Emergency Medicine Programs Research Articles

An Overview of the Allopathic Match.

The number of allopathic emergency medicine (EM) programs has been progressively increasing over the years. In 2018, allopathic EM postgraduate year-1 spots, compared with 2012, increased by around 60% to reach 2278 positions. EM is considered a competitive specialty and therefore, in this article we help guide students interested in EM through the allopathic match requirements, application process, interviews, and ranking EM programs. Additionally, we tackle the combined emergency medicine residency programs, namely the combined EM-Family Medicine (FM), EM-Anesthesiology, EM-Internal Medicine (IM), EM-IM-Critical Care Medicine, and EM-Pediatrics residency programs. Finally, we explain the increased likelihood of matching with the single graduate medical education accreditation system expected to happen in the year2020.

The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program

Blacks, Hispanics/Latinos, American Indians, Pacific Islanders, Alaska Natives, and Native Hawaiians make up 33% of the US population. These same groups are underrepresented in medicine. In 2013, the physician workforce was 4.1% black, 4.4% Hispanic/Latino, 0.4% American Indian or Alaska Native, 11.7% Asian, and 48.9% white. Only 9.9% of emergency physicians identify as underrepresented minority (4.5% black, 4.8% Hispanic/Latino, and 0.6% American Indian/Alaska Native). Efforts to increase the number of underrepresented minority physicians are important because previous studies show improved outcomes when the patient and physician share the same racial/ethnic background. Starting in 2006, the faculty at the Highland EM Residency Program in Oakland, CA, began a diversification initiative to increase the number of underrepresented minority residents. The goal was to closely mirror the US population and match 30% underrepresented minorities with each incoming class. After the initiative, there was a 2-fold increase in the number of underrepresented minority residents (from 12% to 27%). This article is a review of the strategies used to diversify the Highland EM Residency Program. Most components can be applied across emergency medicine programs to increase the number of underrepresented minority residents and potentially improve health outcomes for diverse populations.

Innovation in Residency Selection: The AAMC Standardized Video Interview.

Innovative tools are needed to shift residency selection toward a more holistic process that balances academic achievement with other competencies important for success in residency. The authors evaluated the feasibility of the AAMC Standardized Video Interview (SVI) and evidence of the validity of SVI total scores. The SVI, developed by the Association of American Medical Colleges, consists of six questions designed to assess applicants' interpersonal and communication skills and knowledge of professionalism. Study 1 was conducted in 2016 for research purposes. Study 2 was an operational pilot administration in 2017; SVI data were available for use in residency selection by emergency medicine programs for the 2018 application cycle. Descriptive statistics, correlations, and standardized mean differences were used to examine data. Study 1 included 855 applicants; Study 2 included 3,532 applicants. SVI total scores were relatively normally distributed. There were small correlations between SVI total scores and United States Medical Licensing Examination Step exam scores, Alpha Omega Alpha Honor Medical Society membership, and Gold Humanism Honor Society membership. There were no-to-small group differences in SVI total scores by gender and race/ethnicity, and small-to-medium differences by applicant type. Findings provide initial evidence of the validity of SVI total scores and suggest that these scores provide different information than academic metrics. Use of the SVI, as part of a holistic screening process, may help program directors widen the pool of applicants invited to in-person interviews and may signal that programs value interpersonal and communication skills and professionalism.

An Emergency Medicine Remediation Consult Service: Access to Expert Remediation Advice and Resources.

Resident remediation is a complex and common issue in emergency medicine programs and requires a specific knowledge base. The Remediation Task Force (RTF) of the Council of Residency Directors in Emergency Medicine (CORD-EM) was created to identify remediation best practices and to develop tools for program directors. Initially housed on a Wiki page, and now located within the CORD-EM website, the RTF provides resources including accepted universal language for documentation and sample remediation plans. The RTF also created a remediation consult service composed of experienced educators to provide real-time structured feedback and advice to submitted remediation scenarios with consultation outcomes and conclusions uploaded to the website. CORD-EM members now have easy access to online resources and expert advice for remediation queries through the consult service. The combination of online resources and access to real-time expert advice is an innovative approach to improving resident remediation and recognizing best practices.

Ensuring Patient Safety in Emergency Peripheral Ultrasound-Guided Nerve Blocks: An Evaluation of a Quality Improvement/Patient Safety Initiative

CONTEXTDuring the past two decades, bedside ultrasound has revolutionized the practice of emergency medicine. Physicians are now expected to be competent in utilizing ultrasound skills, for patients presenting with conditions ranging from trauma to skin evaluations. The overall purpose of this quality improvement/patient safety (QIPS) project was to evaluate the effectiveness of a pair of five-hour, hands-on didactic/training sessions, aimed at preparing a sample of emergency medicine physicians, residents and medical students to perform peripheral ultrasound-guided nerve blocks.METHODSThe study location was set in a community-based emergency medicine program in Pontiac, Michigan. Data was collected from N = 54 emergency medicine residents, physicians and medical students. Data was collected from two training sessions in November 2017 and January 2018. The training consisted of a 12-question pre-test, followed by five hours of hands on & didactic training, with a subsequent post-test containing the same questions.RESULTSThe authors compiled the data from both training sessions and found that the participants had an average correct percentage of 5.52 of 12 (46%) on the pre-test. After attending the training session, participants had an overall correct percentage of 9.24 of 12 (77%) on the post-test. This pre-to post-training increase of the mean scores was statistically significant, t (53) = -10.76 (p < 0.01), with an effect size (Cohen’s d) of 1.82. Post hoc power calculations utilizing the d = 1.82 effect size revealed statistical power (1- β) of 100%.CONCLUSIONSThe results of this QIPS evaluation project suggest that emergency physicians, residents and medical students may achieve an improved understanding of key ultrasound-guided nerve block material after a single five-hour session of hands-on training and didactics. Going forward, additional studies employing larger sample sizes that allow for outcome stratification by group (emergency physicians, residents, or medical students) along with relevant demographic variables (age, years in practice, etc.) in similar settings are needed to further verify these findings.

Diagnostic error, quality assurance, and medical malpractice/risk management education in emergency medicine residency training programs.

Background Diagnostic errors in emergency medicine (EM) can lead to patient harm as well as potential malpractice claims and quality assurance (QA) reviews. It is therefore essential that these topics are part of the core education of trainees. The methods training programs use to educate residents on these topics are unknown. The goal of this study was to identify the current methods used to teach EM residents about diagnostic errors, QA, and malpractice/risk management and determine the amount of educational teaching time EM programs dedicate to these topics. Methods An 11-item questionnaire pertaining to resident education on diagnostic errors, QA, and malpractice was sent through the Council of Emergency Medicine Residency Directors (CORD) listserv. Differences in the proportions of responses by duration of training program were analyzed using chi-squared or Fisher's exact tests. Results Fifty-four percent (91/168) of the EM programs responded. There was no difference in prevalence of formal education on these topics among 3- and 4-year programs. The majority of programs (59.5%) offer fewer than 4 h per year of additional QA education beyond morbidity and mortality rounds; a minority of the programs (18.8%) offer more than 4 h per year of medical malpractice/risk management education. Conclusions This needs assessment demonstrated that there is a lack of dedicated educational time devoted to these topics. A more formalized and standard curricular approach with increased time allotment may enhance EM resident education about diagnostic errors, QA, and malpractice/risk management.

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training.

IntroductionRecruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition.MethodsIn this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006–2007 and 2015–2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition.ResultsCompared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7–0.9]), or approximately 51.6 (95% CI [44.7–58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to “health/family reasons” (21.5% vs 9.6%, p=0.019).ConclusionWhile the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

Palliative and end-of-life care education in Canadian emergency medicine residency programs: A national cross-sectional survey.

Emergency physicians play an important role in providing care at the end-of-life as well as identifying patients who may benefit from a palliative approach. Several studies have shown that emergency medicine (EM) residents desire further training in palliative care. We performed a national cross-sectional survey of EM program directors. Our primary objective was to describe the number of Canadian postgraduate EM training programs with palliative and end-of-life care curricula. A 15-question survey in English and French was sent by email to all program directors of both the Canadian College of Family Physicians emergency medicine (CCFP(EM)) and the Royal College of Physicians and Surgeons of Canada emergency medicine (RCPSC-EM) postgraduate training programs countrywide using FluidSurveys™ with a modified Dillman approach. We received a total of 26 responses from the 36 (response rate = 72.2%) EM postgraduate programs in Canada. Ten out of 26 (38.5%) programs had a structured educational program pertaining to palliative and end-of-life care. Lectures or seminars were the exclusive choice to teach content. Clinical palliative medicine rotations were mandatory in one out of 26 (3.8%) programs. The top two barriers to implementation of palliative and end-of-life care curricula were lack of time (84.6%) and curriculum development concerns (80.8%). Palliative and end-of-life care training within EM has been identified as an area of need. This cross-sectional survey demonstrates that a minority of Canadian EM programs have palliative and end-of-life care curricula. It will be important for all EM training programs, RCPSC-EM and CCFP(EM), in Canada, to develop an agreed upon set of competencies and to structure their curricula around them.

Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Program; a Prospective Cross Sectional Study.

Emergency medicine physicians are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health. The present study was performed with the aim of determining the rate of depression and personality disorders in first-year emergency medicine residents and comparing it with the time they reach the 3rd year. In the present prospective cross-sectional study, emergency medicine residents working in multiple teaching hospitals were included via census method and evaluated regarding the rate of depression and personality disorders using the standard MMPI-2 questionnaire upon admission to the program and graduation and their status regarding the evaluated disorders were compared between the 2 phases of evaluation. 99 residents with the mean age of 33.93 ± 5.92 years were evaluated. 85 (85.85%) rated their interest in their discipline as moderate to high. The rates of stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant. Considering the results of the present study, it seems that paying more attention to mental problems and decreasing environmental stressors of medical residents, especially emergency medicine residents, should be among the priorities of managers and policymakers of this discipline.

Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?

Although lesbian, gay, bisexual, and transgender (LGBT) patients are ubiquitous in emergency medicine (EM), little education is provided to EM physicians on LGBT health care needs and disparities. There is also limited information on EM physician behavior, comfort, and attitudes toward LGBT patients. The objective of this study was to assess EM residents behavior, comfort, and attitudes in LGBT health. An anonymous survey link was sent to EM programs via the Council of Residency Director listserv. The primary outcome of the 24-item descriptive survey was the self-reported comfort levels and self-reported practice in LGBT health care. Secondary outcomes included individual comfort toward LGBT colleagues and patients who are LGBT, and the frequency of colleagues making discriminatory statements toward LGBT patients and staff in the emergency department setting. Associations between personal and program demographics and survey responses were also examined. There were 319 responses The majority of respondents were male (63.4%), Caucasian (69.1%), and heterosexual (92.4%). A sizeable minority of respondents felt histories and physical examinations were more challenging for lesbian, gay, or bisexual patients (24.6%) and more so for transgender patients (42.6%). Most residents do not ask patients to identify sexual orientation when presenting with abdominal or genital complaints (63%). Discriminatory LGBT comments were reported from both fellow residents (16.6%) and faculty (10%). A total of 2.5% of respondents were uncomfortable with other LGBT physicians, and 6% did not agree that LGBT patients deserve the same quality care as others. A number of residents find caring for LGBT patients more challenging than heterosexual patients. Even with professed comfort with LGBT health care, most residents report taking incomplete sexual histories that may affect patient care. Attitudes toward LGBT patients are mainly, but not completely, positive in this cohort.

Developing outcome, process and balancing measures for an emergency department longitudinal patient monitoring system using a modified Delphi

BackgroundEarly warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department.MethodsParticipatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE.ResultsUsing the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed.ConclusionThere are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study.

Toxicology education in emergency medicine: an assessment and pilot study

Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine programs have no formal requirements regarding training and education in medical toxicology. From review of previously published survey data less than two-thirds of emergency medicine residencies had formalized access to teaching with toxicologists. To evaluate capacity for toxicology education at ACGME-accredited emergency medicine residency programs, assessment of satisfaction in toxicology education and receptiveness to tele-education modalities. Secondarily to determine feasibility of a pilot web education toxicology program. A survey was conducted in 2015 to evaluate toxicology education capacity, satisfaction with current toxicology education, and technological capabilities of emergency medicine residencies (n = 167). We reviewed websites of non-responding residency programs to determine access to toxicology education. A pilot web-conference-based toxicology education program followed with one residency. Of programs that completed the survey (n = 35, 21%), 77% offered a toxicology rotation for trainees and 60% had an American Board of Medical Toxicology (ABMT)-certified Toxicologist on staff. Programs dissatisfied with toxicology education did not have a toxicology fellowship or an ABMT-certified toxicologist. Participants in the pilot educational program favorably rated the usefulness of the technology, effectiveness of the lecture, value of the subject, and educational value. Barriers exist to implementation of web education. Access to toxicology education through a clinical rotation or medical toxicologist is not consistently available among emergency medicine residency programs, which may indicate programs lacking a toxicologist have lower levels of satisfaction. Successful components of the pilot educational program could be disseminated, but further standardization is indicated.

Integration of Entrustable Professional Activities with the Milestones for Emergency Medicine Residents.

IntroductionMedical education is moving toward a competency-based framework with a focus on assessment using the Accreditation Council for Graduate Medical Education Milestones. Assessment of individual competencies through milestones can be challenging. While competencies describe characteristics of the person, the entrustable professional activities (EPAs) concept refers to work-related activities. EPAs would not replace the milestones but would be linked to them, integrating these frameworks. Many core specialties have already defined EPAs for resident trainees, but EPAs have not yet been created for emergency medicine (EM). This paper describes the development of milestone-linked EPAs for EM.MethodsTen EM educators from across North America formed a consensus working group to draft EM EPAs, using a modified Glaser state-of-the-art approach. A reactor panel with EPA experts from the United States, Canada and the Netherlands was created, and an iterative process with multiple revisions was performed based on reactor panel input. Following this, the EPAs were sent to the Council of Residency Directors for EM (CORD-EM) listserv for additional feedback.ResultsThe product was 11 core EPAs that every trainee from every EM program should be able to perform independently by the time of graduation. Each EPA has associated knowledge, skills, attitudes and behaviors (KSAB), which are either milestones themselves or KSABs linked to individual milestones. We recognize that individual programs may have additional focus areas or work-based activities they want their trainees to achieve by graduation; therefore, programs are also encouraged to create additional program-specific EPAs.ConclusionThis set of 11 core, EM-resident EPAs can be used as an assessment tool by EM residency programs, allowing supervising physicians to document the multiple entrustment decisions they are already making during clinical shifts with trainees. The KSAB list within each EPA could assist supervisors in giving specific, actionable feedback to trainees and allow trainees to use this list as an assessment-for-learning tool. Linking each KSAB to individual EM milestones allows EPAs to directly inform milestone assessment for clinical competency committees. These EPAs serve as another option for workplace-based assessment, and are linked to the milestones to create an integrated framework.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study.

IntroductionResident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).MethodsWe conducted a literature search on SBR practices using the terms “simulation,” “remediation,” and “simulation based remediation.” We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.ResultsFaculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.ConclusionSimulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference.

We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

Development and Utilization of 3D Printed Material for Thoracotomy Simulation.

Medical simulation is a widely used training modality that is particularly useful for procedures that are technically difficult or rare. The use of simulations for educational purposes has increased dramatically over the years, with most emergency medicine (EM) programs primarily using mannequin-based simulations to teach medical students and residents. As an alternative to using mannequin, we built a 3D printed models for practicing invasive procedures. Repeated simulations may help further increase comfort levels in performing an emergency department (ED) thoracotomy in particular, and perhaps this can be extrapolated to all invasive procedures. Using this model, a simulation training conducted with EM residents at an inner city teaching hospital showed improved confidence. A total of 21 residents participated in each of the three surveys [(1) initially, (2) after watching the educational video, and (3) after participating in the simulation]. Their comfort levels increased from baseline after watching the educational video (9.5%). The comfort level further improved from baseline after performing the hands on simulation (71.4%).

ACEM involvement in a successful African emergency medicine programme.

In the past 5 years Botswana graduated its first home-grown doctors and emergency medicine specialists for the country. The postgraduate emergency medicine specialist training arrangement between Botswana and South Africa was challenging in development, implementation and maintenance. Numerous varied supports from ACEM and its International Emergency Medicine Network were integral to these successes. This article encourages further investment of ACEM grants and scholarships in Africa by describing how ACEM supported significant advances in Botswana emergency medicine.

National Clinical Programme for Older People: National Frailty Education Programme "Fundamentals of Frailty"

Introduction: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people (Savva et al., 2013). The associated potential for serious adverse outcomes means that even a relatively minor event such as an infection can result in a dramatic change in health status: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious (Clegg, 2013). Furthermore, frailty has been shown to be a strong and independent predictor of emergency department visits and hospitalisations, hospital readmissions (Pugh et al., 2014) and in-hospital mortality (Bagshaw et al. 2013). Healthcare professionals need to understand the risk factors for frailty to enable them to implement effective programmes for detection, prevention and management. Frailty: What We Know The recognition of frailty is important and should form part of any interaction between an older person and a healthcare professional. An individual’s degree of frailty is not static. It may improve or deteriorate, and is influenced by factors including the care received when an individual presents to a health professional. One of the major challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage frailty Programme Aim: Frailty is an emerging science and this programme was developed to provide healthcare professionals with the knowledge and skills required to provide effective care to older people living with frailty, wherever they access health services. It aims to provide healthcare professionals with an enhanced understanding of frailty and frailty assessments, thereby ensuring earlier recognition , improved healthcare management and better health outcomes for frail older adults. The programme philosophy is based on the belief that education increases knowledge and enhances healthcare professional’s skills in the clinical area. Methodoogy: The National Frailty Education Programme (NFEP) is a collaboration between NCPOP and The Irish Longtitudinal Study on Aging (TILDA), in partnership with the Acute and Emergency Medicine Programmes. Using a proof of concept design the programme is being piloted in three Hospital Groups and corresponding Community Healthcare Organisations. The programme methodology involves: Step 1: Nominated facilitators from participating hospitals and CHOs attend a one day ”Insights into Frailty” education Programme with TILDA. These nominees are representitive of all members of the multidisciplinary team. Step 2: This group attend a one-day workshop with the NCPOP Step 3: These facilitators roll-out the NFEP in an integrated manner across their local organisation. Parallel to this a local governance group is established to support the programme roll-out and to consider new ways of working that will enhance outcomes for the frail older person accessing their services Evaluation: Survey of facilitators knowledge pre and post TILDA Analysis of NFEP participants learning Service outcome evaluation may include: implementation of an assessment tool, audit of the use of the chosen tool, documented referral pathways, initiation of CGA and audit of numbers undertaken. Further examination of impact may involve decreased length of stay, reduction in falls, and audit of delirium management. All outcome measures would be aligned to the NCPOP KPI’s and national strategy.

Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study

IntroductionAlthough emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K).MethodsAt UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012–October 2013 (pre-training) and August 2015–July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).ResultsFrom 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3–7.5%), while post-training EC mortality was 1.2% (95% CI 0.7–1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03–0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9–13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9–9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36–0.94; p = 0.016).DiscussionIn the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.

78 Does Applicant Sex Have an Effect on Standardized Letters of Evaluations Obtained During Medical Student Emergency Medicine Rotations?

Implicit bias in regards to sex and gender has been suspected in the different phases of medical training. A recent study has demonstrated sex bias in emergency medicine residency training as evidenced by a higher rate of milestone achievement in male residents versus female residents. The objective of our study was to assess for sex bias even earlier in the EM training process. The first formal component of an emergency medicine career is the emergency medicine rotation performed in the final year of medical school. A standardized letter of evaluation (SLOE) is written by the institution with whom the student rotated. Over 90 percent of emergency medicine program directors use the SLOE as the most important factor in selecting candidates for their program. This study compared male versus female medical students’ SLOE scores. We performed a retrospective study using SLOEs from 2015 and 2016 that were submitted to a large urban, academic emergency medicine program in southern California. Sex was determined as reported on the student’s residency application. The quantitative measure of SLOE score was determined by a composite score of the 2 components of the global assessment: comparative rank to other rotators and position on institution’s rank list. A perfect score (top 10% on both categories) would be a 2 and the worst score possible is a 9. Each rotation number (either first, second, or third) was compared between male and female applicants using an independent samples t test. 1040 applications were identified with 2,146 total SLOEs. 686 (66%) were male and 354 (34%) were female. Applications came from each region of the country (25% northeast, 24% south, 23% midwest, and 28% west). 933 of the SLOEs were from home institutions and 1213 were from away institutions. The minimum number of SLOEs per student was 1, the maximum was 3, and the mean was 2.1. Male students scored better on their first (4.9 versus 4.6 p<.05), second (5.1 versus 4.7 p<.05), and third rotations (4.9 versus 4.6 p=.14), with the first and second differences being statistically significant. Male applicants also performed better on the USMLE Step 1 exam than female applicants (231.8 versus 228.3 p<.05). However, on the USMLE Step 2 Clinical Knowledge exam, female applicants outperformed male applicants (243.7 versus 241.7 p<.05). Our results indicate that the sex gap that has been identified in emergency medicine residency training exists even earlier than residency. These results further emphasize the need to correct this widespread disparity in training. Several mechanisms for this disparity are proposed and should be addressed. Faculty and evaluators need to be aware of any potential implicit biases they may carry when educating and evaluating students. Access to mentorship for female students needs to be improved.