Emergency Medicine Care Research Articles

Attitude toward end-of-life care in emergency medicine residents- can a short workshop make a difference?

There is a growing demand for palliative care (PC) in Emergency departments (ED) as the number of patients who need end-of-life (EOL) care is increasing. Despite significant variability amongst residency programs, there is a lack of structured core curriculum for PC/EOL care in most emergency medicine (EM) training programs, which often do not meet the needs of EM physicians. In this study, we evaluate the effect of a short EOL care workshop on changing the attitude of Iranian EM residents towards EOL care in ED. In this prospective before/after educational study at Tehran University of medical science, we enrolled 40 EM residents using a random sampling method. We obtained demographic and practice background information, and participants underwent a half-day PC training workshop designed by an expert panel. We administered a translated and validated Standard PEAS (physician End of Life Care Attitude Scale) questionnaire before and four weeks after an educational intervention. Baseline and differences in attitude were reported and compared by paired t-test, repeated measure ANOVA, and ANOVA. None of the participants had prior experience of formal PC training. All of the 40 participants completed the follow-up questionnaire. Baseline attitude was not different among demographic groups. The mean (SD) PEAS score before and four weeks after the workshop was 86.9 (5.8) versus 89(6.9), respectively (P = 0.023). Residents with no previous close exposure to a terminal illness in their family members had significantly more attitude change than those with such an experience (P = 0.045). A brief educational intervention improved EM residents' attitudes toward EOL care. The optimal design and characteristics of this educational intervention yet remain to be defined by further studies.

Desenvolvimento de um aplicativo para ensino de ultrassonografia pulmonar em emergência

Abstract: Introduction: The use of ultrasound protocols has revolutionized care in emergency medicine and can help in the diagnosis of respiratory failure in emergency care; therefore, medical training for the use of these protocols has become important. It has also been demonstrated that medical smartphone apps have positive results in daily practice, in addition to being a potentially valuable educational tool. Objective: Thus, the objective was to develop an emergency pulmonary ultrasound application. The “BLUE SIM” is a cell phone application that simulates clinical cases using the “Bedside Lung Ultrasound in Emergency” protocol, which can help students and health professionals regarding the use of pulmonary ultrasound in the care of acute respiratory failure. The hypothesis is that the “BLUE SIM” will be a usable and acceptable application among users. Method: After the development, the application was evaluated with a group of 36 volunteers, which included 18 physical therapists and 18 other professionals consisting of physicians, nurses and medical students. The usability and usefulness of a mobile application for the iOS system was analyzed, using the System Utility Score (SUS) usability scale and the Technology Acceptance Model (TAM) as references. The obtained data were tabulated and analyzed using Fisher’s exact test or Mann-Whitney test. Result: When applying the SUS questionnaire (usability), the application obtained a score of 76.8%. A score of 75% was obtained exclusively among physical therapists, with no statistical difference between the general group of all emergency professionals and the group of physical therapists only (p=0.239). According to the usefulness perception analysis, 93.9% of the emergency professionals had a positive response, while a score of 88.9% was obtained among physical therapists (p=0.04). Conclusion: It was concluded that the developed application was classified as useful in learning the diagnosis of respiratory failure among health professionals; however, they considered that training is necessary for its use.

Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention.

Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM. The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use. An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.

Potential to be more effective: Reduction in lower urgency emergency department presentations during the COVID-19 period in New South Wales, Australia.

Diverting lower urgency ED presentations to more suitable healthcare is a key goal of several healthcare systems. During the early stages of the COVID-19 pandemic in 2020, there was a substantial drop in ED presentations in New South Wales (NSW), potentially because of lower risk of illness and injury through social restrictions, or ED avoidance for lower urgent care. The present study aimed to better understand the impact of social restrictions during the pandemic on ED presentations, to inform potential shifts to alternative modes of care in emergency medicine. We conducted a quasi-experimental study of public ED presentations in NSW. We compared changes in weekly ED presentation counts by urgency, during and after the period of tightest social restrictions in contrast to the baseline period. Expected weekly counts were estimated using segmented quasi-Poisson regression, accounting for age and seasonality. Lower urgency presentations fell more than mid-high urgency presentations, both during and after the period of tightest social restrictions. Lower urgency presentations reduced 30.9% compared to the baseline period during tightest restrictions, in contrast to 20.9% reduction for mid-high urgency presentations. Lower urgency presentations remained 14.4% lower after the tightest restrictions compared to the baseline period, whereas mid-high urgency presentations returned to usual levels. This finding suggests that reducing lower urgency ED presentation beyond the COVID-19 pandemic maybe feasible, by supporting alternative, more appropriate sources of care.

Identification of barriers, enablers and interventions to inform deimplementation of low-value care in emergency medicine practice: A protocol for a mixed methods scoping review informed by the Theoretical Domains Framework

IntroductionLow-value care can lead to patient harm, misdirected clinician time and wastage of finite healthcare resources. Despite worldwide endeavours, deimplementing low-value care has proved challenging. Multifaceted, context and barrier-specific interventions...

116 Diagnostic Accuracy of Neuroimaging in Emergency Department Patients With Acute Vertigo or Dizziness: A Systematic Review and Meta-analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

Patients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness.

134 Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

134 Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

Interprofessional simulation-based team-training and self-efficacy in emergency medicine situations

ABSTRACT Teamwork quality has been shown to influence patient safety, and simulation-based team-training (SBTT) is an effective means to increase this quality. However, long-term effects are rarely studied. This study aims to investigate the long-term effects of interprofessional SBTT in emergency medicine in terms of global confidence, self-efficacy in interprofessional communication and in emergency medicine situations. Newly graduated doctors, nurses, auxiliary nurses, and medical and nursing students participated. Four emergency medicine scenarios focused on teamwork according to the A-B-C-D-E-strategy. All participants increased their global confidence from 5.3 (CI 4.9–5.8) before to 6.8 (CI 6.4–7.2; p < .0001) after SBTT. Confidence in interprofessional communication increased from 5.3 (CI 4.9–5.8) to 7.0 (CI 6.6–7.4; p < .0001). Students had the greatest gain. The self-efficacy following the A-B-C-D-E strategy increased from 4.9 (CI 4.4–5.3) to 6.6 (CI 6.2–7.0). Again, students had the steepest increase. Newly graduated doctors achieved a superior increase in global confidence as compared to nurses and auxiliary nurses (p < .0001). Their propensity to recommend SBTT to colleagues was 9.9 (CI 9.8–10.0). The positive effects were sustained over a six-month period, indicating that interprofessional SBTT had a positive impact on competence development, and a potential to contribute to increased team quality in emergency medicine care.

Design, development and implementation of the virtual, coordination, access, referral and escalation service in western New South Wales.

People in rural and remote New South Wales experience avoidable admissions, limited access to skilled clinicians and commonly travel >400km to access specialist services within the district and >700km for tertiary services outside. Iterative use of New South Wales Health redesign methodology in the period 2015-2020. Western New South Wales Local Health District is geographically the largest Health District within New South Wales and includes disadvantaged communities. Virtual Coordination Access Referral Escalation is an audio-visually enabled transport, patient flow and clinical advice unit established in 2006 to support patients and clinicians at 35 small, rural and remote hospitals. Right care, right place and right time by the right team the first time. Care delivery close to home and 'on country'. Safe and cost-effective transport. Performance measures to support quality, safety and clinical outcomes. Improving the human experience. Cycles of strategic planning, innovation, productive partnerships, change management and human systems development. Virtual Coordination Access Referral Escalation critical care telehealth more effectively supports rural and remote health care across large distances. Improvements include expanded/redefined management and nursing roles, integration of dedicated critical care emergency medicine specialists within the service, delegated authority to accept transfers, upgraded technology, 24-hour service provision and a central 'Virtual Support' proactive outreach model.

Using community-based participatory research methods to inform care for patients experiencing homelessness: An opportunity for resident education on health care disparities.

People experiencing homelessness (PEH) suffer higher burdens of chronic illnesses, have higher rates of emergency medicine (ED) use and hospitalization, and ultimately are at increased risk for premature death compared to housed counterparts. Structural racism contributes to a disproportionate burden of homelessness among people of color. PEH experience not only significant medical concerns but also complex social needs that need to be addressed concurrently for effective healing, issues that have been magnified by the COVID-19 pandemic. As health disparities and structural racism intersect among PEH, it is critically important to develop PEH-centered interventions to improve care and health outcomes as part of an effort to dismantle racism. One opportunity to address these disparities in care for PEH is through training ED physicians on methods for identifying and intervening on the unique needs of vulnerable patient groups. The Accreditation Council for Graduate Medical Education has outlined health quality pathways in the clinical learning environment to address health disparities. Community-based participatory research (CBPR) is particularly well suited for this scenario as it allows experiential learning for trainees to work with and understand a diverse group of stakeholders, to deepen their knowledge of local health disparities, and to lead research and measure outcomes of interventions to tackle health disparities. In this paper, we highlight the utility of CBPR in fostering experiential learning for EM residents on tackling health disparities and the importance of community collaboration in trainee-led interventions for comprehensive ED care.

Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study

BackgroundDue to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas.MethodsA questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services.ResultsIn total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics.ConclusionsThe study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future.

The Pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care.

The emergence of Covid-19 has caused a pandemic and is a major public health concern. Covid-19 has fundamentally challenged the global health care system in all aspects. However, there is a growing concern for the subsequent detrimental effects of continuing delays or adjustments on time-dependent treatments for Covid-19 negative patients. Patients arriving to the ED with STEMIs and acute CVA are currently presumed to have delays due to Covid-19 related concerns. The objective of this paper is to evaluate the implications of the Covid-19 pandemic on non-Covid19 patients in emergency care settings. We conducted a retrospective study from February 2020 to April 2020 and compared this to a parallel period in 2019 to assess the impact of the Covid-19 pandemic on three distinct non-Covid-19 ED diagnosis that require immediate intervention. Our primary outcome measures were time to primary PCI in acute STEMI, time to fibrinolysis in acute CVA, and time to femoral hip fracture correction surgery. Our secondary outcome measure included a composite outcome of length of stay in hospital and mortality. From 1 February 2020 to 30 April 2020, the total referrals to ED diagnosed with STEMI, Hip fracture and CVA of which required intervention were 197 within Covid-19 group 2020 compared to 250 in the control group 2019. Mean duration to intervention (PCI, surgery and tPA, respectively) did not differ between COVID-19 group and 2019 group. Among femoral hip fracture patients', the referral numbers to ED were significantly lower in Covid-19 era (p = 0.040) and the hospitalization stay was significantly shorter (p = 0.003). Among CVA patients', we found statistical differences among the number of referrals and the patients' age. Coping with the Covid-19 pandemic presents a challenge for the general healthcare system. Our results suggest that with proper management, despite the obstacles of isolation policies and social distancing, any negative impact on the quality of health care for the non-Covid-19 patients can be minimized in the emergency department setting.

Building point-of-care ultrasound capacity in rural emergency departments: An educational innovation.

Point-of-care ultrasound (POCUS) use is the standard of care in emergency medicine (EM), but rural physicians face barriers to obtaining and retaining this skill and cite low confidence in their use of POCUS. Without access to high-quality educational opportunities, this important clinical tool may not be used to its full potential in rural hospitals. The Hands-On Ultrasound Education (HOUSE) programme, launched in 2015 by the University of British Columbia's (BC) Division of Rural Continuing Professional Development, is a rurally focused POCUS training and education programme that travels to rural and remote communities and aims to build a rural POCUS community of practice within BC. In this study, we present and evaluate the HOUSE programme. The HOUSE programme is described. A comprehensive qualitative evaluation of semi-structured interviews pertaining to HOUSE was conducted in the 4th year of the programme to assess participant experience and programme outcomes. Results from 52 semi-structured interviews indicate that there is a significant increase in self-reported confidence on specific POCUS applications and increased POCUS use after completion of the course, and we report positive experiences with the HOUSE programme. By providing a customizable, accessible, hands-on training opportunity, the HOUSE programme removes barriers to POCUS training and education for physicians in rural and remote BC. The rurally focused elements have contributed to education for rural participants that demonstrates increased confidence and the use of POCUS as a clinical tool.

Out with the Old and in With the New: Deimplementation in Emergency Medicine.

Much of emergency medicine care and quality standards are rooted in evidence-based guidelines. The Society for Academic Emergency Medicine (SAEM) and the journal Academic Emergency Medicine through publications, conferences, and various initiatives have encouraged the emergency medicine community to create and disseminate evidence-based guidelines. New and updated guidelines must also be implemented into practice. Increasing numbers of publications in this journal and elsewhere are shining light on how the theories and frameworks of implementation science can increase the uptake, reach, and sustainability of evidence-based guidelines in emergency medicine.

Faculty Sim: Implementation of an Innovative, Simulation-based Continuing Professional Development Curriculum for Academic Emergency Physicians.

Maintaining and enhancing competence in the breadth of emergency medicine (EM) is an ongoing challenge. In particular, resuscitative care in EM involves high-risk clinical encounters that demand strong procedural skills, effective team leadership, and up-to-date clinical knowledge. Simulation-based medical education is an effective modality for enhancing technical and nontechnical skills in crisis situations and has been effectively embedded in undergraduate and postgraduate medical curricula worldwide. To our knowledge, there are few existing systematic department-wide simulation programs to address continuing professional development (CPD) for practicing academic EM faculty. We developed our novel, simulation-based CPD program following Kern's six-step model. Based on the results of a multimodal needs assessment, a longitudinal curriculum was mapped and tailored to the available resources. Institutional support was provided in the form of a departmental grant to fund a physician program lead, monthly session instructors, and operating costs. CPD simulation sessions commenced in January 2017. Our needs assessment identified two key types of educational needs: 1) crisis resource management skills and 2) frequent practice of high-stakes critical care procedures (e.g., surgical airways). Simulation sessions involve two high-fidelity simulated resuscitations and one skills lab per day. To date, 21 sessions have been delivered, reaching 161 practicing EPs. Feedback from our faculty has been positive. We have successfully introduced a curriculum of monthly simulation-based CPD based on the educational needs of our EPs. Future work will include more detailed program evaluation linked to clinical outcomes and program expansion to support nearby institutions.

Examining emergency department inequities: Descriptive analysis of national data (2006-2012).

ObjectiveInternationally, Indigenous and minoritised ethnic groups experience longer wait times, differential pain management and less evaluation and treatment for acute conditions within emergency medicine care. Examining ED Inequities (EEDI) aims to investigate whether inequities between Māori and non‐Māori exist within EDs in Aotearoa New Zealand (NZ). This article presents the descriptive findings for the present study.MethodsA retrospective observational study framed from a Kaupapa Māori positioning, EEDI uses secondary data from emergency medicine admissions into 18/20 District Health Boards in NZ between 2006 and 2012. Data sources include variables from the Shorter Stays in ED National Research Project database and comorbidity data from NZ's National Minimum Dataset. The key predictor of interest is patient ethnicity with descriptive variables, including sex, age group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and trauma status.ResultsThere were a total of 5 972 102 ED events (1 168 944 Māori, 4 803 158 non‐Māori). We found an increasing proportion of ED events per year, with a higher proportion of Māori from younger age groups and areas of high deprivation compared to non‐Māori events. Māori also had a higher proportion of self‐referral and were triaged to be seen within a longer time frame compared to non‐Māori.ConclusionOur findings show that there are different patterns of ED usage when comparing Māori and non‐Māori events. The next level of analysis of the EEDI dataset will be to examine whether there are any associations between ethnicity and ED outcomes for Māori and non‐Māori patients.

EVALUATION OF DIAGNOSTIC QUALITY CRITERIA OF EMERGENCY CARE FOR DISEASES OF SURGICAL PROFILE AT EMERGENCY DEPARTMENTS

The article presents an analysis of diagnostic criteria of quality evaluation for emergency medicine and specialized medical care in emergency departments. The results of the study of emergency medicine care in compliance with quality evaluation criteria showed that in groupe of general criteria for quality evaluation it was achieved in 100 prc cases, in groupe of evaluation criteria of extent of medical aid - in 97,4 prc cases, n groupe of evaluation criteria of timely diagnosis and treatment — 98,2 prc. It also shows the high level of medical care in this department.

Commentary on Facing Structural Racism in Emergency Medicine.

A large body of research affirms the fact that there are racial disparities in healthcare. Overall, literature shows that Black men and women suffer higher rates of death and lower life expectancy at birth than people who self-identify as White.1 A significant portion of the disparity in health status relates to social disadvantage caused by the legacy of discrimination and racism. For example, compared to White people, Black people have dramatically lower levels of wealth to shield them against financial uncertainties, and this inequity impacts health across the life course.

MP40: What are the factors contributing to medico-legal risk of procedural interventions performed by physicians practicing emergency medicine?

Introduction: Physicians who practice emergency medicine (EM) often perform procedural interventions, which can occasionally result in unintended patient harm. Our study's objective was to identify and describe the interventions and contributing factors associated with medico-legal (ML) cases involving emergency physicians performing procedural interventions. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, ML organization which represented over 99,000 physicians at the time of this study. We extracted five years (2014-2018) of CMPA data describing closed ML cases involving procedural interventions (e.g. suturing, reducing a dislocated joint) and excluding interventions related to pharmacotherapy (e.g. injection of local anesthetic), diagnosis (electrocardiograms) and physical assessments (e.g. ear exams), performed by physicians practicing EM. We then applied an internal contributing factor framework to identify themes. We analysed the data using descriptive statistics. Results: We identified 145 cases describing 145 patients who had 205 procedures performed in the course of their EM care. The three most common interventions were orthopedic injury management (47/145, 32.4%), wound management (43/145, 29.7%), and Advanced Cardiac Life Support (24/145, 16.6%). Out of 145 patients, 93.8% (136/145) experienced a patient safety event, and 55.9% (76/136) suffered an avoidable harmful incident. One quarter of patients suffered mild harm (34/76, 25.0%), 18.4% of patients died, 14.5% suffered severe harm, and 13.2% moderate harm. Peer experts were critical of 86/145 cases (59.3%) where the following provider contributing factors were found: a lack of situational awareness (20/68, 29.4%), and deficient physician clinical decision-making (54/68, 79.7%). Clinical decision-making issues included a lack of thoroughness of assessment (33/54, 61.1%), failure to perform tests or interventions (21/54, 38.9%), and a delay or failure to seek help from another physician (17/54, 31.2%). Peer experts were also critical of 48.8% of cases containing team factors (42/86) due to deficient medical record keeping (26/42, 61.9%), and communication breakdown with patients or other team members (25/42, 59.5%). Conclusion: Both provider and team factors contributed to ML cases involving EM physicians performing procedural interventions. Addressing these factors may improve patient safety and reduce ML risk for physicians.

LO12: ClerkCast: a novel online free open access emergency medicine curriculum for medical students

Innovation Concept: Canadian medical students completing their Emergency Medicine (EM) clerkship rotations must develop approaches to undifferentiated patients. Increasingly used in postgraduate EM education, Open Educational Resources (OERs) are a convenient and flexible solution to meeting medical student educational needs on their EM rotation. We hoped to supplement Canadian medical student EM education through the development of ‘ClerkCast’, a novel OER and podcast-based curriculum on CanadiEM.org. Methods: We utilized the Kern Six Step approach to curriculum development for ‘ClerkCast’. A general needs assessment involved a review of available OERs and identified a lack of effective EM OERs specific for medical students. A specific online needs assessment was used to determine which EM topics required further education for medical students. The survey was shared directly with key Canadian medical student and undergraduate medical educator stakeholder groups, and distributed globally through the CanadiEM social media networks. Results of the needs assessment highlighted shared perceptions of educational needs for medical students, with an emphasis on increased need for education on critical care and common EM presentations. We used the topics determined to be highest priority for the development of our first ten episodes of ‘ClerkCast’. Curriculum, Tool or Material: Podcast episodes are released from CanadiEM biweekly. Episodes are 30 to 45 min in length, and focus on cognitive approaches to a common EM presentation for medical students. Content is anchored on medical student interactions with a staff or resident EM co-host. Podcasts are supplemented by infographics and blog posts highlighting the key points from each episode. Learners are also encouraged to interact with the content through review quizzes on a provided question bank. Quality assurance of the content is provided by physician co-hosts who review episode scripts both prior to recording. Post-production feedback is elicited via comments on the curriculum's host website, CanadiEM.org, and through direct email correspondence to the ClerkCast address. Conclusion: With an ever increasing number of OERs in EM and critical care, the systematic development of new resources is important to avoid redundancies in content and medium while also addressing unmet learner needs. We describe the successful use of the Kern Six Steps for curriculum development for the creation of our novel EM OER for Canadian medical students, ‘ClerkCast’.