The 2016 Model of the Clinical Practice of Emergency Medicine

Dissemination, Utilization, and Satisfaction With Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) by North American Residency Programs

OBJECTIVES

Our research team's primary objective was to investigate how a custom standard simulation curriculum for teaching emergency medicine residents about pediatrics was being used by programs across North America. We also wanted to know if program directors were satisfied with the curriculum and whether they had challenges with implementing it. Our long-term goal is to promote the Emergency Medicine Resident Simulation Curriculum for Pediatrics for use by all programs in the United States.

METHODS

We distributed an electronic questionnaire to individuals who have downloaded the Emergency Medicine Resident Simulation Curriculum for Pediatrics in the form of an e-book from the Academic Life in Emergency Medicine Web site. The curriculum was marketed through national emergency medicine (EM) and pediatric emergency medicine (PEM) groups, PEM listserv, and through the International Network for Simulation-Based Pediatric Innovation, Research, and Education. We asked survey recipients how they used the curriculum, plans for future maintenance, satisfaction with curriculum use, and whether they had any challenges with implementation. Finally, we asked demographic questions.

RESULTS

Most survey respondents were EM or PEM health care physicians in the United States or Canada. Respondents' primary goal of using the curriculum was resident education. Through assessment with the Net Promoter Score, satisfaction with the curriculum was net positive with users largely scoring as curriculum promoters. We found COVID-19 and overall time limitations to be implementation barriers, whereas learner interest in topics was the largest cited facilitator. Most responders plan to continue to implement either selected cases or the entire curriculum in the future.

CONCLUSIONS

Of those who responded, our target audience of EM physicians used our curriculum the most. Further investigation on implementation needs, specifically for lower resource emergency programs, is needed.

Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates

Background

More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.

Methods

This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.

Results

A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001).

Conclusions/discussion

This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

Substance use and pre-hospital crash injury severity among U.S. older adults: A five-year national cross-sectional study

BACKGROUND

Alcohol and drug use (substance use) is a risk factor for crash involvement.

OBJECTIVES

To assess the association between substance use and crash injury severity among older adults and how the relationship differs by rurality/urbanicity.

METHODS

We pooled 2017-2021 cross-sectional data from the United States National Emergency Medical Service (EMS) Information System. We measured injury severity (low acuity, emergent, critical, and fatal) predicted by substance use, defined as self-reported or officer-reported alcohol and/or drug use. We controlled for age, sex, race/ethnicity, road user type, anatomical injured region, roadway crash, rurality/urbanicity, time of the day, and EMS response time. We performed a partial proportional ordinal logistic regression and reported the odds of worse injury outcomes (emergent, critical, and fatal injuries) compared to low acuity injuries, and the predicted probabilities by rurality/urbanicity.

RESULTS

Our sample consisted of 252,790 older adults (65 years and older) road users. Approximately 67%, 25%, 6%, and 1% sustained low acuity, emergent, critical, and fatal injuries, respectively. Substance use was reported in approximately 3% of the population, and this proportion did not significantly differ by rurality/urbanicity. After controlling for patient, crash, and injury characteristics, substance use was associated with 36% increased odds of worse injury severity. Compared to urban areas, the predicted probabilities of emergent, critical, and fatal injuries were higher in rural and suburban areas.

CONCLUSION

Substance use is associated with worse older adult crash injury severity and the injury severity is higher in rural and suburban areas compared to urban areas.

Human Trafficking and Emergency Medical Services (EMS)

Human trafficking is associated with wide-ranging mental and physical morbidity, as well as mortality, in the United States and globally. Emergency Medical Services (EMS) providers are often first responders to victims of human trafficking. Given their proximity to patients' social and environmental circumstances, these clinicians need to be familiar with the signs and symptoms of human trafficking, as well understand how to best provide care for suspected or confirmed trafficked patients. Evidence from multiple studies indicates that providers who have received formal training may be better able to recognize the signs and symptoms of human trafficking, and thus, can provide better care to potential victims of human trafficking. This review will summarize the relevance of human trafficking to prehospital emergency care, touch on best practices for the care of patients with suspected or confirmed ties to human trafficking, and outline future directions for education and research.

Exploring a case for education about sexual and gender minorities in postgraduate emergency medicine training: forming recommendations for change

Social medicine and health advocacy curricula are known to be uncommon in postgraduate medical education. As justice movements work to unveil the systemic barriers experienced by sexual and gender minority (SGM) populations, it is imperative that the emergency medicine (EM) community progress in its efforts to provide equitable, accessible, and competent care for these vulnerable groups. Given the paucity of literature on this subject in the context of EM in Canada, this commentary borrows evidence from other specialties across North America. Trainees across specialties and of all stages are caring for an increasing number of SGM patients. Lack of education at all levels of training is identified as a significant barrier to adequately caring for these populations, thereby precipitating significant health disparities. Cultural competency is often mistakenly attributed to a willingness to treat rather than the provision of quality care. However, positive attitudes do not necessarily correlate with trainee knowledge. Barriers to creating and implementing culturally competent curricula are plentiful, yet facilitating policies and resources are rare. While international bodies continuously publish position statements and calls to action, concrete change is seldom made. The scarcity of SGM curricula can be attributed to the universal absence of formal acknowledgment of SGM health as a required competency by accreditation boards and professional membership associations. This commentary synthesizes hand-picked literature in an attempt to inform healthcare professionals on their journey toward developing culturally competent postgraduate medical education. By thematically organizing evidence into a stepwise approach, the goal of this article is to borrow ideas across medical and surgical specialties to inform the creation of recommendations and make a case for an SGM curriculum for EM programs in Canada.

Knowledge, Judgment, and Skills in Reproductive Health Care and Abortion Are Essential to the Practice of Obstetrics and Gynecology

A social contract exists between medicine and society. In fulfilling the social contract to our patients and society, physicians have an obligation to provide the evidence-based care that patients want and need. What do the data regarding knowledge, judgment, and skills required to practice obstetrics and gynecology show? Obstetrics and gynecology job task analyses assess the importance of knowledge, judgment, and skills through surveys asking practicing physicians about the criticality and frequency of a variety of task statements to create an importance score. Excerpts from a 2018 practice analysis survey clearly indicate that reproductive health care and abortion are important components of the knowledge, judgment, and skills to practice obstetrics and gynecology in the United States. These standards help to assure the knowledge, judgment, and skills of current and future generations of ob-gyns, so their patients and the public can be provided the comprehensive reproductive health care they want and need. It is sometimes important to restate principles and standards that have become ingrained in thoughts and practices that guide physicians and serve to protect our patients. This concept is important now, as our country, health care professionals, and patients examine the future of reproductive health care, including abortion.

A Case of 25 Inappropriate Automatic Implantable Cardioverter Defibrillator Shocks and 22 Episodes of Antitachycardia Pacing

An implantable cardioverter defibrillator (ICD) can save lives from fatal tachyarrhythmias. In rare cases, these devices can fail or malfunction. We present a case of a patient that suffered from 25 inappropriate shocks and 22 episodes of antitachycardia pacing (ATP), secondary to a probable non-traumatic dual lead fracture. One episode of ATP induced an R-on-T phenomenon, causing monomorphic ventricular tachycardia in the patient. The inappropriately functioning ICD also required two magnets to be placed on the patient's chest in the emergency department to convert the device to an asynchronous mode. An unexpected case of this magnitude and in such a brief timeframe has not been reported in prior ICD studies.

Exposure to a Virtual Reality Mass-Casualty Simulation Elicits a Differential Sympathetic Response in Medical Trainees and Attending Physicians

BACKGROUND

Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario.

METHODS

An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch's t-test, and multivariate logistic regression were performed with statistical significance established at P <.05.

RESULTS

Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030).

CONCLUSIONS

Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

An Evaluation of Emergency Medicine Core Content Covered by Podcasts

INTRODUCTION

Podcasts are used broadly for learning in emergency medicine (EM); however, there is concern about the potential for knowledge gaps for learners who rely on podcasts for their learning. The extent to which EM podcasts cover the core curriculum of EM is not known; thus, we sought to quantify the extent to which podcasts represent the core content of our specialty.

METHODS

We performed a retrospective review of all EM podcast episodes published in 2019. All podcasts were given credit for the content they covered as it related to the 2016 American Board of Emergency Medicine (ABEM) Model of Clinical Practice in Emergency Medicine (EM Model). The primary outcome was a description of how podcasts represented the ABEM EM Model content topics compared to the topic representation of the ABEM Qualifying Exam.

RESULTS

We included 54 unique EM podcast programs and 1,193 podcast episodes. They covered 2,965 total EM Model core content topics. The topics most covered were "other" (which includes interpersonal skills and professionalism), procedures, and signs and symptoms. Musculoskeletal, hematology, and environmental each accounted for less than 1% of all topics covered. Almost three-quarters of podcast episodes covered other core competencies of the practice of EM.

CONCLUSION

Podcasts had a broad yet imbalanced coverage of the ABEM EM Model core content subtopics in 2019, with a notable coverage of other core competencies of the practice of EM. Learners, educators, and scholars should be mindful of these gaps and focus future work on exploring how podcasts should best be used in EM education.

PEARL: Pharmacy Education Applied to Resident Learners

INTRODUCTION

Emergency medicine residents typically train with the support of emergency medicine pharmacists (EMP), but many EM residents will practice in post-graduation settings without EMP assistance. Therefore, a novel pharmacy curriculum for postgraduate year-1 (PGY-1) EMRs was developed, implemented, and assessed.

METHODS

We performed a controlled study of 25 residents from two separate EM programs in Detroit, MI. One program was the control group and the other program was the intervention group. The primary outcome was pre- and post-curriculum knowledge assessment scores, and the secondary outcome was pre- and post-curriculum, self-perceived knowledge survey responses. We performed statistical analyses with Welch's t-test or the Mann-Whitney U test.

RESULTS

The pre-curriculum assessment scores (41% ± 11; 41% ± 8.1; P = 0.96; mean ± SD) and average pre-curriculum survey responses (2.8 ± 0.92; 3.0 ± 0.60; P = 0.35) were not statistically different between the control and the intervention groups. The post-curriculum assessment scores (63% ± 14; 74% ± 8.3; P = 0.04) and the average post-curriculum survey responses (4.2 ± 0.61; 5.0 ± 0.74, P = 0.02) were statistically different. The increase from the pre- to post-curriculum assessment scores (24% ± 11; 33% ± 11; P = 0.05) was also significantly different.

CONCLUSION

The implementation of a novel pharmacy curriculum for PGY-1 EM residents resulted in improved knowledge of and comfort with pharmaceuticals and therapeutics specific to EM practice. The impact on patient care and frequency of medical errors requires further investigation.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency: An Update and Longitudinal Study

Introduction Musculoskeletal (MSK) complaints and injuries account for a significant percentage of presenting chief complaints to the emergency department in the United States (US). Despite the prevalence of disease and economic impact on the US healthcare system, there is a documented deficiency in MSK education at all training and practicing levels in the US medical system. The purpose of this study is to determine MSK knowledge acquisition after an orthopedic or primary care sports medicine (PCSM) rotation in three emergency medicine (EM) residency programs at a single institution. Methods A total of 115 EM post-graduate year 1 (PGY-1) residents participated in and completed this study over five academic years. Based on existing residency program curricula, the participants were categorized into two groups. One group completed a traditional four-week Orthopedic Surgery rotation and the other group completed a four-week Sports Medicine rotation. The validated written Freedman and Bernstein MSK examination (FB-MSK) was administered to all participants at the start of residency and at completion of their rotation. Fifty-nine of the participants participated in a longitudinal secondary study over five academic years. The FB-MSK was offered to all participants every year following the completion of their rotation during their residency. Results Post-rotation scores improved regardless of which group the resident belonged to. The orthopedic group improved an average of 3.11 points (p = <0.0001, CI 2.39 to 3.82) and the average improvement in the PCSM group was 3.97 points (p = <0.0001, CI 2.81 to 5.83). The post-rotation scores were similar regardless of the group (p = 0.4287, CI -0.73 to 1.70). The amount of improvement in scores between the two groups was not statistically significant (p = 0.209, CI -0.49 to 2.21). Of the longitudinal participants, PGY-3+ significantly scored higher than PGY-1 (p = 0.0325, 95% CI 0.165 to 3.658). Conclusion Regardless of rotation type, MSK knowledge acquisition appears to significantly improve. EM senior residents demonstrate significant MSK knowledge acquisition during residency. Further studies on a multi-institutional level are needed to account for MSK curriculum variability in residency programs.

Block by block: Building on our knowledge to better care for LGBTQIA+ patients

BACKGROUND

Emergency physicians need to recognize the diversity of identities held by sexual and gender minorities, as well as the health implications and inequities experienced by these communities. Identities such as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, aromantic, and many others fall under the LGBTQIA+ acronym. This wide spectrum is seldom discussed in emergency medicine but nonetheless impacts both patient care and patient experience in acute and critical care settings.

AIMS

This commentary aims to provide a brief but nonexhaustive review of LGBTQIA+ identities and supply a critical framework for applying this understanding to patient encounters in the emergency department, as well as describe the challenges and educational aims at the level of medical school, residency, and postresidency.

MATERIALS AND METHODS

The commonly used and widely accepted definitions of LGBTQIA+ terms are described, as well as implications for patient care and emergency physician education. The authors of this writing group represent the Society for Academic Emergency Medicine, LGBTQ Task Force of the Academy of Diversity Inclusion in Medicine.

RESULTS

LGB terms are addressed, with LGBTQIA+ adding "intersex," "asexual," and "+," to include other gender identities and sexual orientations which are not already included. This paper also addresses the terms "transition," "nonbinary," "polyamorous." "two-spirit," "queer," and others. These acronyms and terms continually expand and evolve in the pursuit of inclusivity. Additionally, with some health issues potentially related to medications, hormones, surgery, or to internal or external genitalia, important EM physician tools include gathering an "organ inventory," asking about sexual history, and conducting a physical exam.

DISCUSSION

Most persons have congruent biological sex, gender identity, and attraction to the "opposite" gender. However, humans can have every imaginable variation and configuration of chromosomes, genitalia, gender identities, sexual attractions, and sexual behaviors. Terms and definitions are constantly changing and adapting; they may also vary by local culture. Obtaining relevant medical history, conducting an "organ inventory," asking about sexual history in a nonjudgmental way, and conducting a physical exam when warranted can all be important in delivering best possible medical care. Although there has been increased focus on education at the medical school, residency, and faculty level on LGBTQIA+ patient care in the ED, much work remains to be done.

CONCLUSION

Emergency physicians should feel confident in providing a model of care that affirms the sexual and gender identities of all the patient populations we serve. Optimal patient-centric care requires a deeper understanding of the patient's biology, gender identity, and sexual behavior encapsulated into the ever-growing acronym LGBTQIA+.

Sex trafficking screening and intervention in the emergency department: A scoping review

INTRODUCTION

Human sex trafficking is a global public health crisis. Emergency departments (EDs) are important access points for trafficked persons who seek medical care. However, because of victims' hesitancy to disclose their situation and health care practitioners' lack of training and institutional protocols, many trafficked persons go unrecognized.

METHODS

We performed a scoping review of current literature. PubMed, SCOPUS, and reference lists were searched to identify articles for inclusion. We aimed to identify gaps in knowledge and shortcomings to assist this vulnerable population. Two reviewers independently screened literature search results and abstracted data from included studies. Descriptive analysis was conducted.

RESULTS

We selected and analyzed 23 studies that focused on adult human sex trafficking identification, screening, interventions, or education in the ED. Eight (35%) of the publications used a survey model to quantitatively assess outcomes. Many of the other publications were descriptive or qualitative in nature, with some using a structured interview approach. We have observed that no validated or consistent screening tool exists for the identification of possible adult trafficked patients in the ED. However, we found that educational interventions and screening tools can improve health care practitioners' confidence, victim identification, and knowledge of "next steps" for victims.

CONCLUSIONS

We found that most ED clinicians and staff have little or no formal training in sex trafficking victim identification, support, institutional protocols, or available local resources. Our review demonstrates a paucity of formal training programs, validated adult screening tools, and standardized institutional protocols to aid in the care of trafficked patients in the ED.

Education about sexual and gender minorities within Canadian emergency medicine residency programs

OBJECTIVES

The CAEP 2021 2SLGBTQIA +ⁱ panel sought whether a gap exists within Canadian emergency medicine training pertaining to sexual and gender minority communities. This panel aimed to generate practical recommendations on improving emergency medicine education about sexual and gender minorities, thereby improving access to equitable healthcare.

METHODS

From August 2020 to June 2021, a panel of emergency medicine practitioners, residents, students, and community representatives met monthly via videoconference. A literature review was undertaken, and three mixed methods surveys were distributed to the CAEP member list, CAEP Resident Section, College of Family Physicians of Canada (CFPC)ⁱⁱⁱ Emergency Medicine Members Interest Group, and to emergency medicine residency program directors and their residents. Informed by the review and surveys, recommendations were drafted and refined by panel members before presentation at the 2021 CAEP Academic Symposium. A plenary was presented to symposium attendees composed of national emergency medicine community members, which reported the survey results and literature review. All attendees were divided into small groups to develop an action plan for each recommendation.

CONCLUSIONS

The panel outlines eight recommendations for closing the curricular gap. It identifies three perceived or real barriers to the inclusion of sexual and gender minority content in emergency medicine residency curricula. It acknowledges three enabling recommendations that are beyond the scope of individual emergency medicine programs or emergency departments (EDs), that if enacted would enable the implementation of the recommendations. Each recommendation is accompanied by two action items as a guide to implementation. Each of the three barriers is accompanied by two action items that offer specific solutions to overcome these obstacles. Each enabling recommendation suggests an action that would shift emergency medicine towards sociocultural competence nationally. These recommendations set the primary steps towards closing the educational gap.

Pregnant and bleeding: A model to assess factors associated with the need for emergency care in early pregnancy

OBJECTIVE

To assess the prevalence of Critical or Emergent patient classification among pregnant patients presenting to the Emergency Department (ED) and to identify characteristics that discriminate between patients requiring Emergency care from those who can be safely triaged to the ambulatory setting.

STUDY DESIGN

In this cross-sectional study conducted in 3 urban EDs, patients under 16 weeks gestation who presented with bleeding and/or cramping completed a 7-item questionnaire. We compared baseline clinical variables and survey responses among patients classified as Critical or Emergent per the American Board of Emergency Medicine's patient acuity definitions with those classified as Lower Acuity to identify independent risk factors for outcomes.

RESULTS

Of 484 participants, 21 (4.3%) were classified as Critical or Emergent and required interventions. While no demographic characteristics differentiated Critical patients from Lower Acuity patients, survey questions associated with a higher likelihood of emergency intervention included history of prior ectopic pregnancy (OR 8.7, 95% CI 3.2-23.5) heavy bleeding in the past two hours (OR 11.8, 95% CI 3.8-36.1), as well as having made a prior ED visit in the current pregnancy (OR 1.9, 95% CI 0.7-5.1). Joint consideration of these risk factors in a multivariable model performed well at discriminating between Critical and Lower Acuity patients with an area under the ROC curve of 0.82 (95% CI 0.71-0.93).

CONCLUSION

Patients with a history of ectopic pregnancy, heavy bleeding in the past two hours, and/or prior presentation to the ED in the current pregnancy had the highest risk of needing emergency-level care. The vast majority of patients presenting to the ED with early pregnancy complaints were discharged without intervention.

A Novel Application of the Modified Angoff Method to Rate Case Difficulty in Simulation-Based Research

INTRODUCTION

Simulation use in research is often limited by controlling for scenario difficulty when using repeated measures. Our study assesses the feasibility of the Modified Angoff Method to reach expert consensus regarding difficulty of medical simulations. We compared scores with participant physiologic stress.

METHODS

Emergency medicine physicians with expertise in simulation education were asked to review 8 scenarios and estimate the percentage of resident physicians who would perform all critical actions using the modified Angoff method. A standard deviation (SD) of less than 10% of estimated percentage correct signified consensus. Twenty-five residents then performed the 6 scenarios that met consensus and heart rate variability (HRV) was measured.

RESULTS

During round 1, experts rated 4/8 scenarios within a 10% SD for postgraduate year 3 (PGY3) and 3/8 for PGY4 residents. In round 2, 6/8 simulation scenarios were within an SD of 10% points for both years. Intraclass correlation coefficient was 0.84 for PGY3 ratings and 0.89 for PGY4 ratings. A mixed effects analysis of variance showed no significant difference in HRV change from rest to simulation between teams or scenarios. Modified Angoff Score was not a predictor of HRV (multiple R2 = 0.0176).

CONCLUSIONS

Modified Angoff ratings demonstrated consensus in quantifying the estimated percentage of participants who would complete all critical actions for most scenarios. Although participant HRV did decrease during the scenarios, we were unable to significantly correlate this with ratings. This modified Angoff method is a feasible approach to evaluate simulation difficulty for educational and research purposes and may decrease the time and resources necessary for scenario piloting.

Development of a veterinary emergency open standard competency framework using a competency-based model of medical education

OBJECTIVE

To address the shortage of emergency veterinarians, the profession is exploring accelerated training pathways. We sought to contribute to the solution by developing the foundation for an open standard, competency-based veterinary emergency training curriculum for use by any program. We also developed a curricular delivery, tracking, and assessment system to demonstrate how the framework can be integrated into training programs.  DESIGN: Hybrid Delphi method.  SETTING: Academia and referral practice.  ANIMALS: None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

An emergency veterinary competency framework was developed by adapting the human Model of the Clinical Practice of Emergency Medicine, which aligns with the Competency-Based Veterinary Education framework, to produce 4 areas of core competency: Patient Care, Interpersonal/Communication, Professionalism, and Practice-based Learning/Improvement. A comprehensive list of veterinary emergency skills was generated and organized within the framework utilizing the hybrid Delphi method. An initial survey completed by 133 emergency and critical care specialists and emergency room clinicians produced data regarding the value of specific skills. An 11-member focus group consisting of survey participants iterated upon the survey results to produce a master library of skills and cases, including 56 Patient Care, 43 Interpersonal/Communication, 11 Practice-based Learning/Improvement, and 20 Professionalism skills, as well as 155 case types. The curricular delivery system tracks and assesses case management proficiency and development of knowledge and professional skills using a patient care eLearning program and simulation training environment.  CONCLUSIONS: The increasing need for emergency veterinarians is a shared industry-wide challenge. To contribute toward a collective solution, we have undergone an evidence-based process to create the foundation for an open standard competency framework composed of a library of skills and cases. We offer this open standard framework to the veterinary profession and hope it continues to grow and evolve as we drive toward developing competency-based training programs that address the shortage of emergency veterinarians.

Development, Implementation, and Evaluation of an Open Access, Level-Specific, Core Content Curriculum for Emergency Medicine Residents

BACKGROUND

Leaders in graduate medical education must provide robust clinical and didactic experiences to prepare residents for independent practice. Programs traditionally create didactic experiences individually, requiring tremendous resources with variable content exposure and quality.

OBJECTIVE

We sought to create and implement a free, open access, learner-centric, level-specific, emergency medicine (EM) residency curriculum.

METHODS

We developed Foundations of Emergency Medicine (FoEM) Foundations I and II courses using Kern's model of curriculum development. Fundamental topics were identified through content guidelines from the American Board of Emergency Medicine. We incorporated learner-centric strategies into 2 flipped classroom, case-based courses targeting postgraduate year (PGY) 1 and PGY-2 residents. The curriculum was made freely available online in 2016. Faculty and resident users were surveyed annually for feedback, which informed iterative refinement of the curriculum.

RESULTS

Between 2016 and 2020, registration for FoEM expanded from 2 sites with 36 learners to 154 sites and 4453 learners. In 2019, 98 of 102 (96%) site leaders and 1618 of 2996 (54%) learners completed the evaluative survey. One hundred percent of responding leaders and 93% of learners were "satisfied" or "very satisfied" with FoEM content. Faculty and residents valued FoEM's usability, large volume of content, quality, adaptability, organization, resident-faculty interaction, and resident-as-teacher opportunities. Challenges to implementation included resident attendance, conference structure, technology limitations, and faculty engagement.

CONCLUSIONS

We developed and implemented a learner-centric, level-specific, national EM curriculum that has been widely adopted in the United States.

A novel approach: Simulating multiple simultaneous encounters to assess multitasking ability in emergency medicine

Study objective

The purpose of this feasibility study is to develop and validate a new assessment tool and scoring system for multitasking competency for physicians in-training in a timed simulated setting. The multitasking competency includes ability to appropriately prioritize and implement tasks for different patients who present simultaneously.

Methods

We designed three single task stations with different levels of difficulty and priority. These skill stations were then combined to create a multitasking simulation scenario. Skill checklists and the global rating scale were utilized to assess the participants’ performance. A multitasking score, multitasking index, and priority score were developed to measure the multitasking ability of participants.

Results

Thirty-three first-year postgraduate physicians were recruited for this prospective study. The total performance scores were significantly higher for the single-tasking stations than for the multitasking scenario. In terms of the time needed to complete the tasks, the participants spent more time on the multitasking scenario than on the single-tasking scenario. There were significant correlations between the global rating scale and the multitasking score (rho = 0.693, p < 0.001) and between the global rating scale and the multitasking index (rho = 0.515, p < 0.001). The multitasking score, multitasking index, and priority score did not have any significant correlations with the total single-tasking score.

Conclusion

We demonstrated that the use of a simulated multitasking scenario could be an effective method of assessing multitasking ability and allow assessors to offer better quality feedback.

Images of dark skin in top emergency medicine journals: A cross-sectional analysis of images of emergent cutaneous disorders

INTRODUCTION

Emergency medicine (EM) physicians must recognize emergent cutaneous disorders (CDs) in patients of all skin tones. In other medical specialties, images of CDs in light-skinned individuals (LSI) are published more frequently than images of CDs in dark-skinned individuals (DSI). This study aims to determine the representation of LSI versus DSI in images of emergent CDs published in top EM journals.

METHODS

This is a cross-sectional analysis of CD images published from 2015 to 2020 in the six most influential EM journals as determined by Eigenfactor. The 2016 Model of the Clinical Practice of Emergency Medicine (EM Model) by the American Board of Emergency Medicine was used to classify CDs as "emergent," "nonemergent," or "not listed." The Fitzpatrick skin tone scale was used to classify skin tone as light, dark, or indeterminate. Two blinded reviewers classified each image; for disagreements, a third blinded reviewer determined the final classification. Descriptive statistics and chi-square were used to analyze the data. A kappa coefficient was used to determine reviewer agreement (LSI vs. DSI), and a weighted kappa coefficient was used for agreement between individual Fitzpatrick categories.

RESULTS

There were 314 images of CDs. Forty images were indeterminate, and one image was excluded, leaving 273. Of the 273 images analyzed, 44.0% were emergent, 8.0% were nonemergent, and 48.0% were not listed in the EM Model. DSI comprised 13.6% of images. For emergent CDs, 85.0% were LSI versus 15.0% DSI. For nonemergent CDs, 27.3% were DSI, and for CDs not listed in the EM Model, 9.9% were DSI. The kappa coefficient for reviewer agreement between LSI and DSI was 0.76 (95% confidence interval [CI] = 0.65 to 0.87) and the weighted kappa coefficient for agreement between Fitzpatrick categories was 0.70 (95% CI = 0.64 to 0.76), showing substantial agreement.

CONCLUSION

For emergent and nonemergent CDs, images of LSI were published more than those of DSI in top EM journals.

Simulating a Vertical Evacuation of a NICU and PICU to Examine the Relationship Between Training and Preparedness

OBJECTIVE

The aim of this study was to implement pediatric vertical evacuation disaster training and evaluate its effectiveness by using a full-scale exercise to compare outcomes in trained and untrained participants.

METHODS

Various clinical and nonclinical staff in a tertiary care university hospital received pediatric vertical evacuation training sessions over a 6-wk period. The training consisted of disaster and evacuation didactics, hands-on training in use of evacuation equipment, and implementation of an evacuation toolkit. An unannounced full-scale simulated vertical evacuation of neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) patients was used to evaluate the effectiveness of the training. Drill participants completed a validated evaluation tool. Pearson chi-squared testing was used to analyze the data.

RESULTS

Eighty-four evaluations were received from drill participants. Forty-three (51%) of the drill participants received training and 41 (49%) did not. Staff who received pediatric evacuation training were more likely to feel prepared compared with staff who did not (odds ratio, 4.05; confidence interval: 1.05-15.62).

CONCLUSIONS

There was a statistically significant increase in perceived preparedness among those who received training. Recently trained pediatric practitioners were able to achieve exercise objectives on par with the regularly trained emergency department staff. Pediatric disaster preparedness training may mitigate the risks associated with caring for children during disasters.

Systematic online academic resource (SOAR) review: Endocrine, metabolic, and nutritional disorders

BACKGROUND

Free open-access medical education (FOAM) has become an integral resource for medical school and residency education. However, questions of quality and inconsistent coverage of core topics remain. In this second entry of the SAEM Systematic Online Academic Resource (SOAR) series, we describe the application of a systematic methodology to identify, curate, and describe FOAM topics specific to endocrine, metabolic, and nutritional disorders as defined by the 2016 Model of the Clinical Practice of Emergency Medicine (MCPEM).

METHODS

We developed an automated algorithm to search 264 keywords derived from nine subtopics within the MCPEM category in the FOAM Search (a customized FOAM search tool) and the Social Media index. The top 100 results were extracted for each keyword. Resources underwent a manual iterative screening process, and those relevant to endocrine, metabolic, or nutritional disorders and EM were evaluated with the revised Medical Education Translational Resources: Impact and Quality (rMETRIQ) tool.

RESULTS

The search yielded 36,346 resources, of which 756 met the criteria for quality assessment. After rMETRIQ tool training, four raters demonstrated an average measured intraclass correlation coefficient of 0.94 (95% confidence interval = 0.88 to 0.97, p < 0.001). A total of 121 posts (16% of posts) covering 25 subtopics were identified as high quality (rMETRIQ ≥16). The most covered subtopic was potassium disorders, representing 15% of all posts. Subtopics that did not have a high-quality resource identified include metabolic alkalosis, respiratory alkalosis, fluid overload, phosphorus metabolism, hyperglycemia, malabsorption, malnutrition, and thyroiditis. From most to least common, the overall target audience was junior resident (91%), PGY-1 resident (88%), senior resident (81%), clerk (64%), attending (50%), and preclerkship (9%).

CONCLUSIONS

We systematically identified, described, and curated FOAM resources for EM learners on the topic of endocrine, metabolic, and nutritional disorders. A final list of high-quality resources can guide trainees, educator recommendations, and FOAM authors.

Creation of a standardized pediatric emergency medicine simulation curriculum for emergency medicine residents

BACKGROUND

The majority of children seeking care in emergency departments are seen by general emergency medicine (EM) residency program graduates. Throughout training, EM residents manage fewer critically ill pediatric patients compared to adults, and the exposure to children with illness and injury requiring emergent assessment and management is often limited and sporadic across training sites. This report describes the creation of a robust set of simulation cases for EM trainees incorporating topics identified during a previous modified Delphi study to improve their pediatric acute care knowledge and skills.

METHODS

All 30 pediatric EM topics and 19/26 procedures previously identified as "must be taught by simulation" to EM residents were mapped to 15 simulation case topics. Twenty-seven authors from 16 institutions created cases and supporting materials. Each case was iteratively implemented during a peer review process at two to five sites with EM residents. Feedback from learners and facilitators was collected via electronic surveys and used to revise each case before the next implementation.

RESULTS

Thirty-five institutions participated in the peer review process. Fifty-one facilitators and 281 participants (90% EM residents) completed surveys. Most facilitators (98%) agreed or strongly agreed with the statement "This simulation case is relevant to the field of emergency medicine." A majority of facilitators and participants agreed or strongly agreed with the statements "The simulation case was realistic" (98% of facilitators, 94% of participants) and "This simulation case was effective in teaching resuscitation skills" (92% of facilitators, 98% of participants). Most participants reported confidence in knowledge and skills addressed in the learning objectives after participation.

CONCLUSIONS

Facilitators and EM residents found cases from a novel simulation-based curriculum covering critical pediatric EM topics relevant, realistic, and effective. This curriculum can help provide a standardized, uniform experience for EM residents who will care for critically ill pediatric patients in their communities.

A National Survey of Wilderness Medicine Curricula in United States Emergency Medicine Residencies

INTRODUCTION

Wilderness medicine (WM) is a growing subspecialty of emergency medicine. In 2018, we surveyed all 240 emergency medicine residencies in the United States to assess the scope of WM education in emergency medicine training programs in light of the nearly 30% increase in the number of residencies since 2015.

METHODS

A survey was e-mailed to the Council of Residency Directors in Emergency Medicine listserv and individual program directors of each of the 240 residencies. The survey included questions on educational content, format, number of hours taught, availability of conference credit, offering of an elective or fellowship, and several predefined WM curricula. We evaluated differences between 3-y and 4-y residencies using the χ² test, where P<0.05 was considered significant.

RESULTS

We had a response rate of 57% for completed surveys. Analysis showed 63% of respondent programs teach WM material. The majority (86%) partially or completely developed their curriculum, with 33% offering at least 1 of the predefined curricula. Thirteen percent taught with lecture only, 2% taught by hands-on only, and 85% used a combination of the 2. WM electives were significantly more likely to be offered by 4-y than 3-y residencies (P=0.009).

CONCLUSIONS

Almost two-thirds of respondent residency programs teach WM material. Of these, only one-third teach any of the predefined curricula. Four-year residencies are more likely to offer WM electives but are otherwise comparable to 3-y programs.

Benchmark Performance of Emergency Medicine Residents in Pediatric Resuscitation: Are We Optimizing Pediatric Education for Emergency Medicine Trainees?

BACKGROUND

The majority of children in the United States seek emergency care at community-based general emergency departments (GEDs); however, the quality of GED pediatric emergency care varies widely. This may be explained by a number of factors, including residency training environments and postgraduate knowledge decay. Emergency medicine (EM) residents train in academic pediatric EDs, but didactic and clinical experience vary widely between programs, and little is known about the pediatric skills of these EM residents. This study aimed to assess the performance of senior EM residents in treating simulated pediatric patients at the end of their training.

METHODS

This was a prospective, cross-sectional, simulation-based cohort study assessing the simulated performance of senior EM resident physicians from two Massachusetts programs leading medical teams caring for three critically ill patients. Sessions were video recorded and scored separately by three reviewers using a previously published simulation assessment tool. Self-efficacy surveys were completed prior to each session. The primary outcome was a median total performance score (TPS), calculated by the mean of individualized domain scores (IDS) for each case. Each IDS was calculated as a percentage of items performed on a checklist-based instrument.

RESULTS

A total of 18 EM resident physicians participated (PGY-3 = 8, PGY-4 = 10). Median TPS for the cohort was 61% (IQR = 56%-70%). Median IDSs by case were as follows: sepsis 67% (IQR = 50%-67%), seizure 67% (IQR = 50%-83%), and cardiac arrest 67% (IQR = 43%-70%). The overall cohort self-efficacy for pediatric EM (PEM) was 64% (IQR = 60%-70%).

CONCLUSIONS

This study has begun the process of benchmarking clinical performance of graduating EM resident physicians. Overall, the EM resident cohort in this study performed similar to prior GED teams. Self-efficacy related to PEM correlated well with performance, with the exception of knowledge relative to intravenous fluid and vasopressor administration in pediatric septic shock. A significant area of discrepancy and missed checklist items were those related to cardiopulmonary resuscitation and basic life support maneuvers.

A Model Research Curriculum for Emergency Medicine Residency: A Modified Delphi Consensus

BACKGROUND

Research training is important for all resident physicians to be able to interpret and critically appraise scientific literature. It is particularly important for those desiring future careers in academics or research. However, there is limited literature on research training in residency. The ideal scope and content of a model curriculum for research in emergency medicine (EM) residency programs has not been recently defined.

METHODS

We used a modified Delphi method to achieve expert consensus as to what content should be included in a model research curriculum for EM residents as well as for those who choose to undertake an elective in EM research.

RESULTS

Eight experts in EM clinical and education research participated in the modified Delphi process with two rounds of responses. Cronbach's alpha was 0.82 for round 1 and 0.95 for round 2. A curricular outline of 44 items was produced by this consensus process.

CONCLUSIONS

A model curriculum for EM research is proposed here, along with references to assist residencies in building curricular components.

Social Media Bridges the Training Gap Between Match Day and Internship With ACGME Milestone-based Clinical Case Curriculum

OBJECTIVES

The objective was to bridge the relative educational gap for newly matched emergency medicine preinterns between Match Day and the start of internship by implementing an Accreditation Council for Graduate Medical Education Milestone (ACGME)-based virtual case curriculum over the social media platform Slack.

METHODS

We designed a Milestone-based curriculum of 10 emergency department clinical cases and used Slack to implement it. An instructor was appointed for each participating institution to lead the discussion and encourage collaboration among preinterns. Pre- and postcurriculum surveys utilized 20 statements adapted from the eight applicable Milestones to measure the evolution of preintern self-reported perceived preparedness (PP) as well as actual clinical knowledge (CK) performance on a case-based examination.

RESULTS

A total of 11 institutions collaborated and 151 preinterns were contacted, 127 of whom participated. After participating in the Slack intern curriculum (SIC), preinterns reported significant improvements in PP regarding multiple Milestone topics. They also showed improved CK regarding the airway management Milestone based on examination performance.

CONCLUSIONS

Implementation of our SIC may ease the difficult transition between medical school and internship for emergency medicine preinterns. Residency leadership and medical school faculty will benefit from knowledge of preintern PP, specifically of their perceived strengths and weaknesses, because this information can guide curricular focus at the end of medical school and beginning of internship. Limitations of this study include variable participation and a high attrition rate. Further studies will address the utility of such a virtual curriculum for preinterns and for rotating medical students who have been displaced from clinical rotations during the novel coronavirus pandemic.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department

OBJECTIVES

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.

METHODS

Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.

RESULTS

Twenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.

CONCLUSIONS

Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency

Introduction

Musculoskeletal (MSK) complaints and injuries comprise 18.7% of emergency department visits. However, only 61% of emergency physicians (EP) pass a validated written Freedman and Bernstein MSK examination (FB-MSK). Educational interventions such as a primary care sports medicine (PCSM) rotation aid in MSK residency education. This study utilizes a validated MSK examination to evaluate and compare MSK knowledge acquisition following a traditional orthopedic rotation and a PCSM rotation.

Methods

Forty-nine interns were recruited to participate in this study over two academic years. The FB-MSK was administered to all participants at the start of residency. Participants were divided into two groups based on their residency sites; one group completed a traditional four-week orthopedic surgery rotation and the second group completed a four-week PCSM rotation. Forty-six of the forty-nine participants were administered the FB-MSK after completion of their rotations.

Results

Individual post-rotation scores significantly improved regardless of rotation (mean difference 2.78, p<0.001; 95% CI 2.05-3.52). The orthopedic surgery group significantly improved (mean difference 2.84, p<0.001; 95% CI 1.93-3.73) and the PCSM group significantly improved (mean difference 2.64, p=0.002; 95% CI 1.23-4.07). There was no significant difference in pre-rotation scores between the two groups (p=0.86; 95% CI -2.13 to 1.79). There was no significant difference in post-rotation scores between the two groups (p=0.66; 95% CI -1.98 to 1.26). There was no significant difference in mean score improvement between the two groups (p=0.81; 95% CI -1.33 to 1.69).

Conclusion

This study demonstrates significant MSK knowledge acquisition and no difference in the level of knowledge acquisition after completion of either traditional orthopedic surgery or PCSM residency rotation.

Disaster Preparedness Training for Emergency Medicine Residents Using a Tabletop Exercise

INTRODUCTION

Emergency medicine (EM) physicians serve at the frontline of disasters in our communities. The 2016 Model of Clinical Practice according to the American Board of EM identifies disaster management as an integral task of EM physicians. We described a low-cost and feasible tabletop exercise to implement such training for EM residents.

METHODS

The exercise took place during 2 hours of resident didactic time. A lecture introduced the incident command system (ICS) and triage concepts, followed by a tabletop scenario with a map of a disaster scene or emergency department. Facilitators presented situational prompts of tasks for residents to address during the exercise. These exposed residents to challenges in disaster scenarios, such as surge and limited resources. The exercise concluded with a debrief and short lecture reviewing scenario-specific topics and challenges. Residents completed an online pre- and postexercise assessment, evaluating knowledge and perceptions of disaster scenario management.

RESULTS

Eighteen residents participated in this exercise. The response rates to the pre- and postsurvey were 76% and 72% respectively. Using a Mann Whitney U test, no statistically significant difference was demonstrated on the medical knowledge component of the survey. There was, however, a statistically significant increase in perceived confidence of the residents' ability to manage disaster incidents.

DISCUSSION

We developed a simple exercise that is an easily adaptable and practical option for introduction to disaster preparedness training. These concepts are difficult to teach and assess among learners, however it remains an important component of education for EM physicians-in-training.

A Cost-Effective Task Trainer for Complex Lip Laceration Repair

Facial laceration repair is a common emergency department procedure with important cosmetic implications for patients. In instances where the vermillion border is violated special attention must be paid to accurate opposition, as little as 1 mm of misalignment can result in poor cosmetic results. We sought to construct and evaluate an affordable, effective, and easily reproduced simulation trainer of full-thickness lip laceration requiring vermillion border repair primarily for Emergency Medicine resident education.

To accomplish this we utilized microfoam tape, 4x4 gauze, self-adherent wrap, and markers to simulate a multi-layered lip laceration with vermillion border involvement. The microfoam tape with gauze folded on top of itself simulates the orbicularis oris muscle and subcutaneous fat layer. The self-adherent gauze covered by an additional piece of microfoam tape simulates the dermal/epidermal junction. This training model can be attached to an upside-down emesis basin with tape and then trainees can practice appropriate repair techniques.

This task trainer was then utilized in our scheduled, simulation didactic sessions with Vanderbilt University Medical Center’s Emergency Medicine residents. In total, 23 PGY 1-3 EM residents participate in the session. Nineteen (83%) completed an anonymous reporting survey rating features of the didactic on a five-point Likert scale. Resident comfort level performing the procedure prior to the teaching session was fair (mean 2.53 {SD 1.04}) and afterward significantly higher (mean 4.31 {SD 0.57}) P <0.0001. The task trainer was highly rated (mean 4.74 {SD 0.55}) and the overall didactic was also very highly rated (mean 4.84 {SD 0.50}).

The model we have described here can be constructed in minutes from supplies that are readily available in any healthcare setting and was rated by residents to substantially improve procedural confidence in regards to complex lip laceration repair.

Defining a Focused Pediatric Emergency Medicine Curriculum for Emergency Medicine Residents: A Case Study at Michigan Medicine

OBJECTIVES

Emergency medicine (EM) is dedicated to the treatment of urgent and emergent illness requiring physicians to evaluate, treat, and diagnose patients of all ages. EM residency provides the foundation of knowledge enabling trainees to care for any patient. However, specific pediatric curriculum guidance from governing bodies is limited. The literature includes two potential curricula that are cumbersome to implement. Our primary objective was to identify the components of this curricula that were specific to pediatric emergency medicine (PEM). Secondary objectives were to provide a methods framework and to compare the results with the American Board of Emergency Medicine Model of Clinical Practice (EM Model).

METHODS

With the modified Delphi technique, iterative rounds of expert panels sought to reach consensus on PEM-specific topics. We utilized the published curricula as the foundation and focused this list using a group of local experts. Predetermined consensus was defined as 80% agreement.

RESULTS

The literature-derived list of 190 topics was reviewed by the expert panel. Experts identified 92 PEM-specific topics, and the remaining 98 topics were deemed adequately covered by general EM curricula. All topics reached consensus after three rounds. The final list was sorted in accordance with the EM Model categories. Redundant topics were consolidated resulting in 68 PEM topics. Of these 68 topics, we identified 20 topics (five of which are critical) that were incompletely covered by the EM Model.

CONCLUSIONS

Emergency medicine residency programs should focus their PEM curriculum by deliberately assessing their coverage of key PEM topics. The methods of this study can be replicated to yield locally applicable results in other EM programs. Additionally, the next iteration of the EM Model of Clinical Practice should inform their PEM topics from the available curricula in the literature.

A Virtual Book Club for Professional Development in Emergency Medicine

INTRODUCTION

Professional development is an important component of graduate medical education, but it is unclear how to best deliver this instruction. Book clubs have been used outside of medicine as a professional development tool. We sought to create and evaluate a virtual professional development book club for emergency medicine interns.

METHODS

We designed and implemented a virtual professional development book club during intern orientation. Afterward, participants completed an evaluative survey consisting of Likert and free-response items. Descriptive statistics were reported. We analyzed free-response data using a thematic approach.

RESULTS

Of 15 interns who participated in the book club, 12 (80%) completed the evaluative survey. Most (10/12; 83.3%) agreed or strongly agreed that the book club showed them the importance of professional development as a component of residency training and helped them reflect on their own professional (11/12; 91.7%) and personal development (11/12; 91.7%). Participants felt the book club contributed to bonding with their peers (9/12; 75%) and engagement with the residency program (9/12; 75%). Our qualitative analysis revealed five major themes regarding how the book club contributed to professional and personal development: alignment with developmental stage; deliberate practice; self-reflection; strategies to address challenges; and communication skills.

CONCLUSION

A virtual book club was feasible to implement. Participants identified multiple ways the book club positively contributed to their professional development. These results may inform the development of other book clubs in graduate medical education.

A Case for Risk Stratification in Survivors of Firearm and Interpersonal Violence in the Urban Environment

The emergency department (ED) serves as the main source of care for patients who are victims of interpersonal violence. As a result, emergency physicians across the nation are at the forefront of delivering care and determining dispositions for many at-risk patients in a dynamic healthcare environment. In the majority of cases, survivors of interpersonal violence are treated and discharged based on the physical implications of the injury without consideration for risk of reinjury and the structural drivers that may be at play. Some exceptions may exist at institutions with hospital-based violence intervention programs (HVIPs). At these institutions, disposition decisions often include consideration of a patient’s risk for repeat exposure to violence. Ideally, HVIP services would be available to all survivors of interpersonal violence, but a variety of current constraints limit availability. Here we offer a scoping review of HVIPs and our perspective on how risk-stratification could help emergency physicians determine which patients will benefit most from HVIP services and potentially reduce re-injury secondary to interpersonal violence.

What is the impact of the COVID-19 pandemic on emergency medicine residency training: an observational study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has engendered difficulties for health systems globally; however, the effect of the pandemic on emergency medicine (EM) residency training programs is unknown. The pandemic has caused reduced volumes of emergency department (ED) patients, except for those with COVID-19 infections, and this may reduce the case exposure of EM residents. The primary objective of this study was to compare the clinical exposure of EM residents between the prepandemic and pandemic periods.

METHODS

This was a retrospective study of EM resident physicians' training in a tertiary teaching hospital with two branch regional hospitals in Taiwan. We retrieved data regarding patients seen by EM residents in the ED between September 1, 2019, and April 30, 2020. The first confirmed COVID-19 case in Taiwan was reported on January 11, so the pandemic period in our study was defined as spanning from February 1, 2020, to April 30, 2020. The number and characteristics of patients seen by residents were recorded. We compared the data between the prepandemic and pandemic periods.

RESULTS

The mean number of patients per hour (PPH) seen by EM residents in the adult ED decreased in all three hospitals during the pandemic. The average PPH of critical area of medical ED was 1.68 in the pre-epidemic period and decreased to 1.33 in the epidemic period (p value < 0.001). The average number of patients managed by residents decreased from 1.24 to 0.82 in the trauma ED (p value = 0.01) and 1.56 to 0.51 in the pediatric ED (p value = 0.003) during the pandemic, respectively. The severity of patient illness did not change significantly between the periods.

CONCLUSIONS

The COVID-19 pandemic engendered a reduced ED volume and decreased EM residents' clinical exposure. All portion of EM residency training were affected by the pandemic, with pediatric EM being the most affected. The patient volume reduction may persist and in turn reduce patients' case exposure until the pandemic subsides. Adjustment of the training programs may be necessary and ancillary methods of learning should be used to ensure adequate EM residency training.

A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs

OBJECTIVES

Pediatric training is an essential component of emergency medicine (EM) residency. The heterogeneity of pediatric experiences poses a significant challenge to training programs. A national simulation curriculum can assist in providing a standardized foundation of pediatric training experience to all EM trainees. Previously, a consensus-derived set of content for a pediatric curriculum for EM was published. This study aimed to prioritize that content to establish a pediatric simulation-based curriculum for all EM residency programs.

METHODS

Seventy-three participants were recruited to participate in a three-round modified Delphi project from 10 stakeholder organizations. In round 1, participants ranked 275 content items from a published set of pediatric curricular items for EM residents into one of four categories: definitely must, probably should, possibly could, or should not be taught using simulation in all residency programs. Additionally, in round 1 participants were asked to contribute additional items. These items were then added to the survey in round 2. In round 2, participants were provided the ratings of the entire panel and asked to rerank the items. Round 3 involved participants dichotomously rating the items.

RESULTS

A total of 73 participants participated and 98% completed all three rounds. Round 1 resulted in 61 items rated as definitely must, 72 as probably should, 56 as possibly could, 17 as should not, and 99 new items were suggested. Round 2 resulted in 52 items rated as definitely must, 91 as probably should, 120 as possibly could, and 42 as should not. Round 3 resulted in 56 items rated as definitely must be taught using simulation in all programs.

CONCLUSIONS

The completed modified Delphi process developed a consensus on 56 pediatric items that definitely must be taught using simulation in all EM residency programs (20 resuscitation, nine nonresuscitation, and 26 skills). These data will serve as a targeted needs assessment to inform the development of a standard pediatric simulation curriculum for all EM residency programs.

Learner-centered Survey of Point-of-care Ultrasound Training, Competence, and Implementation Barriers in Emergency Medicine Training Programs in India

BACKGROUND

Point-of-care ultrasound (POCUS) is important to the practice of emergency medicine (EM), but requires training to achieve competence. The purpose of this study was to describe the current state of POCUS practice and perceived barriers to the implementation in EM training programs in India.

METHODS

A cross-sectional survey consisting of 28 questions was administered to 378 faculty and residents in postgraduate EM training programs across India.

RESULTS

Data were collected from 159 physicians from 16 institutions; 76% of them were EM residents, with a response rate of 42%. Respondents overwhelmingly reported high interest (91%) in learning POCUS topics. Respondents identified highest levels of comfort with the performance and interpretation of trauma ultrasound (US) and echocardiography. Conversely, there was a scarce interest and low levels of competence in performing obstetric US, which may be a result of the practice of triaging these complaints to obstetricians and gynecologists. Lack of US equipment and dedicated training were the highest rated barriers by a significant margin, which 56% of respondents ranked as "very important."

CONCLUSIONS

While significant interest in POCUS exists among the Indian EM physicians, comfort and competence were limited to trauma and echocardiography applications. Expansion of and comfort with POCUS use in these settings may be sought through improvement of access to US equipment and a dedicated US curriculum.

Conference Didactic Planning and Structure: An Evidence-based Guide to Best Practices from the Council of Emergency Medicine Residency Directors

Emergency medicine residency programs around the country develop didactic conferences to prepare residents for board exams and independent practice. To our knowledge, there is not currently an evidence-based set of guidelines for programs to follow to ensure maximal benefit of didactics for learners. This paper offers expert guidelines for didactic instruction from members of the Council of Emergency Medicine Residency Directors Best Practices Subcommittee, based on best available evidence. Programs can use these recommendations to further optimize their resident conference structure and content. Recommendations in this manuscript include best practices in formatting didactics, selection of facilitators and instructors, and duration of individual sessions. Authors also recommend following the Model of Clinical Practice of Emergency Medicine when developing content, while incorporating sessions dedicated to morbidity and mortality, research methodology, journal article review, administration, wellness, and professionalism.

Rethinking Residency Conferences in the Era of COVID-19

The COVID-19 pandemic requires a substantial change to the traditional approach to conference didactics. Switching to a virtual medium for conference sessions presents several challenges, particularly with regard to aspects that rely heavily on in-person components (e.g., simulation, ultrasound). This paper will discuss the challenges and strategies to address them for conference planning in the era of COVID-19.

Critically Ill Pediatric Case Exposure During Emergency Medicine Residency

BACKGROUND

Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described.

OBJECTIVE

The objective was to characterize the critically ill pediatric EM case exposure among EM residents.

METHODS

This is a secondary analysis of a multicenter retrospective review of pediatric patients (aged < 18 years) seen by the 2015 graduating resident physicians at four U.S. EM training programs. The per-resident exposure to Emergency Severity Index (ESI) Level 1 pediatric patients was measured. Resident-level counts of pediatric patients were measured; specific counts were classified by age and Pediatric Emergency Care Applied Network diagnostic categories.

RESULTS

There were 31,552 children seen by 51 residents across all programs; 434 children (1.3%) had an ESI of 1. The median patient age was 8 years (interquartile range [IQR] 3-12 years). The median overall pediatric critical case exposure per resident was 6 (IQR 3-12 cases). The median trauma and medical exposure was 2 (IQR 0-3) and 3 (IQR 2-10), respectively. For 13 out of 20 diagnostic categories, at least 50% of residents did not see any critical care case in that category. Sixty-eight percent of residents saw 10 or fewer critically ill cases by the end of training.

CONCLUSION

Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.

Online Medical Control for EMS: A Lecture and Case-Based Teaching Module

INTRODUCTION

The provision of real-time medical direction to emergency medical services (EMS) providers is a core skill for the emergency physician, yet it is one with a wide variability of training received within residency.

METHODS

We developed a complete training module for providing online medical control to EMS providers, including two lectures, multiple case-based scenarios for practice via two-way radio, a survey of participants' self-perceived knowledge and comfort in this area, and a postmodule knowledge test. Participants completed the survey both before and after the module. The module was given during the regularly scheduled didactic conference series. There were 22 participants, some of whom were attendings and medical students.

RESULTS

The survey responses showed a statistically significant improvement after completion of the module for all questions, including improved self-perceived comfort with providing online medical control. Additionally, all participants passed the postmodule knowledge test with a mean score of 95%.

DISCUSSION

This module was well received and showed significant results in improving the participants' self-perceived and tested knowledge of EMS as well as their comfort with providing online medical control. The module offers an excellent baseline training experience for use by other residencies or agency medical directors.

The Effect of Simulation Wars on EM Residents' Global Rating Scales and In-Training Examination Scores

Purpose

The Accreditation Council for Graduate Medical Education (ACGME) restricted the duty hours for residents training in 2004. With less time to learn medicine, residents may not develop the clinical reasoning skills needed. Simulation can provide a remedy for this lack of time by allowing residents to practice skills and develop clinical reasoning in a simulated environment. Simulation Wars (SimWars), a clinical reasoning simulation has been shown to improve clinical reasoning skills. The purpose of the study was to investigate the effect of Simulation Wars on In-Training Examination (ITE) Scores and Global Rating Scale (GRS) Scores in Emergency Medicine (EM) residents.

Methods

The Quasi-Experimental design was used in this retrospective study. The main comparison was between historical controls, the residents who did not participate in the Simulation Wars, and the intervention group comprised of residents who participated in the SimWars.

Results

A total of 127 residents were participants in this study including 70 from the intervention and 57 from the historical control group. There were no significant differences found in GRS scores between both groups except for Communication and Professionalism (p<0.001). No overall improvement in ITE scores for the control group and for the intervention group was found. Furthermore, within the intervention group, while comparing those residents who participated in certain subcategories of SimWars and those who did not, there was a significant improvement in ITE scores in the subcategories of Thoracic Disorders, Abdominal/Gastrointestinal, Trauma Disorders and OBGyn.

Conclusion

SimWars in the subcategories of Abdominal/Gastrointestinal, Thoracic, OBGyn and Trauma were found to be associated with improved ITE scores in those subcategories. Since Emergency Medicine utilizes extensive clinical reasoning skills, SimWars may provide better educational opportunities for EM residents.

Frequency of safety net errors in the emergency department: Effect of patient handoffs

OBJECTIVES

The objective of this study was to determine physician awareness of abnormal vital signs and key clinical interventions (oxygen provision, intravenous access) in the emergency department, and to measure the effect of patient handoffs on this awareness.

METHODS

This was a prospective observational study at two large, urban, academic emergency departments. Emergency department physicians were asked the following about each of the physician's patients: 1) the number of IV lines, 2) whether the patient was on supplemental oxygen, and 3) whether the patient had any abnormal vital signs. Physicians were blind to the nature of the study prior to enrollment. Error rates between physician responses and actual patient status were calculated, and logistic regression, adjusted for physician clustering, was used to calculate association of errors with multiple situational factors, including handoff status.

RESULTS

We analyzed 463 patient encounters from 74 physicians. Physicians missed abnormal vital signs in 19.4% of encounters. They made errors in oxygen status and number of IV lines in 16.6% and 35.8% of encounters, respectively. Physicians were significantly more likely to make all types of errors on patients who had undergone handoff as opposed to their primary patients.

CONCLUSION

Emergency physicians make frequent errors regarding awareness of their patients' vital signs, oxygen and vascular status and patient handoffs are associated with an increased frequency of such errors.

Tools for Measuring Clinical Ultrasound Competency: Recommendations From the Ultrasound Competency Work Group

Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.

Toward Structural Competency in Emergency Medical Education

As the emergency department (ED) is the "front door" of the hospital and the primary site by which most patients access the health care system, issues of inequity are especially salient for emergency medicine (EM) practice. Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians that are cognizant and attentive to their needs in and out of the medical encounter. EM resident education has traditionally incorporated a "cultural competency" model to equip residents with tools to combat individual bias and stigma. Although this framework has been influential in drawing attention to health inequities, it has also been criticized for its potential to efface differences within groups (such as socioeconomic differences), overstate cultural or racial differences, and unintentionally reinforce stereotypes or blaming of patients for their ill health or difficult circumstances. In contrast, emerging frameworks of structural competency call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health. We present here the framework of structural competency, extending it to the unique ED setting. We provide tangible illustrations of the ways in which this framework is relevant to the ED setting and can be incorporated in EM education.