Community Emergency Physicians Research Articles

What Faculty Want: Academic and Community Emergency Physicians' Perceptions of Learner Feedback.

IntroductionFaculty development is often deployed by central medical schools, with little guidance from end-users. How and what faculty members can use to improve their performance requires a deeper understanding from this user group. This study aims to explore how faculty perceive learners’ feedback about their performance as educators.MethodsThis study is an explanatory mixed-method research, wherein community- and academic-based emergency medicine faculty members from nine regional hospitals were surveyed about their perceptions of various outcome measures for faculty development. Selected participants were invited to follow-up interviews. We analyzed the physicians’ perceptions toward teaching and performance feedback data based on faculty’s gender, role as academic or community physician, and work experience.ResultsThe quantitative phase has 104 participants, and 15 of these were followed up with interviews. The gender of faculty does not have statistical or practical differences regarding their perceptions of learner feedback. Type of practice contains meaningful insights about the perception of learner feedback although it does not have a statistical difference. Moreover, an inverse trend exists between the physicians’ years of experience and their perceived value of learner feedback. Kruskal-Wallis test showed a significant difference in the faculty’s experience level and their perceived value for the metric “quantity of feedback commentary compared to their peer group” (H(4) = 12.21, p = 0.02), specifically between junior and senior faculty (p = 0.007). Some faculty stated that experienced faculty may perceive they have a very well-established style.ConclusionsDiversifying feedback sources and delivery may be useful for different groups of faculty members. Junior physicians are more interested in gaining feedback about the quantity of their written feedback to students compared to more senior physicians. Learner feedback holds promise to trigger continuous improvement in community sites for those who fall behind compared to the academic sites.

Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study

Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5). A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation. This 18-month pilot study proved feasible, with an enrollment of 63.6% (n= 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians. The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.

Factors Affecting Community Emergency Physician Treatment of Opioid Use Disorder with Buprenorphine

Although Emergency Departments (EDs) are often the only sites of care for patients with opioid use disorder (OUD), a proven medication, buprenorphine, is underutilized by emergency physicians. Potential theoretical explanations include ideas from Diffusion of Innovations, Social Identity, Structuration, and Attribution theories. Prior research also suggests some physicians may consider replacing one opioid with another unethical; others are concerned about patient costs for buprenorphine. However, while some reasons for underutilization of ED buprenorphine have been studied in academic hospitals, no study has explored underutilization by community emergency physicians (CEPs) working in community hospital EDs. This study investigated factors influencing CEP treatment of OUD. We used an inductive grounded theory approach and conducted semi-structured interviews to identify emergent factors from experiential accounts of 30 CEPs practicing in Ohio, a state hard-hit by the opioid epidemic. Four themes emerged: physician professional identity, image of patients with OUD, physician professional development, and resources. The latter two have been previously described but the former two themes are novel and appear to interact. Altering CEPs’ professional identities by normalizing OUD and its treatment and addressing the stigma attached to the image of patients with OUD, may result in increased CEP treatment of OUD with buprenorphine.

Standardizing Point-of-Care Ultrasound Credentialing Across a Large Health Care System

Point-of-care ultrasound (POCUS) is becoming prevalent in the daily practice of bedside clinicians. As large health care systems standardize practice patterns, an organized approach of credentialing physicians in POCUS is paramount for quality and patient safety. This study describes a systematic approach of credentialing a diverse group of community emergency physicians (EPs) across a large health care system. A multimodal POCUS credentialing initiative for EPs was implemented across 11 hospitals between January 1, 2017, and July 1, 2018, that included (1) standardization of POCUS credentialing for all hospitals in the system, (2) tiered POCUS credentialing (Basic and Intermediate) for manageable attainment of goals with a required POCUS course, (3) automatic privileges for EPs who completed residency or practice-based POCUS pathways prior to employment, and (4) implementation of a practice-based pathway for competency assessment for noncredentialed physicians. Key factors for implementation included executive administrative support, dedicated POCUS courses, equipment standardization, a robust electronic medical record capable of logging training scans, and competency assessment for attainment of privileges. Through the initiative, 78/106 EPs achieved Intermediate credentialing, and 28/106 were without POCUS privileges. All 28 noncredentialed EPs completed the required Basic POCUS course. Almost half (13/28) completed the initiative and became credentialed. From 2016 to 2018, the number of EPs performing scans increased from 52 to 112, and the number of POCUS scans increased from 928 to 3,007. A standardized POCUS credentialing initiative can be successfully implemented in large health care systems. Other specialties can use this initiative to implement POCUS into their daily practice.

Emergency medicine practice environment and impact on concert examination performance

ObjectiveThe ABEM ConCert Examination is a summative examination that ABEM-certified physicians are required to pass once in every 10-year cycle to maintain certification. This study was undertaken to identify practice settings of emergency physicians, and to determine if there was a difference in performance on the 2017 ConCert between physicians of differing practice types and settings. MethodsThis was a mixed methods cross sectional-study, using a post-examination survey and test performance data. All physicians taking the 2017 ConCert Examination who completed three survey questions pertaining to practice type, practice locations, and teaching were included. These three questions address different aspects of academia: self-identification, an academic setting, and whether the physician teaches. ResultsAmong 2796 test administrations of the 2017 ConCert Examination, 2693 (96.3%) completed the three survey questions about practice environment. The majority (N = 2054; 76.3%) self-identified as primarily being a community physician, 528 (19.6%) as academic, and 111 (4.1%) as other. The average ConCert Examination score for community physicians was 83.5 (95% CI, 83.3–83.8); the academic group was 84.8 (95% CI, 84.3–85.3); and the other group was 82.3 (95% CI, 81.1–83.6). After controlling for initial ability as measured by the Qualifying Examination score, there was no significant difference in performance between academic and community physicians (p = .10). ConclusionsAcademic emergency physicians and community emergency physicians scored similarly on the ConCert. Working at a community teaching hospital was associated with higher examination performance. Teaching medical learners, especially non-emergency medicine residents, was also associated with better examination performance.

MP29: Creation of the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist

Introduction: Patients with acute atrial fibrillation or flutter (AAFF) are the most common acute arrhythmia cases requiring care in the ED. Our goal was to adapt the existing Canadian Cardiovascular Society (CCS) AF Management Guidelines into an emergency physician-friendly best practices checklist. Methods: We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the CCS using the GRADE system. We used the Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. We created an Advisory Committee consisting of 14 academic and community emergency physicians, three cardiologists, one PhD methodologist, and two patients. The Advisory Committee communicated by a two-day face-to-face meeting, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues whose written feedback was further incorporated into the final approved version. Results: The final CAEP ED AAFF Guidelines are comprised of two algorithms and four sets of checklists, organized by 1) Assessment and Risk Stratification, 2) Rhythm and Rate Control, 3) Long-term Stroke Prevention with the CHADS-65 Algorithm, and 4) Disposition and Follow-up. The guidelines have been endorsed by CAEP and accepted for publication in the Canadian Journal of Emergency Medicine. During the consensus and feedback processes, we addressed a number of issues and concerns. We highlighted the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. One controversial recommendation is to consider rate control or transesophageal echocardiography guided cardioversion if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated. Conclusion: We have created the CAEP AAFF Best Practices Checklist which we hope will standardize and improve care of AAFF patients in all EDs across Canada. We believe that most of these patients can be managed rapidly and safely with ED rhythm control, early discharge, and appropriate use of anticoagulants.

Discordance Between Patient and Clinician Experiences and Priorities in Rural Interhospital Transfer: A Mixed Methods Study.

Rural emergency department (ED) patients require interhospital transfer for definitive care at nearly 6 times the national rate, yet transfer decision-making is variable. The goal of this study was to understand patient experiences, preferences, and decision-making in the rural interhospital transfer process, and to measure the concordance between patient opinions and provider perceptions. Ours is a mixed methods study of patients transferred to a 711-bed Midwestern academic medical center and the emergency physicians in community hospitals. Qualitative interviews were conducted by a single research assistant with admitted patients transferred from an ED, and a corresponding survey was distributed to community emergency physicians. Standardized scenarios were posed to both groups to understand transfer priorities. Seventy-nine patients and 40 physicians participated in this study. Patients and physicians cited proximity to home, medical expertise, a personal relationship with a health care provider, health insurance, privacy concerns, and patient choice as the primary factors that influenced patient transfer priorities. Compared with patient respondents, physicians overestimated the patient-perceived importance of proximity to home (P = .015) and being cared for by a personal physician (P = .049), but they underestimated the value of receiving treatment in a comprehensive medical center (P = .002). In standardized scenarios, physicians agreed with patients in transfer preferences for conditions requiring neurosurgical consultation, but they underestimated patients' desire for transfer for pneumonia requiring mechanical ventilation. Patients and physicians recognize similar factors that influence patient preferences in interhospital ED transfer, but physicians may overestimate the value of nonmedical influences on decision-making priorities.

326 How Well Do Academic and Community Emergency Physicians Follow Decision Rules for Pulmonary Embolism?

326 How Well Do Academic and Community Emergency Physicians Follow Decision Rules for Pulmonary Embolism?

Positive Predictive Value of Blood Cultures Utilized by Community Emergency Physicians

Objective. To determine the positive predictive value of blood cultures obtained from patients from a suburban ED and how the ED physicians use empirical antibiotics. Method. This retrospective chart review study was conducted at the ED of a suburban teaching hospital. The study consisted of adult patients who presented to the ED with evidence of clinical conditions suggesting bacteremia. Result. Over a 12-month period, 408 patients with positive blood cultures were drawn in the ED. The mean age of the patients was 65.85 years. The positive predictive value was 58.3%, and community ED physicians used appropriate empirical antibiotics in 72.3% of patients with true bacteremia. Conclusion. The positive predictive value indicated that many of the positive blood culture results were false positives from skin contamination. Blood cultures are necessary to follow up any positive results with more reliable tests to obtain a more accurate assessment as to whether bacteremia is present in the emergency department. True positive blood cultures can assist other doctors in adjusting the antibiotics. Emergency physicians overall used appropriate antibiotics in 72.3% of patients with true bacteremia. This study demonstrated that emergency physicians have the potential to improve the empirical treatment in treating patients.

Quantifying Off-hour Emergency Physician Coverage of In-hospital Codes: A Survey of Community Emergency Departments

Background Community emergency physicians (EPs) are often required to respond to unstable patients outside of their department during off-hours. Objective The primary objective of this study was to describe the critical care responsibility of community EPs outside of their departments. Methods A one-page survey was mailed to emergency department (ED) directors of 10 states and Washington, DC. Results Three hundred forty of 1169 surveys were returned. The median (interquartile range [IQR]) number of hospital and intensive care unit (ICU) beds was 145 (IQR 60–242) and 11 (IQR 6–20), respectively. Median ED annual volume and ICU admission percentage was reported to be 25 K (IQR 14–40) and 5% (IQR 2–10), respectively. Seventy-six percent of reporting institutions require EPs to leave their department and respond to medical codes on the floors after hours. In 57% of institutions, the EP was the only physician required to respond. In addition, 48% of EPs must respond to unstable patients in the ICUs after hours. Hospitals in which EPs were required to respond to medical codes and unstable ICU patients were more likely to have fewer hospital beds (137 vs. 275; p < 0.001), fewer ICU beds (12 vs. 27; p < 0.001), and have a smaller ED annual volume (24 K vs. 39 K; p < 0.001). Conclusions Many community EPs are responsible for covering critically ill patients outside of their ED. Further investigation is required to determine the impact on patient care.

Surge Capacity for Healthcare Systems: A Conceptual Framework

This report reflects the proceedings of a breakout session, "Surge Capacity: Defining Concepts," at the 2006 Academic Emergency Medicine Consensus Conference, "Science of Surge Capacity." Although there are several general descriptions of surge capacity in the literature, there is no universally accepted standard definition specifying the various components. Thus, the objectives of this breakout session were to better delineate the components of surge capacity and to outline the key considerations when planning for surge capacity. Participants were from diverse backgrounds and included academic and community emergency physicians, economists, hospital administrators, and experts in mathematical modeling. Three essential components of surge capacity were identified: staff, stuff, and structure. The focus on enhancing surge capacity during a catastrophic event will be to increase patient-care capacity, rather than on increasing things, such as beds and medical supplies. Although there are similarities between daily surge and disaster surge, during a disaster, the goal shifts from the day-to-day operational focus on optimizing outcomes for the individual patient to optimizing those for a population. Other key considerations in defining surge capacity include psychosocial behavioral issues, convergent volunteerism, the need for special expertise and supplies, development of a standard of care appropriate for a specific situation, and standardization of a universal metric for surge capacity.

Surge Capacity for Healthcare Systems: A Conceptual Framework

This report reflects the proceedings of a breakout session, “Surge Capacity: Defining Concepts,” at the 2006 Academic Emergency Medicine Consensus Conference, “Science of Surge Capacity.” Although there are several general descriptions of surge capacity in the literature, there is no universally accepted standard definition specifying the various components. Thus, the objectives of this breakout session were to better delineate the components of surge capacity and to outline the key considerations when planning for surge capacity. Participants were from diverse backgrounds and included academic and community emergency physicians, economists, hospital administrators, and experts in mathematical modeling. Three essential components of surge capacity were identified: staff, stuff, and structure. The focus on enhancing surge capacity during a catastrophic event will be to increase patient-care capacity, rather than on increasing things, such as beds and medical supplies. Although there are similarities between daily surge and disaster surge, during a disaster, the goal shifts from the day-to-day operational focus on optimizing outcomes for the individual patient to optimizing those for a population. Other key considerations in defining surge capacity include psychosocial behavioral issues, convergent volunteerism, the need for special expertise and supplies, development of a standard of care appropriate for a specific situation, and standardization of a universal metric for surge capacity.

Community emergency medical service. Epidemiology and quality of treatment in a rural district

Rapid aid provided by lay witnesses and emergency services can improve the outcome in medical emergencies arising in the community. We attempted to study the quality of first aid rendered by lay persons, paramedical personnel, and community medical practitioners attending out-of-hospital emergencies. We also evaluated the frequency of first aid provided before the arrival of specialised emergency physicians. Over a period of six months all emergencies in a rural district of Germany leading to the pre-hospital medical service being dispatched were studied. Specialised community emergency physicians arriving at the site of the event recorded demographic, clinical, and process data using a standardised instrument. They also assessed the performance of lay persons, paramedical personnel, and community physicians providing immediate care. Implicit and explicit criteria were used. In 97% of cases analysed (n = 1150) members of the above mentioned groups were present before the arrival of the dedicated medical service. Lay persons were judged to provide inadequate care especially with regard to airway management and immobilisation of suspected fractures. For paramedical personnel, the administration of medication, venous lines and immobilisation turned out to be problematic areas. Medical practitioners fell below the defined standards especially in airway management, immobilisation and venous lines. Our project has shown how important the evaluated groups are for community emergency care. Despite methodological problems in this area of study, the shortcomings demonstrated may be targeted by future training at different levels.

DIVING-RELATED EMERGENCIES

The proliferation of sport or recreational divers over the last several decades has resulted in significant increases in the number of patients treated for diving-related emergencies. The treatment of these individuals is no longer confined to a small group of physicians with special training or experience. Rather, community emergency physicians and physicians engaged in the practice of travel medicine are increasingly called on to treat such patients. This article discusses general physical principles relating to diving medicine and common presentations and treatment of diving-related emergencies.

Hepatitis B prevalence in emergency physicians

The seriousness of hepatitis B (HBV) as an occupational hazard to health care workers is well documented. The prevalence of serologic markers for this disease in the general US population is less than 5%, but in medical and dental workers it is significantly higher: 16% in general dentists, 28% in surgeons, 23% in anesthesia personnel, and 30% in emergency department nurses. This study, done under the auspices of the American College of Emergency Physicians (ACEP), focused on the prevalence of HBV markers in emergency physicians. Twenty-five percent of the 1983 ACEP Scientific Assembly attendees participated in the serosurvey. Physicians already vaccinated against hepatitis B were excluded. The majority of participants (58%) were community emergency physicians between 30 and 39 years of age who had six or more years in emergency medicine. A total of 94% of the physicians indicated no prior history of hepatitis, and of these 13.1% had serologic markers for HBV. Including the 10 physicians with both HBV markers and history of hepatitis, the overall prevalence for markers in this study was 15.5%. This prevalence was five times greater than the general population. Emergency physicians should be considered a high-risk group for HBV infection.