Emergency Department Rotation Research Articles

Challenges of Nursing Students during Clinical Practice in Emergency Department: A Case Study

Background: Transitioning from theoretical studies to practical scenarios, particularly in the Emergency Department (ED), poses significant challenges for nursing students. These challenges include high time pressure, the complexity of cases, and the urgent nature of situations often encountered. The impact can lead to increased stress levels, a higher workload, and a potential lack of confidence in handling situations that require quick and accurate responses. This study investigated the initial adaptation process of these students, known as Ners, emphasising their environmental adjustment, interpersonal skill enhancement, professional development, and emotional coping strategies. Method: This qualitative study engaged 25 nursing students in ED rotations from November 2023 to March 2024. It utilised detailed interviews, participatory observation, and document analysis, employing thematic analysis to unearth key themes. Results: Four central themes emerged: acclimatisation to the clinical environment, dynamics of relationships and interactions, skills and competencies enhancement, and coping with emotional and psychological challenges. Initially challenged, students gradually became accustomed to the ED's demands, enhancing their professional and social skills and developing effective stress management strategies. Conclusion: The findings highlight the necessity for comprehensive preparation and ongoing support and suggest significant implications for improving nursing education and practices within the ED.

Determining the Educational Value of an Emergency Medicine Rotation for Non-Emergency Medicine Residents.

Background Residents from diverse specialties perform clinical rotations in the emergency department (ED). There is little research about the value of the ED rotation for them. Objectives We sought to determine the learning objectives of non-EM residents (NEMRs) in the ED, the effectiveness of the rotation, and the highest-yield components of their experience. Methods From 2017-2019, we surveyed NEMR on their pre-rotation learning objectives and their comfort level with 15 common ED presentations/procedures before and after the rotation. We assessed how well their objectives were met, the highest-yield components of their rotation, and opportunities for improvement. Results We collected responses from 56 (47%) pre-rotation and 61 (51%) post-rotation residents over a two-year period. The five most commonly cited learning goals were: management of acutely ill patients, triage skills, procedural competence, and ultrasound. Seventy-eight percent (78%) of residents reported their learning goals were moderately to very well met during their rotation. NEMRs' level of comfort improved in all the commonly encountered clinical experiences in the ED in a statistically significant manner. They cited on-shift teaching by attending physicians and senior EM residents as the most valuable learning resource. Conclusion NEMR from diverse medical and surgical specialties could identify specific learning objectives for their EM rotation with common themes, and the majority felt their educational goals were met. They gained comfort with the management and triage of all the assessed common ED conditions. By collecting and defining their specific needs and goals, we are better equipped to improve the quality and value of the rotation.

Formative Assessments Promote Procedural Learning and Engagement for Senior Pediatric Residents on Rotation in the Pediatric Emergency Department.

IntroductionProcedural training is a universal concern amongst pediatric residents and their teachers. We developed and implemented formative assessments to generate direct and indirect procedural feedback. We analyzed changes in residents’ perceived procedural knowledge, skills, confidence, and entrustment.MethodsSenior pediatric residents rotating in the pediatric emergency department participated in video-recorded formative assessments of informed consent OSCEs and simulated toddler forehead laceration repair and infant lumbar puncture. Residents reflected on their perceived procedural knowledge, skills, confidence, and entrustment through Likert and entrustment scales. Secondary outcomes of formative assessment completion rates and proportions of procedures performed by pediatric residents tracked feasibility and potential clinical impact, respectively.ResultsIncluding the pilot period, 89% of residents (31 out of 35) received direct and indirect procedural feedback. Perceived composite competency and entrustment improved for laceration repair (competency: from 3.1 to 3.9, p < .001; entrustment: from 4.0 to 5.1, p < .001) and lumbar puncture (competency: from 3.5 to 4.0, p < .001; entrustment: from 4.6 to 5.6, p = .001). We observed an increase in the proportion of clinical laceration repairs (11% [97 out of 885] vs. 23% [218 out of 946], p < .001) and lumbar punctures (23% [12 out of 54] vs. 41% [21 out of 52], p = .05) performed by pediatric residents.DiscussionIntegrating feasible procedural formative assessments into the pediatric emergency department rotation had a positive impact on senior pediatric residents’ perceptions of their procedural knowledge, skills, confidence, and entrustment and was associated with increased procedural engagement.

Perception of medical interns about simulation-integrated curriculum of their emergency medicine rotation.

To evaluate the perception of interns about their experience during one-month rotation in the emergency department, and the impact of adding simulation-based training. The retrospective study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, and comprised feedback surveys filled by interns at the end of their rotation in the emergency department between December 2017 and July 2020. The feedback questionnaire in use is aimed at evaluating interns' experience with the emergency department rotation and the common academic activities during the rotation period. A comparison was done between those who had received simulation-based training and those who had not. Data was analysed using SPSS 24. Of the 971 interns having done rotation in the emergency department, 718(74%) had completed the survey. Simulation-based training had been received by 208(29%) interns, while 510(71%) had not received it. Mean points given on a scale of 1-10 by the interns was 8.2+/-1.8. Overall, 684(95%) interns believed the rotation had met or exceeded their expectations (p>0.001). There was no significant difference between those who had received simulation-based training and those who had not (p>0.05). Interns had a positive perception towards the learning experience during their emergency department rotation, but there was no difference between those who had received simulation-based training and those who had not.

Evaluation of the Confidence and Competency of House Officers in Rapid Sequence Intubation (ECCHO-RSI) in Emergency Department of Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia Medical Centre during COVID-19 Pandemic

Rapid sequence intubation (RSI) is a procedural skill that house officers (HO) in Malaysia need to learn during their training in emergency department (ED) posting. This study aimed to evaluate the confidence and competency of HO in RSI after completed training in the ED of a university hospital during the COVID-19 pandemic. A prospective cross-sectional study was conducted among 44 HO. When they begin their posting in ED, a pre-test was done with a questionnaire to evaluate their knowledge and confidence level. A post-test was conducted three months later with a similar questionnaire. They underwent an objective structured clinical examination to evaluate their skill. A feedback survey form was filled in by the HO regarding their satisfaction in training in emergency rotation. The mean score for pre-test and post-test were 8.75 ± 3.005 and 14.86 ± 2.258, respectively (P = 0.000). There was an improvement in knowledge level and confidence level between pre-test and post-test (all P = 0.000). 43.2% were competent in knowledge, while 65.9% were competent in skill. 35 house officers filled in the feedback survey form. It showed that 42.9% (n = 15) were very satisfied and 28.6% (n = 10) were satisfied with the training in ED. There was an improvement in knowledge and confidence level in RSI among the HO after ED rotation. The clinical exposure in intubating real patients was limited among HO due to the COVID-19 pandemic. The training of HO for RSI in ED needs to be further improvised to optimize their learning process.

The Impact of the COVID-19 Pandemic on Medical Interns' Education, Training, and Mental Health: A Cross-Sectional Study.

Background and objectivesThe novel coronavirus disease 2019 (COVID-19) pandemic has challenged healthcare systems worldwide. Various studies have revealed the negative impact of the pandemic on the education and mental health of medical students and residents. In this study, we aimed to explore the effects of the COVID-19 pandemic on medical interns’ educational experience, clinical practice, and mental health. We also engage in a discussion on the compensatory methods that have been adopted to improve medical interns’ learning processes during the ongoing pandemic.MethodsThis cross-sectional survey-based study was conducted at the King Saud University Medical City (KSUMC) in Riyadh, Kingdom of Saudi Arabia (KSA) from March to October 2020. The participants consisted of medical interns. The survey collected information on participants’ demographics, training, and the educational and psychological impact of the pandemic.ResultsThe survey was distributed to 480 medical interns, of whom 345 (71.8%) participated. Most of our sample (75.6%) believed that the COVID-19 pandemic has negatively impacted their cumulative experience. Regarding the pandemic’s impact on training and education, it was found that the emergency department rotation was the most affected rotation (60.3%). The majority of the participants (55.9%) believed that all tracks have received equal education and the volume of patients seen by interns decreased by 91.9%. As for the compensatory methods, 73.3% reported the utilization of remote platforms. Regarding the pandemic’s mental health impact, 36% believed that it has affected their mental health, where increased stress levels were noticed in 47.8% of participants. Statistical significance was found in both Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scores, which indicated that during the pandemic, 20.6% of the participants suffered from depression, and 13.9% had moderate to severe anxiety.ConclusionsThis study highlights the negative educational and psychological impact of COVID-19 on medical interns. With emerging infectious diseases on the rise, recognizing the impact of COVID-19 on medical interns is vital to improving interns’ educational experiences and mental health during future crises.

Comparison of three intraosseous access devices for resuscitation of term neonates: a randomised simulation study

ObjectivesTo compare the success rates and ease of use of three intraosseous (IO) access devices used in term neonates.DesignA three-arm randomised controlled simulation study was conducted.SettingA simulation laboratory.ParticipantsSeventy-two paediatric residents...

A Community Emergency Department Rotation for Pediatric Emergency Medicine Fellows: Development and Evaluation.

There have been increasing job opportunities for pediatric emergency medicine (PEM) specialists within community emergency departments (CEDs), where 90% of children receive emergency care. The majority of training for PEM fellows occurs in academic children's hospitals, which may expose fellows to different resources than CEDs. Our goals were to develop and to evaluate a CED rotation aimed at improving exposure to this care environment for PEM fellows. Kern's 6 steps of curriculum development served as our framework to identify the problem, conduct a needs assessment, develop goals and objectives, formulate an educational strategy, and then plan the implementation and evaluation. Discussion and buy-in among trainees and hospital leadership took place during rotation development. Informal and web-based surveys of PEM fellows and CED attendings evaluated the rotation and assessed participants' reactions, changes in knowledge, and changes in behavior. The CED rotation was piloted at 1 PEM fellowship program over 2 years. Nine PEM fellows participated in the month-long rotation. The majority of participants reported that the rotation goals and objectives were met and that they acquired new skills and rated the CED rotation as good or excellent. Challenges to the CED rotation included lower patient acuity and distance to the CED. A new CED rotation was developed, piloted, and well received by participants. Given the potential differences in practice between tertiary care children's emergency departments and CEDs, as well as increasing job opportunities in CEDs, program directors should consider incorporating a CED rotation for their PEM fellows.

Assessing the effectiveness of pediatric emergency medicine education in emergency medicine residency training: A national survey

Background: Evaluating the effectiveness of pediatric emergency medicine training is essential to ensure that emergency physicians and emergency medicine residents have sufficient knowledge, skill, and confidence in optimizing care for acute pediatric visits. Although the field of pediatric emergency medicine has experienced phenomenal growth in past decades, it still faces challenges in how to best implement the curriculums in emergency medicine residency training programs. Objectives: Exploring emergency physicians’ and emergency residents’ perspectives on pediatric emergency medicine training in emergency residency training programs in Taiwan through a nationwide survey. Methods: The survey was distributed to 1281 emergency physicians and emergency medicine residents in 43 teaching hospitals. The survey inquired about demographic data, hospital type, rank of proctored trainers and assessors, and the setting of pediatric emergency medicine training. Participants’ confidence in managing acute pediatric visits and their satisfaction and reflections of their pediatric emergency medicine training were explored. Results: In all, 258 responses were received from 117 residents and 141 emergency physicians. Seventy-seven percent reported working in medical centers. Clinical supervision was primarily performed by pediatric attending physicians and emergency physicians. Fifty-eight percent of participants felt satisfied with their pediatric emergency medicine training. However, only 52.3% felt confident managing acute pediatric visits, which was attributed to inadequate exposure to pediatric patients. Residents noted lack of confidence in managing newborns, infants, and clinical procedures. Therefore, simulation training and point-of-care ultrasound learning were considered advantageous. Conclusion: The pediatric emergency medicine training in emergency medicine residency programs is diverse in intensive care training, supervisors, and assessors. Surveys demonstrate that learning experience in pediatric wards and emergency department rotations is associated with overall satisfaction with pediatric emergency medicine training; inadequate exposure to pediatric patients contributed to learners having less confidence. Emergency medicine residency program reform might focus on adequate hands-on pediatric patient care.

Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App.

BackgroundThe Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app’s usability and user acceptability.ObjectiveThis study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians).MethodsThe enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened.ResultsA total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app—more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally.ConclusionsThis study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants’ continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact.

Young Doctors’ Emergency Medicine Rotation Qualifications and Relation with Self-Confidence

Introduction:Medicine is one of the most important areas of higher education. It is important that undergraduate students are well educated and have theoretical knowledge, but also have good clinical skills after graduating from medical training.Aim:To understand whether the training objectives of the emergency medical internship was completed or not and to find the relationship between young doctors’ self-confidence and what they can do via using Rosenberg self-esteem scale (RSES). In addition, an objective was to consider which learning methods are more useful based on the feedback.Methods:This survey study was performed in 2018 at Bulent Ecevit University, Faculty of Medicine, Zonguldak, Turkey with the students who completed an emergency department rotation in the 2017-2018 education term. The questionnaire was composed by the researchers. It consisted of three parts which were included demographic information and education methods in emergency medicine of internships, questions about knowledge goals and learning goals for basic medicine applications, and RSES to assess young doctors’ self-confidence.Results:96 young doctors with the mean age of 25.22 ± 1.216 years(minimum 23 and maximum 30 years) were in the study5. 3 (55.2%) of which were female. All young doctors were evaluated with RSES4. (4.2%) of which were low self-confidence and 32 (33.3%) of which were high self-confidence. The best useful learning methods were clinical application of interaction with patients (n=828. 5%) and invasive procedures performed on patients (n=727. 5%).Discussion:The more you practice, the more you learn. Practice-based education is an important factor in a young doctor’s life. Besides, the higher self-confidence you have, the more you can. Young doctors with high self-esteem see themselves as qualified to perform applications even in complicated situations. However, more studies are needed to find out whether they could really perform or not.

Acceptability of a Mobile Clinical Decision Tool Among Emergency Department Clinicians: Development and Evaluation of The Ottawa Rules App.

BackgroundThe Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.ObjectiveThe primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.MethodsThe Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.ResultsA total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.ConclusionsWe have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

Impact of Early Educational Intervention on Coding for First-year Emergency Medicine Residents.

Coding of a medical visit is based on provider documentation in the medical record; the documentation should reflect the level of care that was provided. To maximize coding and subsequent billing, providers must complete various components of the record to best convey the complexity of the case. Little education is provided to resident physicians regarding appropriate documentation practices, and studies suggest a need for improved education in this area. The primary goal of this study is to determine if implementing an early educational intervention will improve billing and coding. This was a randomized, prospective controlled study in an academic Level I emergency department (ED). Interns without prior experience in billing and coding were eligible participants. Participants in the intervention group each received an interactive lecture on coding, evaluation and management (E/M) levels, and documentation macros, prior to their first ED rotation at the base hospital. A pocket card with E/M level requirements was given as a resource. Biweekly feedback was given to the residents to address any patterns of mistakes. The number of charts for each E/M level was collected from both groups, which were converted to relative value units (RVUs). A multivariate analysis using multivariate linear regressions controlling for age, sex of patient, admission rate, and month of encounter was used to statistically evaluate billing outcomes. The mean RVUs per hour and encounter in the intervention group were, respectively, 3.52 and 3.84 while in the control group they were, respectively, 3.36 and 3.72 (p = 0.0112). Intervention group encounters had 27% greater odds (odds ratio = 1.27) of having a level 5 chart compared to the control group (p = 0.0025). The focused longitudinal educational interventions resulted in improved billing performances, reflected by better documentation, in the intervention group versus the control group.

Awareness of Diagnostic Error among Japanese Residents: a Nationwide Study.

Residents' understanding of diagnostic error may differ between countries. We sought to explore the relationship between diagnostic error knowledge and self-study, clinical knowledge, and experience. Our nationwide study involved postgraduate year 1 and 2 (PGY-1 and -2) Japanese residents. The Diagnostic Error Knowledge Assessment Test (D-KAT) and General Medicine In-Training Examination (GM-ITE) were administered at the end of the 2014 academic year. D-KAT scores were compared with the benchmark scores of US residents. Associations between D-KAT score and gender, PGY, emergency department (ED) rotations per month, mean number of inpatients handled at any given time, and mean daily minutes of self-study were also analyzed, both with and without adjusting for GM-ITE scores. Student's t test was used for comparisons with linear mixed models and structural equation models (SEM) to explore associations with D-KAT or GM-ITE scores. The mean D-KAT score among Japanese PGY-2 residents was significantly lower than that of their US PGY-2 counterparts (6.2 vs. 8.3, p < 0.001). GM-ITE scores correlated with ED rotations (≥6 rotations: 2.14; 0.16-4.13; p = 0.03), inpatient caseloads (5-9 patients: 1.79; 0.82-2.76; p < 0.001), and average daily minutes of self-study (≥91min: 2.05; 0.56-3.53; p = 0.01). SEM revealed that D-KAT scores were directly associated with GM-ITE scores (ß = 0.37, 95% CI: 0.34-0.41) and indirectly associated with ED rotations (ß = 0.06, 95% CI: 0.02-0.10), inpatient caseload (ß = 0.04, 95% CI: 0.003-0.08), and average daily minutes of study (ß = 0.13, 95% CI: 0.09-0.17). Knowledge regarding diagnostic error among Japanese residents was poor compared with that among US residents. D-KAT scores correlated strongly with GM-ITE scores, and the latter scores were positively associated with a greater number of ED rotations, larger caseload (though only up to 15 patients), and more time spent studying.

An Inner City Emergency Medicine Rotation Does Not Improve Attitudes toward the Homeless among Junior Medical Learners.

IntroductionLearners in the emergency department (ED) frequently encounter individuals who are homeless. We sought to evaluate the effect of an inner city emergency medicine rotation at the Royal Alexandra Hospital (RAH) on the attitudes of medical students and residents towards this population.MethodsData were collected both pre- and post-rotation using an electronic survey. Data collected included demographic information and as well as scores on the Health Professionals’ Attitudes Towards the Homeless Inventory (HPATHI). Pre- and post-survey results were compared using Wilcoxon tests.ResultsNinety-eight students completed the rotation. A total of 40 (41%) students completed both pre- and post-surveys. Demographic information was available for 66 respondents. Most participants were male (42 {64%}), single (47 {71%}), and 30 years of age or younger (59 {89%}). Most participants were of a Caucasian or East/South Asian background (61 {92%}) and grew up in an urban setting (51 {77%}). Overall, 43 (90%) participants saw at least one person who was homeless during their rotation. There was no significant difference between pre- and post-aggregate scores (z = -0.78, p = 0.44), or any of its three subscales (Personal Advocacy, Social Advocacy, and Cynicism).ConclusionFirst year residents and medical students are frequently exposed to patients who are homeless during an inner city ED rotation. Attitudes towards these patients did not significantly change following the rotation. Educational objectives should be set to improve attitudes of learners towards those with unstable housing throughout the ED rotation.

A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners

Introduction: Stress and burnout are highly prevalent among medical doctors, and are associated with negative consequences for doctors, patients, and organizations. The purpose of the current study was to examine the effectiveness of a mindfulness training intervention in reducing stress and burnout among medical practitioners, by means of a Randomised Controlled Trial design.Methods: Participants were 44 intern doctors completing an emergency department rotation in a major Australian hospital. Participants were randomly assigned to either an active control (one hour extra break per week) or the 10-week mindfulness training intervention. Measures of stress and burnout were taken pre-, mid- and post intervention.Results: Participants undergoing the 10-week mindfulness training program reported greater improvements in stress and burnout relative to participants in the control condition. Significant reduction in stress and burnout was observed for participants in the mindfulness condition. No such reductions were observed for participants in the control condition.Conclusions: Mindfulness interventions may provide medical practitioners with skills to effectively manage stress and burnout, thereby reducing their experience of these symptoms. It is likely that doctors would benefit from the inclusion of such a training program as a part of their general medical education.

Comparison of rates of emergency department procedures and critical diagnoses in metropolitan and rural hospitals

Emergency medicine (EM) workforce studies show low rates of board-certified/residency-trained emergency physicians practising in rural emergency departments (EDs) in the USA. Rural ED rotations for EM residents may lead to increased numbers of residency-trained EM providers in rural areas. There is concern that residents trained in rural environments will not get sufficient procedural experience or patient acuity. The current literature contains only one single-residency study that provides procedural experience and patient acuity comparison between metropolitan and rural EDs. The purpose of this study is to utilize the Nationwide Emergency Department Sample (NEDS) to compare the rate of selected procedures and critical diagnoses at rural and metropolitan EDs in the USA. The NEDS database contains ED visit records from 958 hospitals and approximates a 20% stratified sample of US hospital-based EDs. The procedures analyzed were chosen based upon the Emergency Medicine Residency Review Committee's guidelines for procedural competency and the critical diagnoses were selected based upon the American College of Emergency Physicians Model of the Clinical Practice of Emergency Medicine. Procedures and critical patient diagnoses were identified in the NEDS database by International Classification of Diseases (9th revision) code. The rates of eight procedures and twelve critical diagnoses are compared between two categories: The metropolitan category includes hospitals that are in counties defined as large or small metropolitan; the rural category includes hospitals that are in counties defined as micropolitan or non-metropolitan. When comparing 22 766 219 rural ED visits to 97 267 531 metropolitan ED visits there were significant differences between the rates of procedures and critical diagnoses. For all procedures analyzed, the rate at which they were performed in the rural setting versus the metropolitan was significantly lower. The decreased performance rate in rural EDs compared to metropolitan EDs was greatest for ED procedures such as fracture reduction, endotracheal intubation and lumbar puncture. Overall, procedures were performed twice as often in metropolitan EDs as compared to rural EDs. Critical diagnosis rates also tended to be lower for rural EDs when compared to metropolitan EDs. This difference in identification of critical diagnosis rate was greatest for acute myocardial infarction, cardiac dysrhythmia and ischemic cerebrovascular accident. The rates of critical diagnoses are similar, but are still lower in rural EDs as a recent single-site study has shown. The lower rates of procedures and critical diagnoses in rural EDs confirm the concern that residents receiving a substantial portion of their training in rural EDs may not get sufficient experience in certain procedures or critical diagnoses. The benefits of a rural ED rotation must be weighed against the risk of lower procedure and critical diagnosis rates. The impact of a 1-3 month rotation in a rural ED on overall procedural competency and clinical experience cannot, however, be extrapolated, and further study is required to quantify this effect.

Advanced pharmacy practice experiences for pharmacy students in emergency department settings

PurposePharmacy practice in the emergency department (ED) has grown dramatically over the past decade; however, it is not clear if the growth has provided opportunities for pharmacy students through clinical rotations. The purpose of this investigation was to determine the percentage of schools/colleges of pharmacy that offer an advanced pharmacy practice rotation experience. Secondary objectives included the longevity, how the rotation is classified, and the extent to which these rotations are offered by full-time faculty of the school/college. MethodsThe survey was sent to experiential education coordinators at 130 schools/colleges in the United States and Puerto Rico. Participants could opt in to a drawing for one of eight gift cards. Data were entered into an electronic spreadsheet, and descriptive and inferential statistics were calculated as appropriate. ResultsOverall, 58 valid surveys were returned (44.6%). Most schools/colleges of pharmacy offered this type of rotation (86.2%). The respondents represented 6402 graduates annually, offering 586 (9.2% graduates) rotations for 5.4 ± 5.3 years (mean ± standard deviation). The location for ED rotations were community hospitals (60.3%), academic/university (54.4%), Veterans Affairs/governmental (10.3%), pediatric (6.9%), or other (6.9%). Respondents could check more than one category, so percentages sum to greater than 100%. ConclusionsThe majority of schools/colleges of pharmacy offer a rotation in the ED; however, less than 10% of graduates will be exposed to this type of educational opportunity. Students are most likely to have their APPE rotation in community hospitals.

Increasing Off-Service Resident Productivity while on their Emergency Department Rotation Using Shift Cards

BackgroundDifferences in productivity between off-service residents rotating in the emergency department (ED) and their emergency medicine (EM) resident counterparts have never been directly quantified. ObjectivesWe sought to quantify the difference between off-service residents rotating in the ED and their EM resident counterparts. We also sought to find whether shift cards could be used to increase the productivity of off-service residents rotating in the ED. MethodsThis is a prospective cohort study conducted at an urban, tertiary, Level I trauma center. We implemented the use of shift cards for off-service residents during their EM rotation. Completion of the shift card involved recording patients seen and their dispositions, procedures done, and documenting a learned bedside teaching point from their shift that day. Productivity was measured in terms of patients seen per hour (PPH) and relative value units per hour (RVU/h). ResultsOff-service residents showed a productivity of 0.529 PPH (95% confidence interval [CI] 0.493–0.566) and 1.40 RVU/h (95% CI 1.28–1.53) prior to implementation of shift cards. With the introduction of shift cards, productivity increased to 0.623 PPH (95% CI 0.584–0.663, p = 0.001) and 1.77 RVU/h (95% CI 1.64–1.91, p = 0.001). In comparison, first year EM resident productivity was 0.970 PPH (95% CI 0.918–1.02) and 3.01 RVU/h (95% CI 2.83–3.19). ConclusionsShift cards can be used to foster motivation for off-service residents rotating in the ED, and is a simple and cost-effective method to improve system-based practices and utilization of resources.

Pediatric emergency medicine asynchronous e-learning: a multicenter randomized controlled Solomon four-group study.

Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.