCAP treatment regimens do not.
- If you are giving HCAP treatment regimens, consider also providing atypical coverage (with a respiratory fluoroquinolone or macrolide).
- American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PubMed
- Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: A 2-year prospective multicenter cohort study using risk factors for multidrug resistant pathogens to select initial empiric therapy. Clin Infect Dis 2013;57:1373-83. Pubmed
- Chen J, Slater L, Kurdgelashvili G, Husain K, Gentry C. Treatment with guideline-concordant regimens versus community-acquired pneumonia guideline-concordant regimens for patients admitted to acute care wards from home. Ann Pharmacother 2013;47:9-19. Pubmed
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Emergent airway management and severe sepsis are both high-risk situations that are commonly encountered by emergency physicians. It is well known that complications can be high in both situations, which in turn can lead to increased morbidity and mortality. For instance, about 1/4 of patients who are hemodynamically stable prior to intubation get post-intubation hypotension (PIH) after rapid sequence intubation. Also septic patients may not be reliably identified by systemic inflammatory response syndrome (SIRS) markers early in their disease course. The Shock Index (SI) may be an adjunct that is easy to calculate and could predict both PIH and severe sepsis.
What is Shock Index (SI), and what is a normal value?
- Heart Rate (bpm)/ Systolic Blood Pressure (mmHg)
- Normal Range = 0.5 – 0.7 in healthy adults 
What is the best predictor of PIH during emergency airway management? 
What they did:
- Retrospective cohort study
- 300 patients
- SBP > 90 mmHg, 30 minutes prior to intubation (inclusion criteria)
- 2 groups (PIH vs No PIH)
- PIH defined as SBP < 90 mmHg within 60 minutes of intubation
Primary Outcome: Predictors of PIH after emergency intubation
- PIH occurred in 66/300 (22%) of patients
- Post-intubation cardiac arrest occurred in 8/300 (3%) of patients
- PIH experienced higher in-hospital mortality (35% vs 20%)
- Strongest indicator of PIH: pre-intubation Shock Index (OR 55)
- Shock index ≥ 0.8 predicted PIH with sensitivity 67% and specificity 80%
Predictors of Post-Intubation Hypotension (PIH)
|Preintubation SI||55.1||13 - 232
|End-Stage Renal Disease (ESRD)||3.7||1.1 - 13.1
|Chronic Renal Insufficiency||3.4||1.2 - 9.6
|Intubation for Respiratory Failure||2.1||1.0 - 4.5
|Age||1.03||1.01 - 1.04
- Retrospective study
- Single center, urban tertiary care hospital
- Monitoring was done with non-invasive blood pressure assessment (intermittent monitoring)
Conclusion: Pre-intubation SI ≥ 0.8, strongly and independently predicts PIH after emergency intubation
Can SI predict which sepsis patients have severe sepsis (i.e. elevated lactate) and 28-day mortality? 
What they did:
- Retrospective cohort study
- 2,524 patients
- Screened patients with suspected infection for severe sepsis
- Hyperlactatemia (marker for morbidity)
- 28-day mortality
- 290/2524 (11.5%) had hyperlactatemia
- 361/2524 (14%) died within 28 days
- Shock index (SI) ≥ 0.7 (15.8% of patients) were three times more likely to present with hyperlactatemia vs patients with normal SI (4.9%)
- NPV of SI ≥ 0.7 was 95% (identical to NPV of SIRS)
Performance of Predictors for Hyperlactatemia
SI ≥ 1.0
SI ≥ 0.7
Performance of Predictors for 28-Day Mortality
SI ≥ 1.0
SI ≥ 0.7
- No external validation of study
- Retrospective chart review
- Medication information (i.e. beta blockers) not available
- Elderly cohort with mean age of 73 years
- SI ≥ 0.7 performed as well as SIRS criteria in NPV and was the more sensitive screening test for hyperlactatemia and 28-day mortality
- SI ≥ 1.0 is the most specific predictor of both outcomes
My Final Thoughts
Shock Index (SI) is a quick, easy, and cheap way to predict post intubation hypotension (PIH), hyperlactatemia in sepsis, and 28-day mortality in sepsis, but requires further prospective trials before it is ready for primetime use.
Expert Peer Review
November 25, 2013
One of the critical skills of an Emergency Physician is differentiating “sick vs. not sick.” With training and experience, we develop a gestalt approach to this question. Good clinicians can tell within seconds of being in the room with a patient whether they are sick and need immediate intervention or not. This is how we triage after triage. Vital signs are an important part of this but it’s easy to say that a patient with a heart rate of 140 or a MAP of 45 or an O2 sat of 88% is sick. What’s difficult is the occult ill; those with more subtle signs of “badness.” Tachypnea is often pointed out as one of these more subtle signs because it’s often not counted or reported properly but we all know that a tachypneic patient is one who is or will be in trouble.
This occult or subtlly ill presentation is where shock index (SI) can be helpful. It combines two of our vital signs into one measure. I was taught the utility of this when I was a medical student first rotating in the ED. One of the senior residents picked up a chart of a 25-year-old woman who presented with shortness of breath. Her heart rate was 105 bpm and her blood pressure was 100/60. I remember the resident saying, “this lady is sick. I don’t know why, yet, but I know she is.” The patient ended up having a saddle embolus. When the case was done, we had a 3-minute discussion about SI and its utility.
SI isn’t a new concept
In 1994, Rady et al published a prospective ED study looking at the relationship between an elevated SI and critical illness.1 They found that patients with an SI > 0.9 were more likely to have an illness that required immediate management, admission to the hospital or needed intensive care. Although SI was not very sensitive, specificity was fairly high (admission – 96%, transfer to ICU – 81%). The recent literature cited in the post by Salim furthers this work. Berger and colleagues show that SI can be added to triage criteria to help identify patients with sepsis earlier.2 This is helpful as patients with sepsis often do not meet SIRS based on triage assessment: triage temperature is often inaccurate as it is not a core temp (usually a forehead, mouth or ear – all inaccurate), WBC cannot be immediately assessed and respiratory rate is frequently inaccurately recorded. Rapid sepsis identification is a key to instituting early goal directed therapy and reducing morbidity and mortality. Shock index would be a quick and easy calculation to either build in to triage or for an EP to rapidly perform to assess for sepsis risk.
The use of SI is even more interesting in terms of post-intubation hypotension as put forward by Heffner et al.3 An OR of 55 is a number that should get our attention. How would this change management? Well, the patient isn’t going to get better and walk home if you don’t intubate them. Eventually, their catechoalmines will run out and their pressure will drop. But maybe the SI prompts you to more aggressively fluid load, use a smaller induction agent dose, have push dose vasopressors at the bedside or have your vasopressor drip primed and ready to start as opposed to scrambling to get it set up after the pressure falls.
Limitations abound as Salim points out. Beta-blockers are ubiquitous and will alter presentation and possibly, falsely reassure us (SIRS criteria have the same limitation). Neither of these studies is prospective and both are single center. Additionally, you can imagine that a 19-year-old with pharyngitis could easily have a positive SI simply from fever elevating the heart rate.
My recommendation for using the test is a bit more aggressive than Salim’s. There’s no cost here, no drug company trying to sell us on SI and it’s easily calculated from vital signs we already have. I think it’s reasonable to start using this today and if it’s positive, I would act accordingly. A negative test, though, wouldn’t reassure me.
- Rady MY, Smithline HA, Blake H, Nowak R. A comparison of the shock index and conventional vital signs to identify acute critical illness in the emergency department. Ann Emerg Med 1994; 24: 685-90.
- T. Berger, J. Green, T. Horeczko, Y. Hagar, N. Garg, A. Suarez, E. Panacek, and N. Shapiro. Shock index and early recognition of sepsis in the emergency department: pilot study. WJEM 2013; 14(2): 168-74.
- A.C. Heffner, D.S. Swords, M.L. Nussbaum, J.A. Kline, and A.E. Jones. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care 2012; 27: 587-93.
T. Berger, J. Green, T. Horeczko, Y. Hagar, N. Garg, A. Suarez, E. Panacek, and N. Shapiro, "Shock index and early recognition of sepsis in the emergency department: pilot study.", The western journal of emergency medicine, 2013. http://www.ncbi.nlm.nih.gov/pubmed/23599863
A.C. Heffner, D.S. Swords, M.L. Nussbaum, J.A. Kline, and A.E. Jones, "Predictors of the complication of postintubation hypotension during emergency airway management.", Journal of critical care, 2012. http://www.ncbi.nlm.nih.gov/pubmed/22762924
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The Social Media Index was moved from BoringEM to ALiEM on the morning of Thursday, November 21st. The increased exposure for my previously obscure little prototype got it a lot of attention. By that afternoon Dr. Scott Weingart (@EMCrit) had weighed in with an audio response critical of the index and requested that EMCrit be removed. This set off a lively discussion on Twitter as a good chunk of the FOAM community got in on this important discussion.
This is why an index for FOAM will help learners, educators, and researchers:
This was partly in response to Dr. Weingart’s audio response:
Two Goals for the Social Media Index
As mentioned in my audio response, the two goals I had for the index were to start a conversation and to measure the impact of FOAM in a way that is useful for FOAM learners, educators, and researchers.
Goal 1: This was met during the Twitter conversation three days ago. If you missed it, Tessa Davis (@TessaRDavis) and Teresa Chan (@TChanMD) did a spectacular job of curating the discussion into some consensus points posted today: Lessons Learned from an Impromptu Twitter Consensus Conference on Blog Design.
Goal 2: Some members of the FOAM community argue that the second goal is either not worthwhile or not being met by the index. While I disagree, I do think there is room for improvement. In particular, I think Dr. Weingart’s criticism of the index for using ordinal variables was spot on. I took that feedback into account and revised the index as outlined today on the Social Media Index page.
I expect that in the coming days the FOAM community will continue to weigh in on this topic and we will come up with a standard way to respond to requests to “opt-out” of the index. We look forward to everyone’s responses as we continue to move FOAM forward.
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