Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Acad Emerg Med. 2011 Oct;18 Suppl 2:S92-6. doi: 10.1111/j.1553-2712.2011.01170.x.
Despite an increasing number of elderly emergency department (ED) patients, emergency medicine (EM) residency training lacks geriatric-specific curricula. The objective was to determine if a 1-year geriatric curriculum, designed for residents, would affect residents' attitudes, knowledge, and decision-making for older patients seen in the ED.
The authors created a geriatric curriculum for EM residents composed of six lectures on the following topics: trauma, abdominal pain, transitions of care, medication management, iatrogenic injuries, and confusional states. A second component of the curriculum included seven high-fidelity simulation skills training sessions on aortic aneurysm, salicylate toxicity, drugs of abuse, infection from a posterior pressure ulcer, medication-induced elevated prothrombin time resulting in gastrointestinal bleeding, mesenteric ischemia, and myocardial infarction. Before and after completion of the curriculum, residents were assessed on attitudes toward caring for geriatric patients using a validated survey and knowledge of geriatric principals of care using a 35-question multiple choice test. To determine differences before and after the new curriculum was implemented, the paired t-test was performed on knowledge and attitude scores. ED records were also reviewed for frequency of chemical sedation and urinary catheter placement in patients aged 65 and over, both before and after the educational intervention, as a measure of appropriate decision-making. Appropriateness of urinary catheter placement was determined by two physician reviewers using criteria adapted from the Centers for Disease Control and Prevention indications for appropriate urinary catheter use. Reviewers met to adjudicate any disagreements about appropriateness. Fisher's exact test was used to examine differences in frequency of chemical sedation and urinary catheter placement.
Twenty-nine EM residents underwent the training. There was no measured change in attitudes. Knowledge improved from the pre- to posttest with average scores of 58.5 and 68.0%, respectively (p < 0.0001), among the 25 residents who completed both tests. There was no change in the percentage of elderly patients receiving chemical sedation and urinary catheters before and after the curriculum (5.4% vs. 4.5%, p = 0.47; and 7.4% vs. 5.9%, p = 0.3, respectively). The number of inappropriate urinary catheters placed significantly decreased after the curriculum, from 8 of 49 to 1 of 47 (16.3% vs. 2.1%, p = 0.03).
Geriatric educational curricula for EM residents may positively affect knowledge base and appropriate decision-making when working with older adults in the ED. These educational enhancements may place elderly patients at less risk of adverse outcomes.
尽管急诊科（ED）的老年患者人数不断增加，但急诊医学（EM）住院医师培训缺乏老年病学的具体课程。本研究旨在确定针对住院医师设计的为期 1 年的老年病学课程是否会影响住院医师对 ED 老年患者的态度、知识和决策。
作者为 EM 住院医师创建了一门老年病学课程，内容包括六个关于以下主题的讲座：创伤、腹痛、照护交接、药物管理、医源性损伤和意识混乱状态。课程的第二个组成部分包括七个高保真模拟技能培训课程，内容涉及主动脉瘤、水杨酸盐毒性、药物滥用、来自后部压疮的感染、药物引起的凝血酶原时间升高导致胃肠道出血、肠系膜缺血和心肌梗死。在完成课程前后，使用经过验证的调查评估住院医师对照顾老年患者的态度，并使用 35 个多项选择题测试评估对老年护理原则的了解程度。为了确定新课程实施前后的差异，对知识和态度评分进行了配对 t 检验。还回顾了 ED 记录，以评估在接受教育干预前后 65 岁及以上患者接受化学镇静和导尿的频率，作为适当决策的衡量标准。导尿的适当性由两名医生评审员使用改编自疾病控制和预防中心适当导尿适应证的标准来确定。评审员开会解决了关于适当性的任何分歧。使用 Fisher 确切检验来检查化学镇静和导尿放置频率的差异。
29 名 EM 住院医师接受了培训。态度没有明显变化。知识从预测试到后测试都有所提高，分别为 58.5%和 68.0%（p<0.0001），在完成这两个测试的 25 名住院医师中。在课程前后，接受化学镇静和导尿的老年患者比例没有变化（分别为 5.4%对 4.5%，p=0.47；7.4%对 5.9%，p=0.3）。课程后，不合适的导尿管放置数量显著减少，从 49 例中的 8 例降至 47 例中的 1 例（16.3%对 2.1%，p=0.03）。
针对 EM 住院医师的老年病学教育课程可能会积极影响在 ED 中与老年人合作时的知识库和适当决策。这些教育强化措施可能会降低老年患者发生不良后果的风险。
