Emergency Medicine Residency Training Programs Research Articles

Using Slack to Facilitate Virtual Small Groups for Individualized Interactive Instruction.

Individualized interactive instruction provides an opportunity for significant innovation and advances in curriculum design. We describe the development and implementation of virtual small group exercises into the curriculum of an emergency medicine residency training program using a free social media and communication platform (Slack). Two virtual small group exercises, one case-based and one open-ended, were trialed during the 2016 to 2017 academic year. We found that the exercises were feasible to implement in a learner group where 66% (41/62) had little or no prior experience with Slack. There was a trend toward a more favorable rating of the quality of the dialogue and of the task-technology fit for the case-based format as opposed to the open-ended educational activity.

ACGME Clinical and Educational Work Hour Standards: Perspectives and Recommendations from Emergency Medicine Educators

IntroductionThe American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical Education’s (ACGME) Second Resident Duty Hours in the Learning and Working Environment Congress. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony.MethodsIn 2016 our joint working group of experts in EM medical education conducted a consensus-based, mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv.ResultsA total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions, organizational recommendations were crafted and submitted to the ACGME.ConclusionEM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.

193 Impact of Implementation of Emergency Medicine Training on Emergency Department Mortality in Kigali, Rwanda: An Interrupted Time-Series Quasi-Experimental Design

Although emergency medicine (EM) training programs have recently been introduced in low- and middle-income countries (LMICs), no data exists on their effects on patient-centered outcomes in resource-limited settings. This study evaluated the impact of EM training on emergency department (ED) mortality among patients treated at the University Teaching Hospital of Kigali (UTH-K) ED. The study was conducted at UTH-K, the primary public referral hospital in Rwanda. An EM post-graduate diploma program was begun at UTH-K in October 2013 and full EM residency training program was begun in September 2015. Prior to initiation of these training programs, care was provided exclusively by general practice physicians (GPs); since initiation, ED care has been provided through mutually exclusive shifts allocated between GPs and EM resident (EMR) trainees who have oversight by board certified emergency physicians. All patients presenting to the ED during the nine-month period prior to initiation of the EM training (Jan.-Sept., 2013) and nine-months following the start of the EM residency program (Sept. 2015-June 2016) were eligible for inclusion. Study personnel abstracted data from a random sample of hospital records using a structured collection instrument. Prevalence and risk differences (RD) of all cause ED mortality were compared for cases treated before and after EM training initiation and based on provider type (GPs or EMRs). Secular trends were assessed and magnitudes of effects were quantified using odds ratios (OR) with 95% confidence intervals (CI). Multivariate models were adjusted a priori for age, type and severity of illness. From the 35,491 encounters during the study period, 2,580 cases were randomly sampled. There were 1,480 cases prior to training initiation and 1,100 after. The median age was 32 years (inter-quartile range (IQR): 22, 49) with a male predominance (59.9%). Medical patients comprised 54.0% of cases and injuries account for 46.0%. Median ED length of stay (LOS) was 1 day (IQR: 0, 3). The majority of cases were admitted (55.4%). Compared to the pre-implementation period, post implementation cases were more likely to be admitted (p<0.001). Pre-implementation mortality prevalence was 6.8% (95% CI: 5.4, 8.2%); post-implementation prevalence was 1.2% (95% CI: 0.5, 1.9%). In multivariate regression, as compared to ED cases treated prior to the initiation of the EM training program, those treated after were less likely to suffer ED mortality (aOR=0.14, 95% CI: 0.07, 0.30; p<0.001). In assessment by provider type, ED mortality among cases treated by GPs was 6.6% (95% CI: 5.5, 7.6%) and 1.3% (95% CI: 1.6, 2.4%) for those treated by EMRs. In regression analysis, compared to cases treated by GPs those treated by EM trainees were significantly less likely to experience ED mortality (aOR=0.08, 95% CI: 0.01, 0.55; p=0.011). No differences in secular trends in mortality were identified based on shift type either prior to (RD: 0.5%, 95% CI: -0.4, 4.6%; p=0.79) or after training initiation (RD: 0.9%, 95% CI: -0.8, 2.6%; p=0.35). ED mortality was significantly reduced with implementation of EM training in the studied population in Rwanda. Although limited by design aspects, these results demonstrate the benefit on an objective patient-centered outcome of EM training in a LMIC, and supports further research and investment in EM training in resource-limited settings.

Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs

Strategies to Enhance Wellness in Emergency Medicine Residency Training Programs

PGY 3 Chief Residents in a 4-Year Emergency Medicine Residency Training Program: A Unique Paradigm.

Emergency medicine (EM) chief residents are traditionally drawn from the most-senior class of residents. Our training program's chief residency structure is, to our knowledge, unique in that it is the only 4-year EM training program to select PGY 3 residents as chief residents. This structure allows PGY 4 residents enrolled in a 4-year curriculum to focus their final year of residency training on their professional development and on laying a foundation for a career in academic EM while unencumbered with the responsibilities of chief residency. Conventional thinking holds that the most senior individual is the most capable of serving in a leadership role as chief resident; our experience has shown, however, that selecting chief residents from the PGY 3 class of a 4-year residency program is not only feasible and well received by our residents, our residency training program, and our department, but is invaluable to the development of all individuals in the PGY 4 class regardless of whether or not they served as a chief resident. We recommend that 4-year EM residency training programs in development as well as 4-year programs that currently use-or plan to incorporate-longitudinal academic development or track systems consider this model.

LO42: Ice Cream Rounds: the adaptation and implementation of a peer-support wellness rounds in an emergency medicine residency training program

Introduction/Innovation Concept: Emergency Medicine (EM) is a specialty that requires physicians to deal with acutely ill patients in a fast-paced environment, which can create stress, mental exhaustion and burnout. Continually changing working teams in the Emergency Department does not always allow appropriate debriefing for difficult patient encounters and outcomes on shift. To address these challenges, we sought to adapt and implement a peer-support rounds called ‘Ice Cream Rounds’ used in some Pediatric training programs for an EM training program. Methods: CCFP and Royal College EM residents were surveyed to determine interest and need for Ice Cream Rounds. Of the 31/50 respondents, 87% (26/31) identified their co-residents as their main source of support after difficult patient encounters and 71% (22/31) felt that current opportunities to debrief after difficult experiences were only “sometimes” or “rarely” adequate. Overall, 84% (26/31) were interested in attending Ice Cream Rounds. Residents expressed that they did not want staff present for Ice Cream Rounds so two residents (SCS and TK) obtained training to lead peer-support sessions from The Faculty of Medicine Wellness Program. Attendance at rounds was voluntary and the EM program provided funding for refreshments. Two Ice Cream Rounds were piloted. Attendance and feedback was recorded from pilot sessions. Curriculum, Tool, or Material: Resident-only, peer-run confidential debriefing sessions. Sessions were voluntary and lasted one hour. Approximately 20-30/50 residents attended each Ice Cream Rounds. Discussions were confidential but include topics such as difficult patient encounters, poor patient outcomes, challenges in residency, and ethical issues. In response to positive attendance and feedback, the EM program provided 3-4 one-hour protected time slots with a stipend for refreshments for future academic years. Comments from residents consistently reaffirmed that Ice Cream Rounds was a helpful forum to discuss important issues with colleagues and provided a safe and confidential resource to help cope with residency challenges. Conclusion: We adapted, implemented, and evaluated a novel Peer-Support Wellness Rounds for debriefing resident issues and difficult patient encounters in a EM training program. To our knowledge this is the first Canadian initiative to implement such rounds in an EM training program. We believe that this template can be easily adopted by any EM training program and will effectively address wellness challenges faced by residents during their training.

LO21: Mentorship in Canadian emergency medicine residency training programs: a needs assessment

Introduction: Research supports the role of mentors in the personal development and career advancement of medical trainees. Compared to non-mentored peers, mentored residents are nearly twice as likely to describe excellent career preparation and demonstrate objective career success. In prior research, only 65% of training programs in Canada had a mentorship program, and 40% indicated a need for more formal mentorship models. Methods: A needs assessment survey was distributed to RCPSC Emergency Medicine (EM) Program Directors across Canada regarding mentorship available to resident physicians training at their centers. Additionally, all EM resident and staff physicians involved in mentorship were surveyed on their perceptions of current models at their institutions. Both surveys were comprised of binary, open ended, and 5 point likert scale questions. Responses were analyzed using Fisher’s exact test. Results: Eleven Program Directors responded to the survey. Formal mentorship programs were found in 82% of training centers, with 77% of programs instituted within the past 5 years. Half of resident/mentor pairings were based on a combination of identified career goals, participant personality traits, or resident request. Other pairing methods included perceived resident needs or attending physician request. Most meetings are face-to-face, with one program requiring mutual scheduled shifts. Residents identified that mentorship was significantly associated with benefits to career (p=0.0016) and niche (p=0.0019) development. Formal mentorship was felt to have a significant association with resident academic development (p=0.05) and lower rates of burnout (p=0.0018) by staff physicians. Staff mentors also associated a personal development benefit related to involvement in a mentorship relationship (p=0.0355). Conclusion: The majority of EM programs have adopted formal mentorship programs within the past 5 years. Residents and staff identify that mentorship relationships are associated with improved career and niche development as well as academic advancement. Future research will include a before and after study of the implementation of a formal mentorship program within the RCPSC-EM program at the University of Manitoba.

Creation of a Novel Educational Liaison Position for the Emergency Medicine Residency Training Program at Addis Ababa University: A Model for Maturing Bi-institutional Educational Partnerships

Creation of a Novel Educational Liaison Position for the Emergency Medicine Residency Training Program at Addis Ababa University: A Model for Maturing Bi-institutional Educational Partnerships - Volume 32 Issue S1

Resident Development via Progress Testing and Test-Marking: An Innovation and Program Evaluation.

IntroductionSince 2008, the McMaster University Royal College Emergency Medicine residency training program has run practice Short Answer Question (SAQ) examinations to help residents test their knowledge and gain practice in answering exam-style questions. However, marking this type of SAQ exam is time-consuming.MethodsTo help address this problem, we require that senior residents help mark at least one exam per year alongside faculty members. Examinees’ identities are kept anonymous by assigning a random number to each resident, which is only decoded after marking. Aggregation of marks is done by faculty only. The senior residents and faculty members all share sequential marking of each question. Each question is reviewed, and exemplar “best practice” answers are discussed. As novel/unusual answers appear, instantaneous fact-checking (via textbooks, or the internet) and discussions occur allowing for real-time modification to the answer keys as needed.ResultsA total of 22 out of 37 residents (post graduate year 1 to post graduate year 5 (PGY1 to PGY5)) participated in a recent program evaluation focus group. This evaluation showed that residents feel quite positive about this process. With the anonymization process, residents do not object to their colleagues seeing and marking their answers. Senior residents have found this process informative and have felt that this process helps them gain insight into better “examsmanship.”ConclusionsInvolving residents in marking short-answer exams is acceptable and perceived as useful experience for improving exam-taking skills. More studies of similar innovations would be required to determine to what extent this may be the case.

Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

Utility of 360-degree assessment of residents in a Turkish academic emergency medicine residency program

ObjectivesThis study was designed to test a 360-degree assessment tool for four of the emergency medicine resident competencies as outlined by the Council of Residency Directors in Emergency Medicine on patient care, communication skills, professionalism and system based practice in an academic Emergency Department. Material and methodsUsing the competency framework of the American Accreditation Council for Graduate Medical Education, a 57 item-containing assessment tool was created. Based on the different exposure aspects of the involved evaluator groups, the items were integrated into seven different evaluation forms. All sixteen of 16 residents and members from each evaluator group voluntarily participated in the study. Internal consistency scores, multilayer and multilevel Kappa values were measured. Evaluator group scores and resident ranks in competency areas were compared. All evaluators were asked to comment on the applicability and usefulness of the assessment tool in emergency medicine. ResultsSeven groups completed a total of 1088 forms to evaluate 16 residents. The reliability coefficient for the faculty members was 0.99 while it was 0.60 for the ancillary staff. The interrater Kappa values for faculty members, nurses and peer assessment were relevant with a value of greater than 70%. Discussion and conclusionOur results showed that the 360-degree assessment did meet expectations by the evaluator group and residents, and that this method was readily accepted in the setting of a Akdeniz University Emergency Medicine residency training program. However, only evaluations by faculty, nurses, self and peers were reliable to have any value. Doing a 360° evaluation is time and effort consuming and thus may not be an ideal tool for larger programs.

Moving towards an interactive teaching and learning curriculum - Analysis of Qatar's Emergency Medicine Residency Training Program

Background: The Emergency Medicine Residency Training Program (EMRTP) conducts weekly didactic teaching activities to deliver the curriculum for the Arab Board of Emergency Medicine. Traditional teaching methods often serve to deliver content to the learner passively, while an interactive model engages the resident, and aligns with principles of adult learning. With the accreditation of the EMRTP by the Accreditation Council for Graduate Medical Education - International (ACGME-I), the mode of teaching has also been modified to a more interactive model. Methods: We analysed the EMRTP annual academic planner for 2015–2016 along with the format of teaching and broadly classified the topics and content into traditional vs interactive modes of delivery. Results: The results showed that in 2012–2013, 75% of the content was through lectures but in 2015–2016 this had diminished to 21%, with the remaining 79% being delivered through various interactive means such as multidisciplinary grand rounds, joint conferences, morbidity &amp; mortality meetings, journal clubs, oral board simulations, objective structured clinical examination (OSCE) slide presentations and faculty led clinical skills workshops. Conclusion: The analysis showed an impressive reversal from a traditional to an interactive educational format with clear demonstration of adult learning principles.

Validation of weekly teaching activities of Emergency Medicine Residency Training Program, Qatar against the American Board of Emergency Medicine Curriculum

Introduction: The Emergency Medicine Residency Training Program (EMRTP) in Qatar conducts weekly didactic teaching activities based on syllabus from the Arab Board of Emergency Medicine, but with the accreditation by Accreditation Council for Graduate Medical Education International (ACGMEI) in 2013, we set out to validate the teaching activities against an internationally recognized curriculum of the American Board of Emergency Medicine (ABEM) known as the EM Model. Methods: We undertook a full review of all the teaching topics undertaken throughout the academic year of 2012–13 and found a moderate degree of compliance with the ABEM curriculum. Following this review, we identified developmental points addressed during the last three years. A further review was repeated for the academic year 2015–16 to ensure ongoing improvement. Results: The results show improved content delivery. The overall compliance increased by 16% (58% to 74%) in the domain of medical knowledge and patient care and a staggering 48% (46% to 94%) in the other competencies. Conclusion: On the whole the EMRTP annual curriculum has achieved a strong emphasis on the medical knowledge and patient care competencies (including procedures &amp; skills). Further improvement was noted in other core competencies.

Descriptive case study - Interventions to minimize faculty dropouts in the Emergency Medicine Residency Training Program weekly teaching activity

Background: Managing a weekly educational planner for an Emergency Residency can be a challenging task in a busy Department due to shift pattern of work, personal development and travelling issues. In this descriptive case study, we outline the challenges and solutions to facilitate this issue. We found that key interventions in the form of timely reminders to instructors and faculty, prospectively consulting them before topic allocation and timely reminders and backup plans helps in reducing drop outs. Methods: In this quality improvement study, we describe the interventions undertaken to ensure 100% compliance by the faculty for the teaching schedule for the year 2015/2016. We demonstrated a reduction of the dropouts to almost zero despite significant external pressures. An initial scoping exercise revealed that in the 2014/2015 planner 68.75% presentations were conducted as per the planner where as 31.25% did not follow the planner. The reasons included apologies to present (10%), eleventh hour swapping because presenter was not ready or available in country (12.5%) and non-availability of presenter (8.75%) due to leave issues. An initial questionnaire survey was undertaken to elucidate the factors that were disruptive to the faculty and the planner. We also sought ideas to help improve to the planner. A tentative planner for the year 2015/2016 was announced in advance to the whole department and all the staff and faculty were consulted to send the topics of their interest as well as their dates of annual leaves and holidays. Each presenter was called individually to confirm their availability and topics were assigned to them. Results: We compared the first four month educational planer starting from July 2015 till October 2015 and found the compliance 100% with zero drop outs. Conclusion: Proactive measures in making educational planner always help in maintaining compliance of the planner and reducing drop outs.

Social Workers as Workplace-Based Instructors of Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Emergency Medicine Residents

ABSTRACTProblem: Residency education is challenged by a shortage of personnel and time, particularly for teaching behavioral interventions such as screening, brief intervention, and referral to treatment (SBIRT) to reduce hazardous drinking and drug use. However, social workers may be well placed to teach SBIRT in clinical training settings. Intervention: We describe a curriculum with social workers as SBIRT trainers of emergency medicine (EM) residents during actual clinical shifts in an EM residency training program. The curriculum required 1 EM faculty member working with social workers and 1 additional hour of formal residency conference teaching time. Context: We implemented the curriculum at both a university tertiary care hospital emergency department and a county trauma center. We trained 8 social workers at both sites as SBIRT superusers to teach and assess EM resident SBIRT performance with actual patients. We measured the length and number of sessions to attain SBIRT competence, residents' satisfaction, and resident comments (coded by authors). Outcome: Five of the 8 social workers trained residents between June 2013 and May 2014, 31 EM residents trained to a level indicating SBIRT competence with 114 patients. Each patient interaction averaged 8.8 minutes and residents averaged 3.13 patients. Twenty-four (77%) residents gave ratings of 1.58 (SD = .58) for the quality of teaching, 2.33 (SD = .87) for recommending the training to a colleague, 1.38 (SD = .49) for superusers' knowledge, 1.88 (SD = .95) for usefulness of instruction, 1.54 (SD = .72) for workplace learning, and 1.58 (SD = .78) for valuing learning from social workers (on a scale of 1 [very satisfied/strongly agree] to 5 [very dissatisfied/strongly disagree]). Residents preferred learning SBIRT during the 1st and 2nd training years and in the workplace. Lessons Learned: Social work colleagues can be effective in teaching SBIRT to residents in the workplace, and our residents highly valued learning from social workers, who all had prior training in motivational interviewing. In the implementation of this curriculum, the clinical demands of residents must be taken into account when teaching occurs, and having multiple social worker instructors was instrumental.

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

IntroductionAlthough emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department.MethodsWe developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation.ResultsOf 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0–1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education.ConclusionEM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0–1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.

The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department.

The purpose of this investigation was to compare the incidence of esophageal intubations (EIs) when emergency medicine (EM) residents used a direct laryngoscope (DL) versus a video laryngoscope (VL) for intubation attempts in the emergency department (ED). Prospectively collected continuous quality improvement data on tracheal intubations performed by EM residents in an academic ED over a 6-year period were retrospectively analyzed. Following each intubation, EM residents completed a data form with patient, intubation, and operator characteristics. Data collected included the method of intubation, drugs used, device(s) used, number of attempts, outcome of each attempt, occurrence of EIs, and occurrence of adverse events (hypoxemia, aspiration, dysrhythmia, hypotension, and cardiac arrest). The incidence of EI was compared between intubation attempts with a DL and with a VL (GlideScope(®) or C-MAC(®) ). Propensity score matching and conditional logistic regression were used to analyze the association between the intubation device (DL vs. VL) and EI. Over the 6-year period, 2,677 patients underwent 3,425 intubation attempts by EM residents with a DL or a VL. A DL was used in 1,530 attempts (44.7%) and a VL was used in 1,895 attempts (55.3%). There were 96 recognized EIs (2.8%). The incidence of EI when using a DL was 78 of 1,530 attempts (5.1%; 95% confidence interval [CI]=4.1% to 6.3%) and when using a VL was 18 of 1,895 attempts (1.0%; 95% CI=0.6% to 1.5%). Based on the propensity score matched analysis, the odds ratio for the occurrence of an EI for DL versus VL was 6.9 (95% CI=3.3 to 14.4). Patients who had inadvertent EIs had a higher incidence of adverse events (49.5%; 95% CI=38.9% to 60.0%) than patients in which EI did not occur (19.8%; 95% CI=18.3% to 21.4%). The use of a VL by EM residents during an intubation attempt in the ED was associated with significantly fewer EIs compared to when a DL was used. Patients who had inadvertent EIs had significantly more adverse events than those who did not have EIs. EM residency training programs should consider using VLs for ED intubations to maximize patient safety when EM residents are performing intubation.

Diagnostic characteristics of a clinical screening tool in combination with measuring bedside lactate level in emergency department patients with suspected sepsis.

Early identification of sepsis and initiation of aggressive treatment saves lives. However, the diagnosis of sepsis may be delayed in patients without overt deterioration. Clinical screening tools and lactate levels may help identify sepsis patients at risk for adverse outcomes. The objective was to determine the diagnostic characteristics of a clinical screening tool in combination with measuring early bedside point-of-care (POC) lactate levels in emergency department (ED) patients with suspected sepsis. This was a prospective, observational study set at a suburban academic ED with an annual census of 90,000. A convenience sample of adult ED patients with suspected infection were screened with a sepsis screening tool for the presence of at least one of the following: temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or altered mental status. Patients meeting criteria had bedside POC lactate testing following triage, which was immediately reported to the treating physician if ≥2.0 mmol/L. Demographic and clinical information, including lactate levels, ED interventions, and final diagnosis, were recorded. Outcomes included presence or absence of sepsis using the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions and intensive care unit (ICU) admissions, use of vasopressors, and mortality. Diagnostic test characteristics were calculated using 2-by-2 tables with their 95% confidence intervals (CIs). The association between bedside lactate and ICU admissions, use of vasopressors, and mortality was determined using logistic regression. A total of 258 patients were screened for sepsis. Their mean (± standard deviation [SD]) age was 64 (±19) years; 46% were female, and 82% were white. Lactate levels were 2.0 mmol/L or greater in 80 (31%) patients. Patients were confirmed to meet sepsis criteria in 208 patients (81%). The diagnostic characteristics for sepsis of the combined clinical screening tool and bedside lactates were sensitivity 34% (95% CI = 28% to 41%), specificity 82% (95% CI = 69% to 90%), positive predictive value 89% (95% CI = 80% to 94%), and negative predictive value 23% (95% CI = 17% to 30%). Bedside lactate levels were associated with sepsis severity (p < 0.001), ICU admission (odds ratio [OR] = 2.01; 95% CI = 1.53 to 2.63), and need for vasopressors (OR = 1.54; 95% CI = 1.13 to 2.12). Use of a clinical screening tool in combination with early bedside POC lactates has moderate to good specificity but low sensitivity in adult ED patients with suspected sepsis. Elevated bedside lactate levels are associated with poor outcomes.

Ultrasound competency assessment in emergency medicine residency programs.

In the Model of the Clinical Practice of Emergency Medicine (EM), bedside ultrasound (US) is listed as one of the essential procedural skills. EM milestones released by Accreditation Council for Graduate Medical Education and American Board of Emergency Medicine require residents to demonstrate competency in bedside US. The purpose of this study was to assess the current methods used by EM residency training programs to evaluate resident competency in bedside US. This was a cross-sectional survey study. A questionnaire on US education and competency assessment was electronically sent to all EM residency program directors and emergency US directors. The survey consisted of questions regarding the US rotation, structure of US curriculum, presence of US fellowship, image archiving, quality assurance methods, feedback, competency assessment tools, and frequency of assessment. The survey responses are reported as the percentages of total respondents along with 95% confidence intervals (CIs). A total of 124 of 161 EM residency programs participated in this study, representing a 77% response rate. Twenty-six percent (95% CI = 18% to 34%) of programs assess competency only at the end of the US rotation. Eight percent (95% CI = 3% to 13%) assess competency only every 6 months, and 13% (95% CI = 7% to 19%) assess competency only annually. Eight percent (95% CI = 3% to 13%) assess competency only during the final year of training. Thirty percent (95% CI = 22% to 38%) of programs assess competency with a combination of the above intervals, and 16% (95% CI = 10% to 22%) do not assess US competency. Fourteen percent (95% CI = 8% to 20%) use objective structured clinical examinations (OSCEs), and 21% (95% CI = 14% to 28%) use standardized direct observation tools (SDOTs) to assess resident competency in US. Approximately one-third (33%, 95% CI = 24% to 41%) of standardized testing for US competency is conducted with multiple-choice questions. Thirty percent (95% CI = 21% to 38%) administer practical examinations to assess US skills. Currently, a majority of EM residency programs assess resident competency in bedside US. However, there is significant variation in the methods of competency assessment.

A Module-Based Pediatric ECG Curriculum to Improving Accuracy of ECG Interpretation by Pediatric Emergency Medicine Providers

OPEN ACCESSApril 24, 2014A Module-Based Pediatric ECG Curriculum to Improving Accuracy of ECG Interpretation by Pediatric Emergency Medicine Providers Priya Gopwani, MD, Shilpa Patel, E. Anne Greene, Jennifer Chapman Priya Gopwani, MD Children's National Medical Center Google Scholar More articles by this author , Shilpa Patel Children's National Medical Center Google Scholar More articles by this author , E. Anne Greene Children's National Medical Center Google Scholar More articles by this author , Jennifer Chapman Children's National Medical Center Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9779 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: Electrocardiograms (ECGs) are ordered frequently in the pediatric emergency department (ED). The majority of these ECGs are interpreted initially by pediatric emergency medicine (PEM) physicians, with a cardiologist reinterpreting the ECG after patient disposition has been made. Previous studies have shown that neither emergency medicine nor pediatric residency training programs adequately train residents to read ECGs. We designed a web-based pediatric ECG curriculum aimed specifically at fellow and attending PEM providers. The overall goal of this curriculum is to improve the “first read” accuracy of ECG interpretation and decrease the number of missed diagnoses. Methods: The curriculum consists of seven web-based modules focusing on pediatric ECGs and their interpretation in the ED setting. These modules cover the basics of pediatric ECGs, long QT syndrome & brugada, supraventricular tachycardia and Wolff Parkinson White syndrome, heart block and sick sinus syndrome, ventricular tachycardia, ischemia and infarct, and congenital heart disease. The case-based modules run for 7-12 minutes and are interactive, requiring the user to recognize abnormalities and perform necessary calculations before proceeding. Results: This module was administered to PEM fellows at a large urban pediatric teaching hospital. A pretest consisting of 20 ECGs was administered to all PEM fellows and a self-selected group of PEM attendings. At the completion of the curriculum, a posttest was administered to assess improvement. The average accuracy of identifying the ECG abnormality at pretest was 42.8% (PEM Fellows M = 40.6%, N = 9; PEM Attendings M = 45.7% N = 7). All nine fellows completed the posttest. There was a statistically significant improvement in the PEM fellows' ability to accurately interpret ECG findings using these modules were used (42.0% v 53.1%, p = .047, Wilcoxon Signed-Rank test). On an accompanying satisfaction survey, 100% would recommend the curriculum to a colleague and 76.5% thought the ECG modules could stand alone in teaching ECG interpretation to PEM providers. Discussion: There is a need to improve the ability of PEM physicians to read ECGs, particularly those with clinically significant findings. We designed a web-based pediatric ECG curriculum aimed specifically at PEM providers with the overall goal of improving the “first read” accuracy of ECG interpretation and to decrease the number of missed diagnoses. Based on learner feedback, we determined that the implementation of a combined module-based and didactic pediatric ECG curriculum improved the ability of PEM fellows to accurately interpret ECGs with abnormalities. Educational Objectives By the end of this session, learners will be able to: Demonstrate a systematic approach to reading pediatric ECGs.Describe clinically significant findings on pediatric ECGs.Formulate the initial treatment plan for pediatric patients with clinically significant findings on ECGs. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: MedEdPORTAL Instructors Guide.docx ECG Basics.mp4 LQTS Brugada.swf SVT and WPW.swf HB and SSS.swf VT.swf Ischemia Infarct.swf Congenital Heart Disease.swf To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2014 Gopwani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivatives license.KeywordsPediatricsElectrocardiographyPediatric Emergency MedicineElectrocardiogramsECGs Disclosures None to report. Funding/Support None to report. Loading ...