Objectives to direct the training of emergency medicine residents on off-service rotations: neurology

Is There a Neurologist in the House? A Summary of the Current State of Neurovascular Rotations for Emergency Medicine Residents

OBJECTIVES

Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents.

METHODS

A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty.

RESULTS

Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive.

CONCLUSIONS

Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

Redefining emergency medicine procedures: Canadian competence and frequency survey

OBJECTIVE

To redefine the Royal College of Physicians and Surgeons (RCPS) procedural skills list for Canadian emergency medicine (EM) residents through a national survey of EM specialists to determine procedural performance frequency and self-assessment of competence.

METHODS

The survey instrument was developed in three phases: 1) an EM program directors survey identified inappropriate or dated procedures, endorsing 127 skills; 2) a search of EM literature added 98 skills; and 3) an expert panel designed the survey instrument and finalized a list of 150 skills. The survey instrument measured the frequency of procedure performance or supervision, self-reported competence (yes/no), and endorsement of one of four training levels for each skill: undergraduate (UG), postgraduate (PG), knowledge only, or unnecessary (i.e., too infrequently performed to maintain competence).

RESULTS

All 289 Canadian EM specialists were surveyed by mail; 231 (80%) responded, 221 completed surveys, and 10 were inactive. More than 60% reported competence in 125 (83%) procedures, and 55 procedures were performed at least three times a year. The mean competence score was 121 (SD +/- 17.7, median = 122) procedures. Competence score correlation with patient volume was r = 0.16 (p = 0.02) and with hours worked was r = 0.19 (p = 0.01). Competence score was not associated with year or route (residency vs grandfather) of certification. Each procedure was assigned to a training level using response consensus and decision rules (UG: 1%; PG: 82%; unnecessary: 17%).

CONCLUSIONS

A survey of EM clinicians reporting competence and frequency of skill performance defined 127 procedural skills appropriate for Canadian RCPS postgraduate training and EM certification.

Emergency procedures important to the training of emergency medicine residents: who performs them in the emergency department?

OBJECTIVE

To quantify one aspect of emergency medicine (EM) training by determining the proportion of emergency procedures performed by emergency physicians (EPs) in EDs with EM residency programs (EMRPs).

METHODS

Cross-sectional descriptive survey of all allopathic EMRPs accredited by the EM Residency Review Committee (RRC-EM) as of July 1, 1993. Using a modified visual analog scale, program directors indicated the proportion of ten index procedures performed in the ED by EPs vs all other physicians.

RESULTS

All 98 EMRPs meeting entry criteria responded to the survey. The medians for the percentage of times index procedures were performed in the ED by an EP were as follows (parentheses following percentages enclose 95% CIs): endotracheal intubation, 97% (95%, 100%); reduction of anterior shoulder dislocation, 93% (88%, 97%); thoracostomy, 63% (50%, 75%); transvenous pacer insertion, 60% (50%, 75%); cricothyrotomy, 50% (50%, 75%); thoracotomy, 50% (25%, 50%); diagnostic peritoneal lavage, 50% (25%, 50%); fiberoptic laryngoscopy, 22% (6%, 25%); sigmoidoscopy, 0% (0%, 6%); and pelvic sonography, 0% (0%, 0%).

CONCLUSION

EPs in EDs of institutions that have EMRPs perform, on average, 50% of all index procedures (95% CI 47%, 52%). This information may assist EM programs experiencing difficulty in ensuring that their residents receive an equitable share of those procedures that are critical to their training.