The impact of emergency physician turnover on planning for prospective clinical trials

Resilience-Related Resources Predict Physicians' Fatigue, Job Search Behavior, and Productivity Outcomes

OBJECTIVE

The objective of this research was to assess the relative contribution of three resilience-related dispositional resources (trait mindfulness, core self-evaluations, and optimism) to emergency medicine physicians' fatigue, retention, and productivity.

METHODS

We surveyed emergency physicians employed by a national (US) medical staffing organization. The survey included measures of work stressors, resilience resources, job search behavior, and fatigue. We linked the survey responses to objective demographic and productivity measures from the organization's records.

RESULTS

A total of 371 respondents completed the survey. Multiple regression analyses demonstrated support for each of the three resilience-related resources as predictors. Relative weights analyses showed that resilience accounted for 14% and 62% of the outcome variance, whereas work demands accounted for between 32% and 56%.

CONCLUSIONS

Multiple facets of dispositional resilience are important predictors of emergency medicine physicians' occupational health, retention, and productivity.

Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study

Background

The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED).

Methods

Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework.

Results

We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework.

Conclusions

Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4012-6) contains supplementary material, which is available to authorized users.

Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and management capacity

STUDY HYPOTHESIS

Since the 1990s, Italian hospitals are required to comply with emergency disaster plans known as Emergency Plan for Massive Influx of Casualties. While various studies reveal that hospitals overall suffer from an insufficient preparedness level, the aim of this study was to better determine the preparedness level of Emergency Departments of Italian hospitals by assessing the knowledge-base of emergency physicians regarding basic disaster planning and procedures.

METHODS

A prospective observational study utilized a convenience sample of Italian Emergency Departments identified from the Italian Ministry of Health website. Anonymous telephone interviews were conducted of medical consultants in charge at the time in the respective Emergency Departments, and were structured in 3 parts: (1) general data and demographics, (2) the current disaster plan and (3) protocols and actions of the disaster plan.

RESULTS

Eighty-five Emergency Departments met inclusion criteria, and 69 (81 %) agreed to undergo the interview. Only 45 % of participants declared to know what an Emergency Plan for Massive Influx of Casualties is, 41 % believed to know who has the authority to activate the plan, 38 % knew who is in charge of intra-hospital operations. In Part 3 physicians revealed a worrisome inconsistency in critical content knowledge of their answers.

CONCLUSIONS

Results demonstrate a poor knowledge-base of basic hospital disaster planning concepts by Italian Emergency Department physicians-on-duty. These findings should alert authorities to enhance staff disaster preparedness education, training and follow-up to ensure that these plans are known to all who have responsibility for disaster risk reduction and management capacity.

Prevention of emergency physician migratory contamination in a cluster randomized trial to increase tissue plasminogen activator use in stroke (the INSTINCT trial)

OBJECTIVES

Cluster randomized trials (CRTs) are increasingly used to evaluate quality improvement interventions aimed at health care providers. In trials testing emergency department (ED) interventions, migration of emergency physicians (EPs) between hospitals is an important concern, as contamination may affect both internal and external validity. We hypothesized that geographically isolating EDs would prevent migratory contamination in a CRT designed to increase ED delivery of tissue plasminogen activator (tPA) in stroke (the INSTINCT trial).

METHODS

INSTINCT was a prospective, cluster randomized, controlled trial. Twenty-four Michigan community hospitals were randomly selected in matched pairs for study. Contamination was defined at the cluster level, with substantial contamination defined a priori as greater than 10% of EPs affected. Nonadherence, total crossover (contamination+nonadherence), migration distance, and characteristics were determined.

RESULTS

Three hundred seven EPs were identified at all sites. Overall, 7 (2.3%) changed study sites. One moved between control sites, leaving 6 (2.0%) total crossovers. Of these, 2 (0.7%) moved from intervention to control (contamination); and 4 (1.3%) moved from control to intervention (nonadherence). Contamination was observed in 2 of 12 control sites, with 17% and 9% contamination of the total site EP workforce at follow-up, respectively. Average migration distance was 42 miles for all EPs moving in the study and 35 miles for EPs moving from intervention to control sites.

CONCLUSION

The mobile nature of EPs should be considered in the design of quality improvement CRTs. Increased reporting of contamination in CRTs is encouraged to clarify thresholds and facilitate CRT design.