Emergency Medicine Staff Research Articles

P042: Workplace-based assessment in emergency medicine: how do physicians use entrustment anchors?

Introduction: Competency based medical education (CBME) has triggered widespread utilization of workplace-based assessment (WBA) tools in postgraduate training programs. These WBAs predominately use rating scales with entrustment anchors, such as the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). However, little is known about the factors that influence a supervising physician's decision to assign a particular rating on scales using entrustment anchors. This study aimed to identify the factors that influence supervisors’ ratings of trainees using WBA tools with entrustment anchors at the time of assessment and to explore the experiences with and challenges of using entrustment anchors in the emergency department (ED). Methods: A convenience sample of full-time emergency medicine (EM) faculty were recruited from two sites within a single academic Canadian EM hospital system. Fifty semi-structured interviews were conducted with EM physicians within two hours of completing a WBA for an EM trainee. Interviews were audio-recorded, transcribed verbatim, and independently analyzed by two members of the research team. Themes were stratified by trainee level, rating and task. Results: Interviews involved 73% (27/37) of all EM staff and captured assessments completed on 83% (37/50) of EM trainees. The mean WBA rating of studied samples was 4.34 ± 0.77 (2 to 5), which was similar to the mean rating of all WBAs completed during the study period. Overall, six major factors were identified that influenced staff WBA ratings: amount of guidance required, perceived competence through discussion and questioning, trainee experience, clinical context, past experience working with the trainee, and perceived confidence. The majority of staff denied struggling to assign ratings. However, when they did struggle, it involved the interpretation of WBA anchors and their application to the clinical context in the ED. Conclusion: Several factors appear to be taken into account by clinical supervisors when they make decisions regarding the particular rating that they will assign a trainee on a WBA that uses entrustment anchors. Not all of these factors are specific to that particular clinical encounter. The results from this study further our understanding on the use of entrustment anchors within the ED and may facilitate faculty development regarding WBA completion as we move forward in CBME.

P041: Point-of-care ultrasound utilization and monetary outcomes (POCUMON) study

Introduction: Point-of-care ultrasound (POCUS) is an integral tool in the modern emergency physician's toolkit. Evidence suggests many imaging and lab investigations are ordered without true medical indications; it is unknown how POCUS utilization impacts health care costs at a patient level. The purpose of this study was to assess whether POCUS use in the emergency department (ED) was associated with cost savings via decreased laboratory and radiographic testing. Methods: POCUMON is a single-center, prospective pilot study. The participants were a convenience sample of ED staff physicians and PGY-5 Emergency Medicine (EM) residents working in the ED from July-October 2019. Physicians who used POCUS as part of their assessment had the cost of their patient investigation plans compared with those proposed by a control group of ED physicians simultaneously on-shift. The control group was blinded to the POCUS findings but had access to the patient and medical record. The lab investigations and imaging studies ordered by both groups were recorded with respective costs. Data were analyzed using a paired T-test, with sub-group analyses. Ethics approval was obtained from the Queen's University HSREB (No.6026732). Results: 50 patient assessments using POCUS were captured in the study period. 76% of patient assessments were performed by EM staff physicians; 94% of control assessments were provided by EM staff physicians. Patient chief complaints included abdominal pain (7), chest pain/dyspnea (10), flank pain (3), pregnancy concerns (4), trauma (7), extremity complaints (4), back pain (3), and other (12). The POCUS group had a trend for lower number of laboratory tests (4.7 ± 0.44 vs 5.22 ± 0.39; p = 0.28) and imaging studies (0.94 ± 0.14 vs 1.1 ± 0.11; p = 0.33). Overall health care costs were similar in both groups, with a trend to cost savings in the POCUS group ($142.00 ± 15.44 vs $174.60 ± 17.00; p = 0.12). Subgrouping identified significant cost savings in the POCUS group for patients with a chief complaint of flank pain ($43.64 vs $248.82, p = 0.01). Conclusion: POCUS use was not associated with significant health care cost savings. ED POCUS usage did see a trend towards decreased laboratory and imaging investigations. Patients presenting with flank pain had significantly lower expenditures associated with their visit when POCUS was incorporated into their assessment. Large scale prospective studies are needed to investigate if POCUS is associated with cost-savings in ED patients.

Perceived versus actual cricothyroid membrane landmarking accuracy by emergency medicine residents and staff physicians.

Cricothyrotomy is an intervention performed to salvage "can't intubate, can't ventilate" situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models. Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated. Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30-65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12-51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = -0.081-0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1-0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33). We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

Observational study of the handover with the SBAR method at Bari Polyclinic complex

The handing over of deliveries between the emergency service personnel 118 and the Emergency Medicine and Surgery staff (MeCHAU) is fundamental for the continuity of care for the patient. The study aims to investigate the methods of handing over medical staff from the ambulance to the MeCHAU nurses of the Policlinico di Bari to verify if it has been applied and, if so, to what extent the SBAR method has been used ("Situation", "Background", "Assessment", "Recommendation") recommended both in literature and by the World Health Organization (WHO). A card was created referring to the SBAR method and was applied in all cases of trauma and illness accepted by the MeCHAU in the period between July-August 2017. For each case, the following were evaluated: start and end delivery times, total time, color code assigned by 118, color code assigned by MeCHAU, type of ambulance assigned. A total of 140 deliveries were considered. Of these, the average time in relation to the color code (in minutes), the number of information received based on the color code, whether or not the SBAR order was complied with and the completeness of deliveries based on the type was evaluated. of ambulance assigned from 118. From the results obtained, the transmission of deliveries has not been shown to be effective, resulting in prolonged times and a low percentage of information provided for all color codes. It follows that the use of the SBAR method in the handing over of deliveries could improve the effectiveness of the intervention and make the delivery.

Delays in the management of acute coronary syndroms with ST segment elevation and extending factors: Prospective study about 50 cases in cardiology department of Aristide Le Dantec hospital.

Management of acute coronary syndromes with ST segment elevation (STEMI) is a race again time: time is myocardium». Treatment consist in reperfusion strategy by coronary intervention or thrombolysis. The main objective of this work was to evaluate the time delays of treatment and the extending factors during STEMI. It was a prospective, descriptive and analytic study on 6 months including all patients admitted for STEMI. We studied the time delays and the extending factors. We included 50 patients. The average age was 58,4 years and the sex ratio M/F was 2,5. Chest pain was typical for 39 patients. Mean time delay between pain onset and first medical contact was 12 h16 min. The first medical contact was a general physician for 33 patients and a cardiologist for 8 patients. The average time delay between the first medical contact and an electrocardiogram was 9 h57 min. The main factor of late diagnosis were unavailability of electrocardiograph and absence of prescription of an electrocardiogram. The average time delay between the diagnosis electrocardiogram and admission in cardiology department was 3 h02 min. The transport was the main extending factor. Aspirin and clopidogrel were used respectively for 17 and 10 patients. Among the patients admitted directly in cardiology, the average time delay for a diagnostic electrocardiogram was 30 min. Thrombolysis was performed in 17 patients within an average delay of 2 h11 min. A rupture of streptokinase was the most common extending factor. Twenty-three patients underwent percutaneous coronary intervention with a main time delay between diagnostic electrocardiogram and cath lab of 2 h42 min. The unavailability of medical team was the first extending factor. Factors related to long delay in admission and care are a proof of lack of codified management of STEMI. It is necessary to develop the prehospital emergency medicine, educate population and medical staff.

Spokes for Our Folks: Public Health Bike Tour.

Nearly half of medical care in the United States is managed through the emergency department, a large portion of which could be managed by "lateral" health services provided by public health facilities like human immunodeficiency virus (HIV) prophylaxis, alcohol and drug treatment programs, emergency psychiatric resources, and medical respite or rehabilitation centers. These options may be underutilized due to lack of knowledge of their services and demographics by patients and health care workers alike. We aimed to educate all levels of emergency medicine trainees and staff to citywide services via bike tour. Participants reported an improved understanding of health services as well as a sense of "camaraderie" toward lateral health services and other providers on the rides.

P032: Video-based learning modules as an adjunct for teaching emergency medicine procedural skills

Innovation Concept: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and to gauge its utility as an adjunctive resource for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale (measures the value of a module for overall learning), respectively. Curriculum, Tool or Material: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 (1 = lowest value, 5 = highest value) on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9/5 for inclination to access more modules such as these, and a score of 4.4/5 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.

P002: Effectiveness of video-based learning modules in emergency medicine procedural skill training

Introduction: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and gauge their utility as adjunctive resources for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a pre-prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures, including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale, respectively. Results: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9 for inclination to access more modules such as these, and a score of 4.4 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video-based modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.

LO56: Measuring cognitive load on shift: Application of cognitive load theory during clinical work in the emergency department

Introduction: By virtue of the nature of their work, emergency medicine physicians and residents experience high cognitive load and stress, which are known to affect physician performance and patient outcomes. However, the contribution of cognitive load has not previously been measured during the clinical work of emergency physicians. The objectives of this study were to measure cognitive load and stress in emergency physicians and residents during clinical work, evaluate the relative contribution of multiple factors on cognitive load, and to determine the effect of experience on these results. Methods: This observational study was conducted at an academic Canadian Urgent Care Centre from July to August 2018. Emergency medicine residents and staff physicians completed a survey while on shift to evaluate measures of cognitive load and acute stress. Patient acuity and the number of active patients for each physician, hours worked and patients in the waiting room were recorded. Correlational analyses and multivariable linear regression were performed to evaluate the effect of each predictor on measures of overall cognitive load. Results: A total of 131 questionnaires were completed by 42 physicians (87 questionnaires from 26 staff physicians and 44 questionnaires from 16 residents). Results showed that staff physicians carried a significantly higher patient load compared to residents (p &amp;lt; 0.001). There were no differences in mean overall cognitive load (p = 0.25), acute stress (p = 0.17) or measured subcomponents of cognitive load between the two groups. Perceived case difficulty and acute stress were strong predictors of overall cognitive load, while level of distraction did not correlate with the other outcomes. The number of patients in the waiting room predicted acute stress in staff physicians, while the number of higher acuity patients was a significant predictor in residents. Conclusion: Measures of overall cognitive load and acute stress were strongly correlated in the clinical setting. Different factors affect cognitive load and acute stress in staff physicians compared to residents. Appreciating these differences may help medical educators understand the cognitive challenges faced by learners in a clinical context, and aid in the design of cognitive and educational strategies to help mitigate these challenges and reduce stress.

Bad blood: A coagulopathy associated with trauma and massive transfusion review.

Coagulopathy in trauma patients is a known contributor to death due to hemorrhage. In fact, it seen as frequently as 35% of the time. The complexity of the coagulopathy pathway requires a deliberate and planned approach. The methods used to assess and detect if a patient is coagulopathic remain challenging, but tools have been developed to assist the practitioner to effectively manage and even quickly reverse the coagulopathy. The purpose of this review is to educate trauma and emergency medicine staff on the currently available diagnostic tools to assess coagulopathy, to provide an overview of the coagulopathy pathway, as well as provide examples of how to intervene and treat coagulopathy, including the use of crew resource management during mass transfusion protocol activations.

Why our doctors are leaving Irish emergency medicine training.

In recent years, attrition from Emergency Medicine (EM) training in Ireland has increased. Australian data illustrates that increasing numbers of Irish-trained doctors are embarking on EM training in Australia. This has implications for EM in Ireland, particularly for Emergency Departments already under strain. An adequate supply of qualified specialist EM doctors is essential to provide high-quality patient care. The aim of this study is to gain insights into the reasons for attrition from EM training in Ireland. EM trainees who exited EM training in Ireland 2011-2016 were invited to complete a survey which included quantitative and free-text questions. Of 43 doctors who had exited EM training, 71% responded and although some respondents spoke positively about the speciality, overall, their feedback illustrated levels of frustration and dissatisfaction with EM trainingin Ireland. Respondents exited their EM training programme due to a lack of training received, despite being formally registered on anIrish EM training scheme. The other factors raised included dissatisfaction with the general working conditions in EM in Ireland with respondents highlighting heavy workloads, high work intensity, stress, staff shortages, and poor work-life balance. Our findings indicate the need to improve training and working conditions in Emergency Medicine in Ireland. These improvements are necessary to reduce attrition and improve retention of EM staff.

Intrinsic CanMEDS Competencies Expected of Medical Students During Emergency Medicine Core Rotation: A Needs Assessment.

ObjectivesThere are few high-quality free open-access medical (FOAM) education resources to guide medical students in the development of key non-medical expert skills and competencies during their emergency medicine (EM) clerkship core rotation. In our endeavor to develop a novel online educational EM curriculum for medical students, a needs assessment is required to effectively address needs specifically focused on aptitudes that are deemed to be imperative by educators in the EM academia.MethodsAn online needs assessment survey was developed and shared with residents, staff, nurses, and program/clerkship directors of Canadian emergency medicine programs by email correspondence and embedding the form on CanadiEM.org. The survey consisted of twelve proposed topics for a potential EM curriculum, which were graded on a five-point Likert scale. Free-typed responses for additional topics were also solicited from participants.ResultsOver the course of four weeks, 84 participants responded to the survey. Participants outside of North American were excluded (n=10). Most participants were North American staff physicians (n=52), which included residency program directors (n=10) and clerkship directors (n=6), followed by residents (n=14), and nurses (n=8). All 12 topics proposed by the authors were considered important for inclusion in an EM curriculum. Nine additional topics were identified from typed free-text responses. Top ranking topics included: how to present a case to an EM staff or resident, how to chart patient encounters, and how to effectively communicate with nurses and other healthcare professionals.ConclusionsThis online needs assessment analysis revealed a total of 21 topics that were deemed to be relevant to the development of an online curriculum to foster the development of core competencies of medical students during their EM core rotation.

Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents.

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents. A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs. Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED). Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

MP16: Development, implementation and evaluation of a curriculum for healthcare students working at electronic dance music events

Introduction: Mass Gathering Medicine (MGM) is a growing field within emergency medicine (EM) and providing care at electronic dance music events (EDMEs) is an increasingly popular activity with MGM groups. Often, health care students are allowed to participate. However, there is a lack of documented curricula to train junior learners in providing medical care at these events. To address this, we developed and initiated an interprofessional, simulation-based workshop for University of Alberta health care students interested in working at EDMEs. Methods: We used Kerns six-step approach to develop the workshops. Our MGM Interest Group identified a need for educational sessions in toxicology case management at EDMEs. A subsequent literature review revealed a paucity of pre-existing curricula on this topic for MGM learners. We created goals and objectives for the workshops, reflecting the knowledge, skills and attitudinal competencies required to provide appropriate medical care at these events. The workshops were implemented and evaluated in November 2016 and 2017. Results: A total of 44 medical and nursing students attended the workshops. An EM resident and staff physician, both with prior experience working at EDMEs, led each session. Each workshop began with a short didactic lecture followed by two hours of case-based training using two standardized patients and a high fidelity simulator. Topics were chosen based on previously published articles describing medical cases seen at EDMEs. The simulation replicated the actual space, noise and equipment available at the medical tents at these events. Two interprofessional learner groups took turns managing a different set of 3 patients: Set 1-opioid overdose (OD), alcohol/vomiting, sympathomimetic OD; Set 2-opioid OD not responsive to naloxone, anticholinergic/seizure, OD with hyperthermia. Initial assessment, medical management and team communication skills were emphasized. Debriefing was provided to learners immediately after each set of cases. After each workshop, the learners completed evaluation forms utilizing both Likert scale and open-ended responses. Overall, students were extremely complimentary about the workshop structure, content and communication skills teaching. They were especially appreciative of the opportunity to participate in their first interprofessional team experience. Conclusion: To address local needs, a well-received simulation-based workshop was created to train students in toxicology case management at EDMEs. Future work will include using this workshop in a just-in-time fashion before upcoming EDMEs and documenting students actual use of skills taught (Kirkpatrick level 3). The workshop will also be further modified to implement more detailed interprofessional objectives and can provide a venue for EM residents to practice teaching interprofessional education competencies as part of their CanMEDS Scholar role.

MP18: Development and implementation of a workshop for advanced care planning and goals of care conversations in the emergency department

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P&lt;0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.

Barriers to Effective Teamwork Relating to Pediatric Resuscitations: Perceptions of Pediatric Emergency Medicine Staff.

In the pediatric emergency department (PED), resuscitations require medical teams form ad hoc, rarely communicating beforehand. Literature has shown that the medical community has deficiencies in communication and teamwork. However, we as medical providers do not know or understand the perceived barriers of our colleagues. Physicians may perceive a barrier that is different from nurses, respiratory therapists, pharmacists, or technicians. Perhaps we do not know in which area of teamwork and communication we are deficient. Only when we understand the perceptions of our fellow coworkers can we take steps toward improvement in quality resuscitations and therefore patient safety. The primary objectives of this study were to describe and understand the perceived barriers to effective communication and teamwork among different disciplines forming spontaneous resuscitation teams at a tertiary urban PED and to determine if providers of different disciplines perceived these barriers differently. This was a mixed-methods study conducted in a single, tertiary care freestanding children's hospital emergency department. Survey questions were iteratively developed to measure the construct of barriers and best practices within resuscitation teamwork, which was administered to staff among 5 selected roles: physicians, nurses, respiratory technicians, PED technicians, and PED pharmacists. It contained open-ended questions to provide statements on specific barriers or goals in effective teamwork, as well as a priority ranking on 25 different statements on teamwork extracted from the literature. From the participant data, 9 core themes related to resuscitation teamwork were coalesced using affinity diagramming by the authors. All statements from the survey were coded to the 9 core themes by 2 authors, with high reliability (κ = 0.93). Descriptive statistics were used to summarize the prevalence of themes mentioned by survey participants. A χ test was used to determine differences in prevalence of core themes by role. Rank data for the 25 statements were converted to a point system (5 points for most important, 4 points for second most important, etc), and a mixed within-between analysis of variance was used to determine the association of role and relative rank. There were 125 respondents (62% response rate) who provided 893 coded statements. The core theme of communication-in particular, closed-loop communication-was the most prevalent theme, although no differences in the proportion of themes represented were seen by PED staff of different roles (P = 0.18). There was a significant effect from the core theme (P = 0.002, partial η = 0.13), with highest priority on team leader performance (mean points out of 5 = 2.5 ± 1.9), but neither effect nor interaction with role (P = 0.6, P = 0.7). When answering open-ended questions regarding barriers to effective resuscitations, all disciplines perceived communication, particularly closed-loop communication, as the primary theme lacking during resuscitations. However, when choosing from a list of themes, all groups except physicians perceived deficiencies in team leader qualities to be the greatest barrier. We as physicians must work on improving our communication and leadership attributes if we want to improve the quality of our resuscitations.

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.

P026: Need for training in medical education: staff emergency physician perspectives

Introduction: Emergency medicine physicians in our urban/suburban area have a range of training in medical education; some have no formal training in medical education, whereas others have completed Master’s level training in adult education. Not all staff have a university appointment; of those who are affiliated with our university, 87 have appointments through the Department of Medicine, 21 through the Department of Pediatrics, and 117 through the Department of Family Medicine. Emergency physicians in our area are a diverse group of physicians in terms of both formal training in adult education and in the variety of settings in which we work. The purpose of this study was to gauge interest in formal training in adult education among emergency medicine physicians. Methods: With research ethics board approval, we created and sent a 10-item electronic questionnaire to emergency medicine staff in our area. The questionnaire included items on demographics, experience in emergency medicine, additional post-graduate training, current teaching activities and interest in short (30-60 minute) adult education sessions. Results: Of a potential 360 active emergency physicians in our area, 120 responded to the questionnaire (33.3%), representing 12 area hospitals. Nearly half of respondents had been in practice over 10 years (48.44%). Respondents were mainly FRCP (50%) or CCFP-EM (47.50%) trained. 33.3% of respondents had masters degrees, of which 15% were MEd. Most physicians were involved in teaching medical students (98.33%), FRCP residents (80%) and family medicine residents (88.3%), though many were also teaching off-service residents, and allied health professionals. More than half of respondents (60%) were interested in attending short sessions to improve their skills as adult educators. The topics of most interest were feedback and evaluation, time-efficient teaching, the learner in difficulty, case-based teaching and bedside teaching. Conclusion: Emergency physicians in our area have a wide variety of experience and training in medical education. They are involved in teaching learners from a range of training levels and backgrounds. Physicians who responded to our survey expressed an interest in additional formal teaching on adult education topics geared toward emergency medicine.

Usability evaluation of an emergency department information system prototype designed using cognitive systems engineering techniques

This article presents an evaluation of novel display concepts for an emergency department information system (EDIS) designed using cognitive systems engineering methods. EDISs assist emergency medicine staff with tracking patient care and ED resource allocation. Participants performed patient planning and orientation tasks using the EDIS displays and rated the display's ability to support various cognitive performance objectives along with the usability, usefulness, and predicted frequency of use for 18 system components. Mean ratings were positive for cognitive performance support objectives, usability, usefulness, and frequency of use, demonstrating the successful application of design methods to create useful and usable EDIS concepts that provide cognitive support for emergency medicine staff. Nurse and provider roles had significantly different perceptions of the usability and usefulness of certain EDIS components, suggesting that they have different information needs while working.

Physician’s changes in management of return visits to the Emergency Department

Return visits to the Emergency Department (ED) are estimated between 2-3.1%, which impacts ED care costs and wait times. Adverse events for unscheduled return visits (URVs) have been reported to be as high as 30%. The objective of this study was to characterize the attitudes and management of Emergency Medicine (EM) physicians regarding patients presenting with the same chief complaint to the ED for an URV. An online survey questionnaire was developed and sent to 160 accredited EM Graduate Medical Education programs in the United States. The questionnaire consisted of case vignettes wherein providers were asked to submit what orders they would place for each scenario. The mean numbers of tests and treatments were compared from initial visit to repeat visit with same chief complaint. Physicians also provided feedback regarding their management of URVs. There were estimated 6988 eligible participants with 397 responses (response rate 5.7%). There was a statistical significance (P&amp;lt;0.001) in provider management of URVs with pediatric fever, but there was no statistical significance for management of the other chief complaints. There were 77% of physicians that felt an increased work up is warranted for URVs. The results of this study indicate that majority of EM residents and staff working in training programs feel that they should approach the management of URV patients with a more extensive workup despite no clinical change. These findings suggest that further analysis should be performed regarding provider management of URVs and the associated healthcare costs.