Emergency Medicine Training Programs Research Articles

Is a postintubation chest radiograph necessary in the emergency department?

BackgroundPostintubation chest X-rays (CXR) are standard practice in emergency department (ED) intubations. In the operating room, it is not usually a standard practice to confirm endotracheal tube placement with a CXR.AimsWe seek to study the utility of postintubation CXR in ED patients.MethodsThis was a retrospective case series of 157 adult patients intubated in the ED of an urban academic hospital with an emergency medicine training program. Standardized chart review was performed by two emergency physicians (EP) using a structured data abstraction tool and final radiology attending reads of postintubation CXR to assess placement. Endotracheal tube placement was graded as satisfactory, too high, too low, or malpositioned in the esophagus. Descriptive statistics were used, and 95% confidence intervals (CI) were reported. Hospital Institutional Review Board approval was obtained.ResultsA total of 157 patients were intubated in the ED during the study period: 127 (81%, 95% CI: 74–86) had adequate tube placement by CXR confirmation, 9 (6%, 95% CI: 3–11) endotracheal tubes were judged to be too high, and 20 (13%, 95% CI: 8–19) were judged to be too low with 10 (6.5%, 95% CI: 3–11) of these being right mainstem bronchus intubations. One patient (<1%, 95% CI:<0.0001–4) had a CXR confirming esophageal intubation.ConclusionED intubations were judged to have “satisfactory” placement by CXR in 81% of patients. CXR is able to identify a small subset of patients that likely need immediate intervention based on their CXR. Until further studies refute the utility of postintubation CXR in ED intubations, they should remain a part of routine practice.

Industry Relations With Emergency Medicine Graduate Medical Education Programs

A panel of physicians from the Society for Academic Emergency Medicine (SAEM) Graduate Medical Education (GME), Ethics, and Industry Relations Committees were asked by the SAEM Board of Directors to write a position paper on the relationship of emergency medicine (EM) GME with industry. Using multiple sources as references, the team derived a set of guidelines that all EM GME training programs can use when interacting with industry representatives. In addition, the team used a question-answer format to provide educators and residents with a practical approach to these interactions. The SAEM Board of Directors endorsed the guidelines in June 2009.

The Business of Emergency Medicine: A Nonclinical Curriculum Proposal for Emergency Medicine Residency Programs

Over the course of their postgraduate medical education, physicians are expected not only to acquire an extensive knowledge of clinical medicine and sound procedural skills, but also to develop competence in their other professional roles as communicator, collaborator, mediator, manager, teacher, and patient advocate. Although the need for physicians to develop stronger service delivery skills is well recognized, residency programs may underemphasize formal training in nonclinical proficiencies. As a result, graduates can begin their professional careers with an incomplete understanding of the operation of health care systems and how to utilize system resources in the manner best suited to their patients' needs. This article proposes the content, educational strategy, and needs assessment for an academic program entitled The Business of Emergency Medicine (BOEM). Developed as an adjunct to the (predominantly) clinical content of traditional emergency medicine (EM) training programs, BOEM is designed to enhance the existing academic curricula with additional learning opportunities by which EM residents can acquire a fundamental understanding of the nonclinical skills of their specialty.

395: Bedside Teaching in an Academic Emergency Department

The purpose of this study was to assess the perceptions of bedside teaching encounters in an academic emergency medicine training program. The viewpoints of the attending physician, resident physician, and patient were surveyed and evaluated to determine the overall academic value of bedside teaching and patient comfort during the encounter.

Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.

A perspective on developing emergency medicine as a specialty

AimsA rapidly increasing number of countries are developing their capacities to respond to acute illness and injury and organizing emergency medicine training programs. This article offers some insight into the way emergency medicine has undergone development in the Australasian region.MethodsThe perspective is built from experience in Australia, New Zealand and Papua New Guinea.ConclusionThe challenges are many, but with persistence can be surmounted. Lessons derived from these diverse environments are presented.

The Eight Cs: A Guide to Success in an International Emergency Medicine Educational Collaboration

The Tuscan Emergency Medicine Initiative (TEMI) is a comprehensive emergency medicine (EM) training program designed to build an EM training infrastructure in Tuscany, Italy. The program has successfully trained a team of instructors using a train-the-trainers model, certified 350 physicians who are already practicing in emergency departments (EDs), and established a master's program as a bridge to specialty training at the region's three universities. Using lessons learned from this program, the authors identify eight factors (The Eight Cs) that can serve as a guide to implementing a collaborative EM program in other environments: collaboration, context, culture, credibility, consulting, consistency, critique, and conclusion. Each of these topics is described in detail and may be useful to other international interventions.

18 Graduate Medical Education and Knowledge Translation: One Problem‐Specific Approach in Residency

Traditional graduate medical education approaches to improving clinical performance based upon the latest research have included Journal Club and didactic lectures. Unfortunately, these educational interventions have rarely been demonstrated to change practice behavior or improve patient‐important outcomes. Using a structured approach to identifying a gap between best‐evidence knowledge and clinical practice, an illustrative one‐year residency‐wide translational research project was developed in a four year emergency medicine training program. Step one (assigned to the second year residents): identify and quantitatively justify a Knowledge Translation (KT) deficit within our institution. They identified steroids in adult bacterial meningitis as an unequivocal therapeutic option. Based upon a structured one‐year chart review, they next demonstrated that only 7% of meningitis patients received pre‐antimicrobial steroids. The next step (assigned to the first year residents): identify and quantify the physician “leaks” within the pipeline of information from publication to bedside utilization via an online survey. The third year residents hypothesized plugs for these information leaks, including examples of other specialties or institutions which have successfully navigated this specific clinical scenario. Finally, at an end‐of‐year Journal Club, the fourth year residents formulated a protocol for the appropriate use of steroids in suspected adult meningitis and brought together individuals from within the institution contributing to the best‐practice leak. Knowledge Translation involves multiple stages beyond simple evidence awareness and usually involves continuation beyond the emergency department. The Washington University KT project offers a structured, multidisciplinary example of moving beyond contemplation to implementation of an unequivocal therapy.

Effects of postgraduate emergency training among general practitioners working in emergency units in Denizli, Turkey

Emergency medicine is characterised by rapid decision-making to help patients in life-threatening situations. For this purpose, special qualifications are necessary. The aim of our study was to evaluate the emergency medicine knowledge obtained during an obligatory postgraduate emergency medicine training programme that has been recently applied among Turkish physicians. The training targeted all general practitioners (GPs) working in emergency units in the city hospitals, city-wide primary healthcare centres, public health offices, emergency services and private hospitals. Over an 8-month period between September 2004 and April 2005, seven individual groups of approximately 45 physicians were formed. Each group undertook an identical 5-day training programme and every participant completed identical pre-and post-training tests. Two-hundred and ninety-eight physicians participated in the training programme. The majority of participants were male (n=224, 75.2%), aged between 35 and 39 years (n=127, 42.6%), had been in the medical professional for 11 to 15 years (n=121, 40.7%), and were employed in city hospitals (n=102, 34.2%). Surprisingly, the majority of GPs had never participated in a postgraduate training programme before (n=166, 55.7%). Mean post-test scores of the participants were significantly higher than the pre-test scores (89.70%+/-12.41% vs 43.15%+/-10.47%, respectively; P<0.001). Mean pretest scores were significantly higher in the emergency services subgroup (51%, P=0.001) and in the subgroup of participants that had previously undertaken two or more postgraduate training courses (47.9%, P=0.004) compared with the mean pre-test scores of the other subgroups. However post-test scores were not statistically different between the groups. This postgraduate emergency medicine training programme appears to be effective in improving physicians' knowledge regarding emergencies. Any developing emergency medicine system in Turkey should include continuous, up-to-date, standardised educational programmes for emergency professionals. These may include postgraduate workshops to improve the knowledge and skill levels of emergency professionals.

Substance Use in Emergency Medicine Training Programs

To explore the prevalence of substance use among emergency medicine (EM) residents and compare to a prior study conducted in 1992. A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national in-service examination. Data regarding 13 substances, demographics, and perceptions of personal patterns of substance use were collected. A total of 133 of 134 residencies distributed the surveys (99%). The response rate was 56% of the total EM residents who took the in-service examination (2,397/4,281). The reported prevalence of most illicit drug use, including cocaine, heroin, amphetamines, and other opioids, among EM residents are low. Although residents reporting past marijuana use has declined (52.3% in 1992 to 45.0% in 2006; p < 0.001), past-year use (8.8%-11.8%; p < 0.001) and past-month use (2.5%-4.0%; p < 0.001) have increased. Alcohol use appears to be increasing, including an increase in reported daily drinkers from 3.3% to 4.9% (p < 0.001) and an increase in number of residents who indicate that their consumption of alcohol has increased during residency (from 4% to 12.6%; p < 0.001). Self-reported use of most street drugs remains uncommon among EM residents. Marijuana and alcohol use, however, do appear to be increasing. Educators should be aware of these trends, and this may allow them to target resources for impaired and at-risk residents.

49: Morbidity and Mortality Conference Use in Emergency Medicine

Morbidity and Mortality (M&M) conferences fulfill the ACGME requirement for practice-based learning and hold large educational potential relating to quality improvement and patient safety initiatives. The conference provides a forum for residents and faculty to analyze unforeseen complications of patient care, address unexpected mortality, and the opportunity to address both systems and medical errors. However, specific guidelines for content, frequency and format of this conference have not been standardized. This study seeks to describe and quantify the different types M&M conferences in emergency medicine training programs.

31. The birth of a new specialty: The history of emergency medicine in Canada

Modern day emergency rooms across Canada have almost completely transformed over the past 30 years; perhaps more so than any other specialty. Before the 1970’s, it was primarily general practitioners working on a part-time basis who ran our emergency departments. Some hospitals used interns and residents as first-line emergency care providers, often under the direction of a surgeon or internist. Emergency Medicine has evolved into a highly sophisticated and respected medical specialty that extends beyond clinical medicine, into both research and academia. The appeal of Emergency Medicine is so great that it is now one of the most sought after specialties in the annual CaRMS match. The success story of Emergency Medicine is characterized by the tireless efforts and determination of its founders across the country. They fought for adequate and supervised care of the acutely ill or traumatized patient, believing in a special body of knowledge that should be available to physicians who spend most, if not all, their time in Emergency Departments. In 1977, these founders formally united and The Canadian Association of Emergency Physicians was born. A few years later, in 1980, Emergency Medicine was finally designated as a free-standing specialty by the Royal College of Physicians and Surgeons of Canada. Meanwhile, the College of Family Physicians of Canada also sought to establish a parallel route for Emergency Training of Family Physicians, feeling that Emergency Medicine lay within the realm of Family Medicine. The result was that both colleges established Emergency Medicine training programs that exist until this day. &#x0D; Using journals, archives, a survey, and interviews, the paper will trace the history of the professionalization of Emergency Medicine in Canada.&#x0D; Johnson R. The Canadian Association of Emergency Physicians. The Journal of Emergency Medicine 1993; 11:362-364.&#x0D; Reudy J, Seaton T, Walker D, Rowat B, Cassie J. Report of the Task Force on Emergency Medicine: RCPSC Accreditation Section, 1988.&#x0D; Walker DMC. History and Development of the Royal College Specialty of Emergency Medicine. Annals Royal College of Physicians and Surgeons of Canada 1987; 20:349-352.

Emergency Department Operational Changes in Response to Pay-for-performance and Antibiotic Timing in Pneumonia

Background:The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b. Objectives:To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia. Methods:The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation. Results:Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n= 33; 37%), prioritized CXRs over other radiographs (n= 13; 14%), and improved inpatient bed availability (n= 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5–7). All sites reported engaging in at least three operational changes to address PN-5b. Conclusions:All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.

Emergency Department Operational Changes in Response to Pay‐for‐performance and Antibiotic Timing in Pneumonia

The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b. To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia. The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation. Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5-7). All sites reported engaging in at least three operational changes to address PN-5b. All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.

Trends and challenges in international pediatric emergency medicine

Pediatric emergency care internationally is practiced in a wide variety of local contexts, and the quality of care varies. International pediatric emergency medicine refers to the spectrum of care provided to children with serious illnesses and injuries globally. This article serves as the first of its kind to characterize current trends and challenges in this area. Current trends in international pediatric emergency medicine include international dissemination of pediatric emergency medicine guidelines, pediatric-specific disaster relief training, increasing numbers of pediatric emergency medicine research collaboratives, interest groups and training programs, and increasing numbers of spaces dedicated to pediatric emergency care. Current challenges to the field include inequalities in access to medical research and information, various nonmedical barriers and lack of reports describing approaches to the delivery of pediatric emergency care. While there are many recent advances in the state of pediatric emergency medicine internationally, there still exist many barriers to the improvement in its quality. Many of these obstacles are not specific to pediatric emergency medicine, but reflect overall disparities between the developing and developed worlds. One first step to overcoming pediatric emergency medicine practiced in isolation is a formal organization of the field of international pediatric emergency medicine.

Prehospital Emergency Medical Services in Malaysia

Once a very slowly developing country in a Southeast Asia region, Malaysia has undergone considerable change over the last 20 years after the government changed its focus from agriculture to developing more industry and technology. The well-known “Vision 2020,” introduced by the late Prime Minister, set a target for the nation to be a developed country in the Asia region by the year 2020. As the economy and standard of living have improved, the demand from the public for a better health care system, in particular, emergency medical services (EMS), has increased. Despite the effort by the government to improve the health care system in Malaysia, EMS within the country are currently limited, best described as being in the “developing” phase. The Ministry of Health, Ministry of Education, Civil Defense, and non-governmental organizations such as Red Crescent and St. John’s Ambulance, provide the current ambulance services. At the present time, there are no uniform medical control or treatment protocols, communication systems, system management, training or education, or quality assurance policies. However, the recent development of and interest in an Emergency Medicine training program has gradually led to improved EMS and prehospital care.

Rural hospital generalist and emergency medicine training in Papua New Guinea

The present paper describes the role of the hospital generalist in rural Papua New Guinea (PNG) and the contribution of emergency medicine training to that practice. Generalist practice in Tinsley District Hospital in Western Highlands Province is described, with emphasis on emergency surgery and anaesthesia. The potential of the PNG emergency medicine training programme for preparing generalists is discussed. Tinsley Hospital served a population of 40,000 people, with 4000 admissions and 300-400 operations performed annually. Two doctors and 50 nurses and community health workers provided care with minimal resources. The doctors provided supervision and teaching for nurses, community health workers, hospital administrators and primary health carers, including on long range medical patrols. Over 16 months, doctors performed 243 emergency surgical procedures including orthopaedics, general surgery, obstetrics and gynaecology. The generalist in rural hospitals is required to perform a wide variety of medical tasks in isolated settings yet there is no active postgraduate training programme. The Master of Medicine, Emergency Medicine programme includes rotations through the major disciplines of surgery, anaesthesia, internal medicine, paediatrics, obstetrics and gynaecology. It has the potential to train doctors in PNG for a generalist role as graduates will learn the foundations of the required skills.

Integrating the Core Competencies: Proceedings from the 2005 Academic Assembly Consortium

The Accreditation Council for Graduate Medical Education mandated the integration of the core competencies into residency training in 2001. To this end, educators in emergency medicine (EM) have been proactive in their approach, using collaborative efforts to develop methods that teach and assess the competencies. The first steps toward a collaborative approach occurred during the proceedings of the Council of Emergency Medicine Residency Directors (CORD-EM) academic assembly in 2002. Three years later, the competencies were revisited by working groups of EM program directors and educators at the 2005 Academic Assembly. This report provides a summary discussion of the status of integration of the competencies into EM training programs in 2005.

Integrating the Core Competencies: Proceedings from the 2005 Academic Assembly Consortium

The Accreditation Council for Graduate Medical Education mandated the integration of the core competencies into residency training in 2001. To this end, educators in emergency medicine (EM) have been proactive in their approach, using collaborative efforts to develop methods that teach and assess the competencies. The first steps toward a collaborative approach occurred during the proceedings of the Council of Emergency Medicine Residency Directors (CORD-EM) academic assembly in 2002. Three years later, the competencies were revisited by working groups of EM program directors and educators at the 2005 Academic Assembly. This report provides a summary discussion of the status of integration of the competencies into EM training programs in 2005.

101: Substance Use in Emergency Medicine Training Programs

Substance abuse among resident physicians may present a significant risk to both the resident using those substances as well as the patients they treat. A previous survey of emergency medicine (EM) residents in 1992 indicated past year use of cocaine, oral opiates and marijuana to be 1.0%, 1.5% and 8.8%, respectively.