Should we believe emergency department patients self-reported tetanus vaccine status?
AL and RM conceived the study and designed the trial. AL super- vised the conduct of the trial and data collection. AL undertook re- cruitment of organizations and managed the data, including quality control. KN and RM provided statistical advice on study design and analyzed the data; KN chaired the data oversight committee. KN and AL drafted the manuscript, and all authors contributed substan- tially to its revision. KN and AL takes responsibility for the paper as a whole.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2018.09.040.
Kian Niknam
Stanford University School of Medicine, Department of Emergency
Medicine, United States of America
Rakesh Mistry, MD
University of Colorado, Department of Pediatrics, United States of America
Angela Lumba-Brown, MD
Stanford University School of Medicine, Department of Emergency
Medicine, United States of America
Corresponding author at: 900 Welch Road – #350/MC: 5119, Palo Alto,
CA 94304, United States of America.
E-mail addresses: [email protected].
10 September 2018
https://doi.org/10.1016/j.ajem.2018.09.040
References
- Hinson HE, Stein D, Sheth KN. Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med Jan-Feb 2013;28(1):3-11.
- Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992;4(1): 4-10.
- Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents–second edition. Pediatr Crit Care Med 2012;13(Suppl. 1):S1-82. https://doi.org/10.1097/PCC. 0b013e31823f435c.
- Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992;4(1):4-10.
- Berger Pelletier E, Emond M, Lauzier F, Savard M, Turgeon AF. Hyperosmolar therapy in severe traumatic brain injury: a survey of emergency physicians from a large Ca- nadian province. PLoS One 2014;9(4):e95778.
- Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents–second edition. Pediatr Crit Care Med 2012; 13(Suppl. 1):S1-82. https://doi.org/10.1097/PCC.0b013e31823f435c.
- Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, chil- dren, and adolescents–second edition. Pediatr Crit Care Med 2012;13(Suppl. 1): S1-82. https://doi.org/10.1097/PCC.0b013e31823f435c (Epub 2012/01/11, PubMed PMID: 22217782).
- Kerwin AJ, Schinco MA, Tepas 3rd JJ, Renfro WH, Vitarbo EA, Muehlberger M. The use of 23.4% hypertonic saline for the management of Elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma 2009;67(2): 277-82. https://doi.org/10.1097/TA.0b013e3181acc726 [Epub 2009/08/12, PubMed PMID: 19667879].
- Nakagawa K, Chang CW, Koenig MA, Yu M, Tokumaru S. Treatment of refractory intracranial hypertension with 23.4% saline in children with severe traumatic brain injury. J Clin Anesth 2012;24(4):318-23 Epub 2012/05/23 https://doi.org/10.1016/j.jclinane.2011.10.011. [PubMed PMID: 22608588].
- Luu JL, Wendtland CL, Gross MF, Mirza F, Zouros A, Zimmerman GJ, et al. Three- percent saline administration during pediatric critical care transport. Pediatr Emerg Care 2011;27(12):1113-7. https://doi.org/10.1097/PEC.0b013e31823aff59 [PubMed PMID: 22134236, Epub 2011/12/03].
- Brenkert TE, Estrada CM, McMorrow SP, Abramo TJ. Intravenous hypertonic saline use in the pediatric emergency department. Pediatr Emerg Care 2013;29(1):71-3. https://doi.org/10.1097/PEC.0b013e31827b54c3 [Epub 2013/01/04, PubMed PMID: 23283268].
- Luu JL, Wendtland CL, Gross MF, Mirza F, Zouros A, Zimmerman GJ, et al. Three- percent saline administration during pediatric critical care transport. Pediatr Emerg Care 2011;27(12):1113-7. https://doi.org/10.1097/PEC.0b013e31823aff59 [Epub 2011/12/03, PubMed PMID: 22134236].
- Lumba-Brown A, Harley J, Lucio S, Vaida F, Hilfiker M. Hypertonic saline as a therapy for pediatric concussive pain: a randomized controlled trial in the emergency de- partment. Pediatr Emerg Care 2014;30(3):139-45.
- Khanna S, Davis D, Peterson B, Fisher B, Tung H, O’Quigley J, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med 2000;28(4):1144-51 [Epub 2000/ 05/16. PubMed PMID: 10809296].
- Peterson B, Khanna S, Fisher B, Marshall L. Prolonged hypernatremia controls elevated intracranial pressure in head-injured pediatric patients. Crit Care Med 2000;28(4):1136-43 [Epub 2000/05/16. PubMed PMID: 10809295].
- Gonda DD, Meltzer HS, Crawford JR, Hilfiker ML, Shellington DK, Peterson BM, et al. Complications associated with prolonged hypertonic saline therapy in children with elevated intracranial pressure. Pediatr Crit Care Med 2013;14(6):610-20. https:// doi.org/10.1097/PCC.0b013e318291772b [Epub 2013/07/05, PubMed PMID: 23823197].
- Froelich M, Ni Q, Wess C, Ougorets I, Hartl R. Continuous hypertonic saline therapy and the occurrence of complications in neurocritically ill patients. Crit Care Med 2009;37(4):1433-41. https://doi.org/10.1097/CCM.0b013e31819c1933 [Epub
2009/02/27, PubMed PMID: 19242317].
Hartl R, Medary MB, Ruge M, Arfors KE, Ghahremani F, Ghajar J. Hypertonic/ hyperoncotic saline attenuates microcirculatory disturbances after traumatic brain injury. J Trauma 1997;42(5 Suppl):S41-7 [Epub 1997/05/01. PubMed PMID: 9191695].
- Coimbra R, Hoyt DB, Junger WG, Angle N, Wolf P, Loomis W, et al. Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock. J Trauma 1997;42(4):602-6 discussion 6-7. [Epub 1997/04/01, PubMed PMID: 9137245].
- Shein SL, Ferguson NM, Kochanek PM, Bayir H, Clark RS, Fink EL, et al. Effectiveness of pharmacological therapies for intracranial hypertension in children with severe traumatic brain injury-results from an automated data collection system time- synched to drug administration. Pediatr Crit Care Med 2016;17(3):236-45. https://doi.org/10.1097/pcc.0000000000000610.
- Rickard AC, Smith JE, Newell P, Bailey A, Kehoe A, Mann C. Salt or sugar for your in- jured brain? A meta-analysis of Randomised controlled trials of mannitol versus hy- pertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury. Emerg Med J 2014;31(8):679-83. https://doi.org/10.1136/emermed-2013- 202679.
- Li M, Chen T, Chen SD, Cai J, Hu YH. Comparison of equimolar doses of mannitol and hypertonic saline for the treatment of elevated intracranial pressure after trau- matic brain injury: a systematic review and meta-analysis. Medicine (Baltimore) 2015;94(17):e736. https://doi.org/10.1097/md.0000000000000736.
- Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A systematic review of random- ized controlled trials comparing hypertonic sodium solutions and mannitol for trau- matic brain injury: implications for emergency department management. Ann Pharmacother 2016;50(4):291-300. https://doi.org/10.1177/1060028016628893.
- Tsaousi G, Stazi E, Cinicola M, Bilotta F. Cardiac output changes after osmotic therapy in neurosurgical and Neurocritical care patients: a systematic review of the clinical lit- erature. Br J Clin Pharmacol 2018;84(4):636-48. https://doi.org/10.1111/bcp.13492.
- Urbano J, Lopez-Herce J, Solana MJ, Del Castillo J, Botran M, Bellon JM. Comparison of normal saline, hypertonic saline and hypertonic saline colloid resuscitation fluids in an infant animal model of hypovolemic shock. Resuscitation 2012;83(9):1159-65. https://doi.org/10.1016/j.resuscitation.2012.02.003.
- Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents–second edition. Pediatr Crit Care Med 2012; 13(Suppl. 1):S1-82. https://doi.org/10.1097/PCC.0b013e31823f435c.
- Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992;4(1):4-10.
- The joint commission website. https://www.jointcommission.org/about_us/about_ the_joint_commission_main.aspx, Accessed date: 30 August 2018.
- The joint commission website. https://www.jointcommission.org/standards_ information/jcfaqdetails.aspx?StandardsFAQId=1534, Accessed date: 30 August 2018.
- Suttipongkaset P, Chaikittisilpa N, Vavilala MS, Lele AV, Watanitanon A, Chandee T, et al. Blood pressure thresholds and mortality in pediatric traumatic brain injury. Pe- diatrics 2018;142(2). https://doi.org/10.1542/peds.2018-0594.
Should we believe emergency department patients self-reported Tetanus vaccine status?Immunization surveying is the milestone in prevention of diseases and screening for populations at risk yet its reliability needs to be
Received questionnaires N=1542
Patient VS not up-to-date N=121
Included questionnaires N=1535
Tetanus vaccination status (VS) known by
Tetanus vaccination status not known by patient Or not sure to know (N=352)
Excluded questionnaires N=7 (doubles)
Fig. 1. Flow of our study’s tetanus surveying of emergency department patients.
confirmed [1]. No study has assessed the reliability of ED patients’ self-reported immunization status for tetanus. The reliability of self-reported immunization status for tetanus in ED has only been assessed by performing a rapid bed-side tetanus Antibody testing. The lack of description for surveying methodology or reliability could not confer conclusive results [2-5]. We conducted this multicenter, pro- spective study to assess the agreement between self-reported tetanus immunization status and true recorded status (Fig. 1). This was aimed to provide answers to the followings.
- Whether ED patients were capable of truly reporting their immuniza- tion status?
- Whether the validity varied by socio-demographic [6] and tetanus risk factors?
There was a difference in % of self-reported coverage between unemployed patients compared with other socio-economic classes (p = 0.013), yet they were as equally vaccinated (Table 1). Manual workers (farmers, small business employers, blue-collar workers) and non-manual workers (executives, managers, white-collar workers) and students knew their coverage status consistent with other socio-economic classes (p N 0.05). This was inconsistent with the literature [2,3]. This can be explained by the difference in study design and methodology.
Under- and over-reporting of vaccination coverage have been sug- gested to be correlated with some socio-demographic factors [4]. We did not assess ethnic origins and income levels however, unemployed and small business owners under-reported their tetanus coverage (Table 5). We believe that latter socio-economic strata of ED patients could be regarded as low-risk for tetanus.
Some of our results (Tables 2-1, 2-2) were consistent with those by Talan et al. [5]. The immunization rate was lower in the elderly (72.7 in >=70 yo vs. 89.9 in 18-69 yo vs. 95.8 in b18 yo), the unem- ployed (84.6%), the retired (74.5%). No significant difference was ob- served between the manual profession (92.9%) and intellectual profession (92.6%). According to our results, the younger and active population (students and working) strata have better tetanus immu- nization coverage (Table 4). Yet the younger over-reported and the unemployed under-reported their immunization coverage (Table 5) thus could be regarded as high-risk and low-risk ED pa- tients for tetanus, respectively.
Patients self-reported not to be up-to-date, were truly not up-to- date in 61.7% (Table 3). This was consistent with 57.6% truly not up- to-date reported by Talan et al. [5]. Those who self-reported to be up- to-date were truly up-to-date in 96.8%.
Reliability of self-reported vaccination coverage has been reported to be controversial across studies [7-10] most likely due to unsuitable methodology (e.g. not designed for self- reported coverage) and reliability tests (e.g. bedside rapid antibody tests).
Given our good agreement and excellent sensitivity results (Tables 3, 4), this report can be used as a guide to tetanus vaccination practices and follow-up for health care providers. The unemployed, small business owners, the elderly could be regarded as low-risk ED patients for tetanus. The younger than 69 yo could be regarded as high-risk. Moreover, for these strata of ED population, clinicians should take into account the wound severity to decide on administration of tetanus prophylaxis. In the presence of tetanus-prone wound and given the absence of tetanus toxoid or immunoglobulin related adverse side effects clinicians should not
Table 1
ED patient’s self-reported knowledge of tetanus immunization according to patients characteristics and socio-demographic.??
Overall
(N = 1535)
Self-reported to not know tetanus vaccine status
(N = 352)
Self-reported to know tetanus vaccine
status (N = 1183)
p?
Sex
Missing
6 (0.4%)
1 (0.3%)
5 (0.4%)
0.404
Homme
670 (43.8%)
147 (41.9%)
523 (44.4%)
Femme
859 (56.2%)
204 (58.1%)
655 (55.6%)
Age (years old)
N (N missing)
1522 (13
350 (2 missing)
1172 (11 missing)
missing)
Mean +- SD
31.79 +- 24.68
38.74 +- 24.56
29.72 +- 24.34
b0.001
Median (q1;
28.0 (10.0;50.0)
36.1 (21.0;56.8)
24.3 (8.1;48.0)
q3)
Min;max
0;99
0;99
0;92
Age rankings
Missing
13 (0.8%)
2 (0.6%)
11 (0.9%)
b0.001
b18 yo
581 (38.2%)
70 (20.0%)
511 (43.6%)
18-69 yo
807 (53.0%)
236 (67.4%)
571 (48.7%)
>=70 yo
134 (8.8%)
44 (12.6%)
90 (7.7%)
Adult (age N 18 yo)
Missing
13 (0.8%)
2 (0.6%)
11 (0.9%)
b0.001
No
581 (38.2%)
70 (20.0%)
511 (43.6%)
Yes
941 (61.8%)
280 (80.0%)
661 (56.4%)
Seniors (age >= 70 yo)
Missing
13 (0.8%)
2 (0.6%)
11 (0.9%)
0.005
Yes
134 (8.8%)
44 (12.6%)
90 (7.7%)
No
1388 (91.2%)
306 (87.4%)
1082 (92.3%)
Unemployed
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.013
No
776 (93.6%)
226 (90.4%)
550 (95.0%)
Yes
53 (6.4%)
24 (9.6%)
29 (5.0%)
Farmers
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.165
No
814 (98.2%)
243 (97.2%)
571 (98.6%)
Yes
15 (1.8%)
7 (2.8%)
8 (1.4%)
Small business employers
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.332
No
809 (97.6%)
242 (96.8%)
567 (97.9%)
Yes
20 (2.4%)
8 (3.2%)
12 (2.1%)
Executives
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.852
No
801 (96.6%)
242 (96.8%)
559 (96.5%)
Yes
28 (3.4%)
8 (3.2%)
20 (3.5%)
Managers
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.843
No
765 (92.3%)
230 (92.0%)
535 (92.4%)
Yes
64 (7.7%)
20 (8.0%)
44 (7.6%)
White-collar workers
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.068
No
629 (75.9%)
200 (80.0%)
429 (74.1%)
Yes
200 (24.1%)
50 (20.0%)
150 (25.9%)
Blue-collar workers
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.886
No
644 (77.7%)
195 (78.0%)
449 (77.5%)
Yes
185 (22.3%)
55 (22.0%)
130 (22.5%)
Retired
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.653
No
598 (72.1%)
183 (73.2%)
415 (71.7%)
Yes
231 (27.9%)
67 (26.8%)
164 (28.3%)
Students
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.685
No
796 (96.0%)
239 (95.6%)
557 (96.2%)
Yes
33 (4.0%)
11 (4.4%)
22 (3.8%)
Manual profession (Farmers, small business employers, blue-collar
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.531
workers) No
609 (73.5%)
180 (72.0%)
429 (74.1%)
Yes
220 (26.5%)
70 (28.0%)
150 (25.9%)
Intellectual profession (executives, managers, white-collar workers)
Missing
112 (11.9%)
30 (10.7%)
82 (12.4%)
0.111
No
537 (64.8%)
172 (68.8%)
365 (63.0%)
Yes
292 (35.2%)
78 (31.2%)
214 (37.0%)
Place of birth other than France
No
1503 (97.9%)
344 (97.7%)
1159 (98.0%)
0.779
Yes
32 (2.1%)
8 (2.3%)
24 (2.0%)
Immunocompromized status
No
1507 (98.2%)
346 (98.3%)
1161 (98.1%)
0.849
Yes
28 (1.8%)
6 (1.7%)
22 (1.9%)
At risk for tetanus
No
1492 (97.2%)
344 (97.7%)
1148 (97.0%)
0.494
Yes
43 (2.8%)
8 (2.3%)
35 (3.0%)
* Student t-test for quantitative variables; Chi square or Fisher exact-test for qualitative variables.
?? Sociodemographics included only adults and excluded pediatric population.
hesitate to administrate the suitable prophylaxis (e.g. in the low-risk strata).
One strength of our study was its population representing a wide range of ED patient strata (e.g. various age groups, diver so- cioeconomic strata, all comer medical and traumatic indications), in comparison with other reports (i.e. included either adult or pedi- atric population) [3,11-14].
Our ED survey of tetanus coverage is the most recent one in France and the last one before 2013 up-date of the tetanus coverage guidelines (i.e. vaccination reminder injection time interval was prolonged from 10 to 20 years in b65 y.o [15].
Our results were most likely overestimated due to high rate (38%) of children (i.e. better immunization coverage than adults). Our study’s population mean age was much younger (31.8 yo vs.
Self-reported tetanus immunization according to patients characteristics and socio-demographics.??
Table 2-1
Self-reported status
Overall
Not up-to-date
Up-to-date
p?
(N = 1183)
(N = 121)
(N = 1062)
Sex Missing
5 (0.4%)
0 (0.0%)
5 (0.5%)
0.660
Men
523 (44.4%)
56 (46.3%)
467 (44.2%)
Women
655 (55.6%)
65 (53.7%)
590 (55.8%)
Age (years old) N (N missing)
1172 (11 missing)
120 (1 missing)
1052 (10 missing)
Mean +- SD
29.72 +- 24.34
52.79 +- 24.05
27.09 +- 22.96
b0.001
Median (q1;q3)
24.3 (8.1;48.0)
55.9 (38.1;70.6)
20.4 (7.0;43.5)
Min; max
0;92
0;92
0;91
Age rankings Missing
11 (0.9%)
1 (0.8%)
10 (0.9%)
b0.001
b18 yo
511 (43.6%)
12 (10.0%)
499 (47.4%)
18-69 yo
571 (48.7%)
77 (64.2%)
494 (47.0%)
>=70 yo
90 (7.7%)
31 (25.8%)
59 (5.6%)
Adult (age N 18 yo) Missing
11 (0.9%)
1 (0.8%)
10 (0.9%)
b0.001
No
511 (43.6%)
12 (10.0%)
499 (47.4%)
Yes
661 (56.4%)
108 (90.0%)
553 (52.6%)
Seniors (age >= 70 yo) Missing
11 (0.9%)
1 (0.8%)
10 (0.9%)
b0.001
Yes
90 (7.7%)
31 (25.8%)
59 (5.6%)
No
1082 (92.3%)
89 (74.2%)
993 (94.4%)
Unemployed Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.127
No
550 (95.0%)
90 (91.8%)
460 (95.6%)
Yes
29 (5.0%)
8 (8.2%)
21 (4.4%)
Farmers Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.363
No
571 (98.6%)
98 (100.0%)
473 (98.3%)
Yes
8 (1.4%)
0 (0.0%)
8 (1.7%)
Small business employers Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.001
No
567 (97.9%)
91 (92.9%)
476 (99.0%)
Yes
12 (2.1%)
7 (7.1%)
5 (1.0%)
Executives Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.224
No
559 (96.5%)
97 (99.0%)
462 (96.0%)
Yes
20 (3.5%)
1 (1.0%)
19 (4.0%)
Managers Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.023
No
535 (92.4%)
96 (98.0%)
439 (91.3%)
Yes
44 (7.6%)
2 (2.0%)
42 (8.7%)
White-collar workers Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.004
No
429 (74.1%)
84 (85.7%)
345 (71.7%)
Yes
150 (25.9%)
14 (14.3%)
136 (28.3%)
Blue-collar workers Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.008
No
449 (77.5%)
86 (87.8%)
363 (75.5%)
Yes
130 (22.5%)
12 (12.2%)
118 (24.5%)
Retired Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
b0.001
No
415 (71.7%)
44 (44.9%)
371 (77.1%)
Yes
164 (28.3%)
54 (55.1%)
110 (22.9%)
Students Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.036
No
557 (96.2%)
98 (100.0%)
459 (95.4%)
Yes
22 (3.8%)
0 (0.0%)
22 (4.6%)
Manual profession (farmers, small business employers, blue-collar workers) Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
0.106
No
429 (74.1%)
79 (80.6%)
350 (72.8%)
Yes
150 (25.9%)
19 (19.4%)
131 (27.2%)
Intellectual profession (executives, managers, white-collar workers) Missing
82 (12.4%)
10 (9.3%)
72 (13.0%)
b0.001
No
365 (63.0%)
81 (82.7%)
284 (59.0%)
Yes
214 (37.0%)
17 (17.3%)
197 (41.0%)
Place of birth other than France No
1159 (98.0%)
118 (97.5%)
1041 (98.0%)
0.729
Yes
24 (2.0%)
3 (2.5%)
21 (2.0%)
Immunocompromized status No
1161 (98.1%)
117 (96.7%)
1044 (98.3%)
0.272
Yes
22 (1.9%)
4 (3.3%)
18 (1.7%)
At risk for tetanus No
1148 (97.0%)
114 (94.2%)
1034 (97.4%)
0.080
Yes
35 (3.0%)
7 (5.8%)
28 (2.6%)
* Student t-test for quantitative variables; Chi square or Fisher exact-test for qualitative variables.
?? Socio-demographics included only adults and excluded pediatric population.
40 yo) than that of French 2012 census [16]. This age discrepancy can also be explained by the fact that we excluded patients not capable of reporting or recalling past events, i.e. mostly the elderly with cogni- tive disorders. In addition, the imbalance of our sample size across socio-economic strata must have limited the power of some analysis (Tables 2-1, 2-2).
This study puts into light the use of patient surveying (i.e. more time consuming at the least cost) instead of current substantiating tetanus antibody tests with low clinical evidence.
An ED patient self-reporting to be up-to-date is truly in 96.8% of the cases and 95.9% of the patients truly up-to-date, are reliable when self- reporting their tetanus vaccine status. Healthcare providers should
Table 2-2
Confirmed tetanus immunization according to patients characteristics and socio-demographics.???, ??
Checked vaccination status
Overall (N = 1108)
Not up-to-date (N = 98)
Up-to-date (N = 1010)
p?
Sex
Missing
3 (0.3%)
0 (0.0%)
3 (0.3%)
0.497
Men
494 (44.7%)
47 (48.0%)
447 (44.4%)
Women
611 (55.3%)
51 (52.0%)
560 (55.6%)
Age (years old)
Age rankings
N (N missing) Mean +- SD Median (q1;q3) Min;max
Missing
1101 (7 missing)
30.05 +- 24.63
25.0 (7.8;48.8)
0;92
7 (0.6%)
98 (0 missing)
48.53 +- 26.66
52.9 (32.3;69.3)
1;90
0 (0.0%)
1003 (7 missing)
28.24 +- 23.67
23.0 (7.0;45.3)
0;92
7 (0.7%)
b0.001
b0.001
b18 yo
476 (43.2%)
20 (20.4%)
456 (45.5%)
18-69 yo
537 (48.8%)
54 (55.1%)
483 (48.2%)
>=70 yo
88 (8.0%)
24 (24.5%)
64 (6.4%)
Adult (age N 18 yo)
Missing
7 (0.6%)
0 (0.0%)
7 (0.7%)
b0.001
No
476 (43.2%)
20 (20.4%)
456 (45.5%)
Yes
625 (56.8%)
78 (79.6%)
547 (54.5%)
Seniors (age >= 70 yo)
Missing
7 (0.6%)
0 (0.0%)
7 (0.7%)
b0.001
Yes
88 (8.0%)
24 (24.5%)
64 (6.4%)
No
1013 (92.0%)
74 (75.5%)
939 (93.6%)
Unemployed
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.559
No
525 (95.3%)
66 (94.3%)
459 (95.4%)
Yes
26 (4.7%)
4 (5.7%)
22 (4.6%)
Farmers
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.605
No
543 (98.5%)
70 (100.0%)
473 (98.3%)
Yes
8 (1.5%)
0 (0.0%)
8 (1.7%)
Small business employers
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.153
No
540 (98.0%)
67 (95.7%)
473 (98.3%)
Yes
11 (2.0%)
3 (4.3%)
8 (1.7%)
Executives
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.094
No
531 (96.4%)
70 (100.0%)
461 (95.8%)
Yes
20 (3.6%)
0 (0.0%)
20 (4.2%)
Managers
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.090
No
507 (92.0%)
68 (97.1%)
439 (91.3%)
Yes
44 (8.0%)
2 (2.9%)
42 (8.7%)
White-collar workers
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.170
No
412 (74.8%)
57 (81.4%)
355 (73.8%)
Yes
139 (25.2%)
13 (18.6%)
126 (26.2%)
Blue-collar workers
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.008
No
428 (77.7%)
63 (90.0%)
365 (75.9%)
Yes
123 (22.3%)
7 (10.0%)
116 (24.1%)
Retired
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
b0.001
No
390 (70.8%)
29 (41.4%)
361 (75.1%)
Yes
161 (29.2%)
41 (58.6%)
120 (24.9%)
Students
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.152
No
532 (96.6%)
70 (100.0%)
462 (96.0%)
Yes
19 (3.4%)
0 (0.0%)
19 (4.0%)
Manual profession (farmers, small business
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.019
employers, blue-collar workers)
No
409 (74.2%)
60 (85.7%)
349 (72.6%)
Yes
142 (25.8%)
10 (14.3%)
132 (27.4%)
Intellectual profession (executives, managers,
Missing
74 (11.8%)
8 (10.3%)
66 (12.1%)
0.004
white-collar workers)
No
348 (63.2%)
55 (78.6%)
293 (60.9%)
Yes
203 (36.8%)
15 (21.4%)
188 (39.1%)
Place of birth other than France
No
1087 (98.1%)
97 (99.0%)
990 (98.0%)
1.000
Yes
21 (1.9%)
1 (1.0%)
20 (2.0%)
Immunocompromized status
No
1086 (98.0%)
94 (95.9%)
992 (98.2%)
0.122
Yes
22 (2.0%)
4 (4.1%)
18 (1.8%)
At risk for tetanus
No
1073 (96.8%)
90 (91.8%)
983 (97.3%)
0.009
Yes
35 (3.2%)
8 (8.2%)
27 (2.7%)
* Student t test for quantitative variables; Chi square or Fisher exact-test for qualitative variables.
?? Socio-demographics included only adults and excluded pediatric population.
Table 3
Agreement (overall) between self-reported patient status of tetanus immunization and checked vaccination status
Checked vaccination status
Total
Self report to know vaccination status
Up-to-date
Up-to-date 969 (96.8%)
Not up-to-date 32 (3.2%)
1001
Not up-to-date
41 (38.3%)
66 (61.7%)
107
Total
1010
98
1108
Mc Nemar test – p-value Cohen Kappa (CI95%) Sensitivity (CI95%) Specificity (CI95%)
PPV (CI95%) NPV (CI95%)
0.349
0.61 (0.53; 0.69)
95.9 (94.5; 97.1)
67.3 (57.1; 76.5)
96.8 (95.5; 97.8)
61.7 (51.8; 70.9)
Table 4
Agreement between self-reported patient status of tetanus immunization and checked vaccination status according to patient characteristics and socio-demographics
Strats variables
p-value from Mc Nemar test
Kappa (CI95%)
Sensitivity (CI95%)
Specificity (CI95%)
PPV (CI95%)
NPV (CI95%)
Sex
Men (n = 611)
0.430
0.59 (0.48;0.71)
95.9 (93.9;97.4)
66.7 (52.1;79.2)
96.9 (95.1;98.2)
59.7 (45.8;72.4)
Women (n = 494)
0.728
0.62 (0.50;0.74)
96.0 (93.7;97.6)
68.1 (52.9;80.9)
96.6 (94.5;98.1)
64.0 (49.2;77.1)
Age
b18 yo (n = 476)
0.052
0.04 (0.00;0.17)
98.3 (96.6;99.2)
5.0 (0.1;24.9)
95.9 (93.7;97.5)
11.1 (0.3;48.3)
18-69 yo (n = 537)
0.017
0.68 (0.58;0.78)
94.8 (92.5;96.6)
81.5 (68.6;90.8)
97.9 (96.1;99.0)
63.8 (51.3;75.0)
>= 70 yo (n = 88)
0.227
0.70 (0.54;0.87)
87.5 (76.9;94.5)
87.5 (67.6;97.3)
94.9 (85.9;98.9)
72.4 (52.8;87.3)
Unemployed
No (n = 525)
0.008
0.71 (0.62;0.80)
94.1 (91.6;96.1)
84.9 (73.9;92.5)
97.7 (95.9;98.9)
67.5 (56.3;77.4)
Yes (n = 26)
0.625
0.51 (0.10;0.92)
86.4 (65.1;97.1)
75.0 (19.4;99.4)
95.0 (75.1;99.9)
50.0 (11.8;88.2)
Farmers
No (n = 543)
0.004
0.70 (0.61;0.78)
93.7 (91.1;95.7)
84.3 (73.6;91.9)
97.6 (95.7;98.8)
66.3 (55.5;76.0)
Yes (n = 8)
NA
NA
100.0 (63.1;100.0)
NA
100.0 (63.1;100.0)
NA
Small business employers
No (n = 540)
0.014
0.71 (0.62;0.79)
94.3 (91.8;96.2)
83.6 (72.5;91.5)
97.6 (95.7;98.8)
67.5 (56.3;77.4)
Yes (n = 11)
0.250
0.48 (0.05;0.91)
62.5 (24.5;91.5)
100.0 (29.2;100.0)
100.0 (47.8;100.0)
50.0 (11.8;88.2)
Executives
No (n = 531)
0.006
0.70 (0.32;0.79)
93.7 (91.1;95.8)
84.3 (73.6;91.9)
97.5 (95.6;98.8)
67.1 (53.2;76.7)
Yes (n = 20)
NA
NA
95.0 (75.1;99.9)
NA
100.0 (82.3;100.0)
100.0 (2.5;100.0)
Managers
No (n = 507)
0.004
0.69 (0.60;0.78)
93.2 (90.4;95.3)
93.8 (72.9;91.6)
97.4 (95.4;98.7)
65.5 (54.6;75.4)
Yes (n = 44)
NA
1.00 (1.00;1.00)
100.0 (91.6;100.0)
100.0 (15.8;100.0)
100.0 (91.6;100.0)
100.0 (15.8;100.0)
White-collar workers
No (n = 329)
0.001
0.71 (0.61;0.80)
92.7 (89.5;95.2)
87.7 (76.3;94.9)
97.9 (95.8;99.2)
65.8 (54.0;76.3)
Yes (n = 139)
1.000
0.66 (0.44;0.88)
96.8 (92.1;99.1)
69.2 (38.6;90.9)
96.8 (92.1;99.1)
69.2 (38.6;90.9)
Blue-collar workers
No (n = 428)
0.005
0.72 (0.64;0.81)
93.2 (90.1;95.5)
87.3 (76.5;94.4)
97.7 (95.5;99.0)
68.8 (57.4;78.7)
Yes (n = 123)
0.727
0.47 (0.15;0.78)
95.7 (90.2;98.6)
57.1 (18.4;90.1)
97.4 (92.5;99.5)
44.4 (13.7;78.8)
Retired
No (n = 390)
0.152
0.60 (0.46;0.75)
95.6 (92.9;97.5)
72.4 (52.8;87.3)
97.7 (95.6;99.0)
56.8 (39.5;72.9)
Yes (n = 161)
0.013
0.74 (0.63;0.86)
88.3 (81.2;93.5)
92.7 (80.1;98.5)
97.3 (92.2;99.4)
73.1 (59.0;84.4)
Students
No (n = 532)
0.004
0.70 (0.61;0.78)
93.5 (90.9;95.6)
84.3 (73.6;91.9)
97.5 (95.6;98.8)
66.3 (55.5;76.0)
Yes (n = 19)
NA
NA
100.0 (82.4;100.0)
NA
100.0 (82.4;100.0)
NA
Manual profession
No (n = 409)
0.016
0.73 (0.64;0.82)
93.7 (90.6;96.0)
86.7 (75.4;94.1)
97.6 (95.4;99.0)
70.3 (58.5;80.3)
Yes (n = 142)
0.226
0.52 (0.27;0.77)
93.9 (88.4;97.4)
70.0 (34.8;93.3)
97.6 (93.3;99.5)
46.7 (21.3;73.4)
Intellectual profession
No (n = 348)
0.002
0.70 (0.60;0.79)
91.5 (87.7;94.4)
87.3 (75.5;94.7)
97.5 (94.8;99.0)
65.8 (53.7;76.5)
Yes (n = 203)
1.000
0.69 (0.49;0.88)
97.3 (93.9;99.1)
73.3 (44.9;92.2)
97.8 (94.6;99.4)
58.8 (41.3;89.0)
Ethnic origin
No (n = 1087)
0.349
0.60 (0.52;0.69)
95.9 (94.4;97.0)
67.0 (56.7;76.2)
96.7 (95.4;97.8)
61.3 (51.4;70.6)
Yes (n = 21)
NC
NC
100.0 (83.1;100.0)
100.0 (2.5;100.0)
100.0 (83.2;100.0)
100.0 (2.5;100.0)
At risk for tetanus
No (n = 1073)
0.288
0.58 (0.50;0.67)
95.8 (94.4;97.0)
65.6 (54.8;75.3)
96.8 (95.5;97.8)
59.0 (48.7;68.7)
Yes (n = 35)
1.000
0.92 (0.75;1.00)
100.0 (87.2;100.0)
87.5 (47.4;99.7)
96.4 (81.7;99.9)
100.0 (59.0;100.0)
Immunocompromized status
No (n = 1086)
0.349
0.59 (0.51;0.68)
95.9 (94.4;97.0)
66.0 (55.5;75.4)
96.7 (95.4;97.8)
60.2 (50.1;69.7)
Yes (n = 22)
NC
1.00 (1.00;1.00)
100.0 (81.5;100.0)
100.0 (39.8;100.0)
100.0 (81.5;100.0)
100.0 (39.8;100.0)
believe ED patients’ vaccine coverage self-report of being up-to-date. This would avoid unnecessary prophylaxis vaccinations such as tetanus toxoid or tetanus immunoglobulin.
Florence Gatineau
Inserm, CIC 1412 – Brest Medical university hospital, France
Yannick Auffret? Jacques Y. Rousseaux;
CHIC, Emergency Department, Cornouaille Hospital, Quimper, France
?Corresponding author.
E-mail address: [email protected].
Florian Hamoniaux
Emergency Department, Pont l’Abbe Hospital, Pont l’Abbe, France
Maelenn Gouillou
Inserm, CIC 1412 – Brest Medical University Hospital, France
Table 5
Descriptive results of surveying validity in three groups: under-, true- and over-reported immunization status.
Under (N = 41)
True (N = 1035)
Over (N = 32)
p?
Sex
Missing
0 (0.0%)
3 (0.3%)
0 (0.0%)
0.965
Men
18 (43.9%)
461 (44.7%)
15 (46.9%)
Women
23 (56.1%)
571 (55.3%)
17 (53.1%)
Age (years old)
N (N missing)
41 (0 missing)
1028 (7 missing)
32 (0 missing)
Mean +- SD
44.86 +- 27.57
29.66 +- 24.33
23.61 +- 24.32
b0.001
Median (q1;q3)
46.5 (23.8;66.0)
24.9 (7.8;48.1)
12.6 (3.5;41.3)
Min;Max
0;92
0;91
2;81
Age rankings
Missing
0 (0.0%)
7 (0.7%)
0 (0.0%)
b0.001
b18 yo
8 (19.5%)
449 (43.7%)
19 (59.4%)
18-69 yo
25 (61.0%)
502 (48.8%)
10 (31.3%)
>=70 yo
8 (19.5%)
77 (7.5%)
3 (9.4%)
Adult (age N 18 yo)
Missing
0 (0.0%)
7 (0.7%)
0 (0.0%)
0.002
No
8 (19.5%)
449 (43.7%)
19 (59.4%)
Yes
33 (80.5%)
579 (56.3%)
13 (40.6%)
Seniors (age >= 70 yo)
Missing
0 (0.0%)
7 (0.7%)
0 (0.0%)
0.002
Yes
8 (19.5%)
77 (7.5%)
3 (9.4%)
No
33 (80.5%)
951 (92.5%)
29 (90.6%)
Unemployed??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.037
No
27 (90.0%)
488 (95.7%)
10 (90.9%)
Yes
3 (10.0%)
22 (4.3%)
1 (9.1%)
Farmers??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.537
No
30 (100.0%)
502 (98.4%)
11 (100.0%)
Yes
0 (0.0%)
8 (1.6%)
0 (0.0%)
Small business employers??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.014
No
27 (90.0%)
502 (98.4%)
11 (100.0%)
Yes
3 (10.0%)
8 (1.6%)
0 (0.0%)
Executives??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.253
No
29 (96.7%)
491 (96.3%)
11 (100.0%)
Yes
1 (3.3%)
19 (3.7%)
0 (0.0%)
Managers??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.029
No
30 (100.0%)
466 (91.4%)
11 (100.0%)
Yes
0 (0.0%)
44 (8.6%)
0 (0.0%)
White-collar workers??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.220
No
26 (86.7%)
379 (74.3%)
7 (63.6%)
Yes
4 (13.3%)
131 (25.7%)
4 (36.4%)
Blue-collar workers??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.696
No
25 (83.3%)
395 (77.5%)
8 (72.7%)
Yes
5 (16.7%)
115 (22.5%)
3 (27.3%)
Retired??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.097
No
16 (53.3%)
366 (71.8%)
8 (72.7%)
Yes
14 (46.7%)
144 (28.2%)
3 (27.3%)
Students??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.224
No
30 (100.0%)
491 (96.3%)
11 (100.0%)
Yes
0 (0.0%)
19 (3.7%)
0 (0.0%)
Manual profession (farmers, small business employers, blue-collar workers)??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.986
No
22 (73.3%)
379 (74.3%)
8 (72.7%)
Yes
8 (26.7%)
131 (25.7%)
3 (27.3%)
Intellectual profession (executives, managers, white-collar workers)??
Missing
10 (30.3%)
69 (11.9%)
2 (15.4%)
0.062
No
25 (83.3%)
316 (62.0%)
7 (63.6%)
Yes
5 (16.7%)
194 (38.0%)
4 (36.4%)
Place of birth other than France
No
41 (100.0%)
1014 (98.0%)
32 (100.0%)
0.470
Yes
0 (0.0%)
21 (2.0%)
0 (0.0%)
Immunocompromized status
No
41 (100.0%)
1013 (97.9%)
32 (100.0%)
0.220
Yes
0 (0.0%)
22 (2.1%)
0 (0.0%)
At risk for tetanus
No
41 (100.0%)
1001 (96.7%)
31 (96.9%)
0.099
Yes
0 (0.0%)
34 (3.3%)
1 (3.1%)
* Anova test for quantitative variables; Chi square or Fisher exact test for qualitative variables.
?? Sociodemographics included only adults and excluded pediatric population.
Lydie Abalea Le Dreff
Emergency Department, Brest Medical University Hospital, France
Simplice Pina Silas
Emergency Department, Morlaix Hospital, France
Frank Rakatobe
Emergency Department, Brest Medical University Hospital, France
Zarrin Alavi
Inserm, CIC 1412 – Brest Medical University Hospital, France
Corresponding author.
E-mail address: [email protected].
14 September 2018
https://doi.org/10.1016/j.ajem.2018.09.041
Mc Vicar J. Should we test for tetanus immunity in all emergency department pa- tients with wounds. Emerg Med J 2013;30(3):177-9.
- Guthmannn JP, Fonteneau L, Antona D, Levy Bruhl D. La couverture vaccinale diphterie, tetanus, poliomyelite chez l’adulte en France: resultats de l’enquete Sante et Protection Sociale, 2002. Bull Epidemiol Hebd 2007;51-52:441-5.
- Guthmann JP, Fonteneau L, Antona D, Levy-Bruhl D. Factors associated with tetanus vaccination coverage in adults in France and with knowledge of vaccination status. Med Mal Infect 2010;60:560-7.
- Rolnicka SJ, Parkera ED, Nordinb JD, Hedbloma BD, Weic F, Kerbya T, et al. Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors? Vaccine August 20 2013;31(37):3928-35.
- Talan DA, Abrahamian FM, Moran GJ, Mower WR, Alagappan K, Tiffany BR, et al. Teta- nus immunity and physician compliance with trtanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 2004;43: 305-14.
- INSEE. Nomenclature des professions et categories socioprofessionnelles. (Online June 20, 2018. Available) http://www.insee.fr/fr/methodes/default.asp?page=
nomenclatures/pcs2003/pcs2003.htm; Fevrier 2012.
Elkharrat D, Sanson-Le Pors MJ, Arrouy L, Beauchet A, Benhamou F. Evaluation of a bedside immunotest to predict individual anti-tetanus seroprotection: a prospective concordance study of 1018 adults in an emergency department. Emerg Med J 2010; 27(1):36-42.
- Stubbe M, Swinnen R, Crusiaux A, Mascart F, Lheureux PE. Seroprotection against tetanus in patients attending an emergency department in Belgium and evaluation of a bedside immunotest. Eur J Emerg Med 2007;14:14-24.
- Colombet I, Saguez C, Samson-Le pors MJ, Coudert B, Chatellier G, Espinoza P. Scien- tific committee of the TetaQuick 1000 study. Diagnosis of immunizations status: multicenter assessment of a rapid biological test. Clin Diagn Lab Immunol 2005;12 (9):1057-62.
- Baratin D, Del Signore C, Thierry J, Caulin E, Vanhemset Ph. Evaluation of adult dtPaP vaccination coverage in France: experience in Lyon city, 2010-2011. BMC Public Health Nov 1 2012;12:940.
- Thebaud V, Lietard C, Ktaiche D. Couverture vaccinale des enfants de CM2 (10-11 ans) du Finistere en 2004 – Comparaisons avec les resultats nationaux. , 21SFSP; 2009; 55-64.
- Gareau AB, Eby RJ, BA McLellan, Williams DR. Tetanus immunisation status and im- munologic response to a booster in an emergency department Geriatric population. Ann Emerg Med 1990;19(12):1377-82.
- Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales, 1984-2000. Epidemiol Infect 2003;130(1):71-7.
- Lee CY, Naguel C, Gyurech D, Duvoisin N, Schilling J. Awareness of vaccination status and its predictors among working people in Switzerland. BMC Public Health 2003;3: 18.
- Calendrier des vaccinations. Point sur les principales nouveautes. (Online 20 June, 2018. Available) http://www.sante.gouv.fr/IMG/pdf/Point_sur_les_principales_
nouveautes_calendrier_vaccinations_2013.pdf; 2013.
INSEE. Evolution de l’age moyen et de l’age median de la population jusqu’en. (On- line June 20, 2018. Available) http://www.insee.fr/fr/themes/tableau.asp?ref_id=
NATnon02147; 2013.
Issues in professionalism confronting beginning medical students during a clerkship in emergency medicineMedical literature largely supports the concept that professionalism is learned in a latent, implicit, and experiential manner [1]. This informal curriculum is defined as the interpersonal experiences between stu- dents and their teachers, residents, and patients. It is these critical inter- actions, not exposures to classroom didactics, that are the more formative influence on medical students first exposed to Emergency Medicine (EM) [1,2]. Medical educators need to understand how these day-to-day experiences, modeling positive and negative behaviors, shape student perceptions of the specialty and its values. Student narra- tive essays provide a rich source of information about such professional issues confronted during clerkships. Routinely assigned to encourage reflection and to support the educational experience of students, narra- tive essays are underused as a data source for curricular reform [3]. The aim of this study was to review student narratives for insight into pro- fessionalism dilemmas and the impact they might have on beginning students adapting to the clinical world.
This was a prospective observational study of first- and second- year medical students, electing to do a clinical clerkship in EM at a single university-affiliated hospital during a four-year study period.
Table 1
Frequency of professionalism incidents documented in student narratives (N = 387).
Caring and compassion
59 (15.2%)
Sensitivity (culture, age, gender, disabilities)
43 (11.1%)
Appropriate symptomatic care
42 (10.9%)
Integrity (trustworthy, honesty)
40 (10.3%)
Leadership (effectively coordinates team)
38 (9.8%)
Respect patient’s dignity and privacy
36 (9.3%)
Observable patient advocacy
35 (9.0%)
Listen to patients and respect their views
22 (5.7%)
Deal with complexity and uncertainty
19 (4.9%)
Responsive to feedback (staff, patients, families, peers)
17 (4.4%)
Confidentiality
9 (2.3%)
Discusses death honestly, compassionately
6 (1.6%)
Uses humor/language appropriately
6 (1.6%)
Managing conflicts of interest
5 (1.3%)
Responsibility/accountability
4 (1.0%)
4 (1.0%)
Personal life interferes with work
1 (0.3%)
Appropriate dress and cleanliness
1 (0.3%)
Impaired physician
0
Sexual misconduct
0
Risk-taking
0
Elective students signed up for three 4-h shifts during which they shadowed an attending or resident physician in the Emergency De- partment (ED). During the study period, students were asked to write short narrative descriptions of three cases that had the greatest impact on them during the elective. The faculty, residents, and stu- dents were blinded to the Study objectives. Each narrative essay was deidentified and independently analyzed by three EM investiga- tors with different clinical and academic backgrounds. Our Coding system and data abstraction for professionalism was adapted from an Association of American Medical Colleges (AAMC) report on pro- fessionalism. The main outcomes were the frequency and type of professionalism issues reported by students. After coding, profes- sionalism incidents were reviewed in order to characterize the re- markable properties of each incident, whether it was ‘negative’ in the sense of violating a norm or ‘positive’ by exemplifying it. Descrip- tive statistics were used to summarize the data. A blinded critical re- view of a random sample of 10% of the narratives was done to determine rater reliability. The interrater reliability was moderate, with a median kappa statistic of 0.67.
During the four-year study period, 292 consecutive student essays were evaluated from 103 medical students. The mean student age was 26 +- 3 years; 55% were male. Overall, 207 of the 292 reflections (70.9%) included professionalism issues. A total of 387 specific incidents were coded across 21 categories of professionalism (Table 1). The four most common categories were incidents related to caring and compassion (15.2%); sensitivity (11.1%); appropriate use of symptomatic care (10.9%); and integrity (10.3%). The majority of incidents involved clinician interaction with patients or families (59%), followed by interprofessional incidents (41%). Overall, 282 of the 387 (72.3%) incidents were depictions of exemplary instances of professionalism, 87 (22.5%) were considered normal interactions, and 18 (4.7%) were negative interactions. The nega- tive interactions were generally related to insensitivity to patient’s pain/ emotional state (5), lack of caring and compassion (4), treating patients/ family and staff with disrespect (3), acknowledging mistakes (2), inappro- priate use of humor (2), lack of confidentiality (1) and personal/profes- sional balance (1). While students were impressed by their observations of EM clinicians and residents, their eyes were opened to the Improper treatment of acutely ill patients, be it poor pain management, discrimina- tion, inadequate patient education, or a perceived lack of empathy.
Medical student narrative essays showed a wide variety of interest- ing professional interactions. Drawn from daily experience, student es- says provided insight into learning not easily measured by traditional evaluation. As others have noted, the list of real-world ethical and pro- fessional dilemmas that beginning students face every day does not
Should we believe emergency department patients self-reported 
Issues in professionalism confronting beginning medical students during a clerkship in emergency medicine