• ACGME Clinical and Educational Work Hour Standards: Perspectives and Recommendations from Emergency Medicine Educators

      Wolf, Stephen; Akhtar, Saadia; Gross, Eric; Barnes, David; Epter, Michael; Fisher, Jonathan; Moreira, Maria; Smith, Michael; House, Hans; Univ Arizona, Coll Med Phoenix, Maricopa Med Ctr, Dept Emergency Med (WESTJEM, 2018-01)
      Introduction: The American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical Education's (ACGME) Second Resident Duty Hours in the Learning and Working Environment Congress. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony. Methods: In 2016 our joint working group of experts in EM medical education conducted a consensus-based. mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv. Results: A total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions. organizational recommendations were crafted and submitted to the ACGME. Conclusion: EM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.
    • Augmenting the Disaster Healthcare Workforce

      Iserson, Kenneth; Univ Arizona, Dept Emergency Med (WESTJEM, 2020-04-13)
      In disasters such as the COVID-19 pandemic, we need to use all available resources to bolster our healthcare workforce. Many factors go into this process, including selecting the groups of professionals we will need, streamlining their licensing and credentialing processes, identifying appropriate roles for them, and supporting their health and well-being. The questions we must answer are these: How many staff will we need? How do we provide them with emergency licenses and credentials to practice? What interstate licensing compacts and registration systems exist to facilitate the process? What caveats are there to using retired healthcare professionals and healthcare students? How can we best avoid attrition among and increase the numbers of international medical graduates? Which non-clinical volunteers can we use and in what capacities? The answers to these questions will change as the crisis develops, although the earlier we address them, the smoother will be the process of using augmentees for the healthcare system.
    • Development of a Novel Ultrasound-guided Peritonsillar Abscess Model for Simulation Training

      Ng, Vivienne; Plitt, Jennifer; Biffar, David; Univ Arizona, Dept Emergency Med; Univ Arizona, Arizona Simulat Technol & Educ Ctr (WESTJEM, 2018-01)
      Introduction: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck presenting to emergency departments.(1) No commercial PTA task trainer exists for simulation training. Thus, resident physicians often perform their first PTA needle aspiration in the clinical setting, knowing that carotid artery puncture and hemorrhage are serious and devastating complications. Mile several low-fidelity PTA task trainers have been previously described, none allow for ultrasound image acquisition.(6-9) We sought to create a cost-effective and realistic task trainer that allows trainees to acquire both diagnostic ultrasound and needle aspiration skills while draining a peritonsillar abscess. Methods: We built the task trainer with low-cost, replaceable, and easily cleanable materials. A damaged airway headskin was repurposed to build the model. A mesh wire cylinder attached to a wooden base was fashioned to provide infrastructure. PTAs were simulated with a water and lotion solution inside a water balloon that was glued to the bottom of a paper cup. The balloon was fully submerged with ordnance gelatin to facilitate ultrasound image acquisition, and an asymmetric soft palate and deviated uvula were painted on top after setting. PTA cups were replaced after use. We spent eight hours constructing three task trainers and used 50 PTA cups for a total cost <$110. Results: Forty-six emergency medicine (EM) residents performed PTA needle aspirations using the task trainers and were asked to rate ultrasound image realism, task trainer realism, and trainer ease of use on a five-point visual analog scale, with five being very realistic and easy. Sixteen of 46 (35%) residents completed the survey and reported that ultrasound images were representative of real PTAs (mean 3.41). They found the model realistic (mean 3.73) and easy to use (mean 4.08). Residents rated their comfort with the drainage procedure as 2.07 before and 3.64 after practicing on the trainer. Conclusion: This low-cost, easy-to-construct simulator allows for ultrasound image acquisition while performing PTA needle aspirations and is the first reported of its kind. Educators from EM and otolaryngology can use this model to educate inexperienced trainees, thus ultimately improving patient safety in the clinical setting.
    • Educator Toolkits on Second Victim Syndrome, Mindfulness and Meditation, and Positive Psychology: The 2017 Resident Wellness Consensus Summit

      Chung, Arlene; Smart, Jon; Zdradzinski, Michael; Roth, Sarah; Gende, Alecia; Conroy, Kylie; Battaglioli, Nicole; Univ Arizona, Dept Emergency Me (WESTJEM, 2018-03)
      Introduction: Burnout, depression, and suicidality among residents of all specialties have become a critical focus of attention for the medical education community. Methods: As part of the 2017 Resident Wellness Consensus Summit in Las Vegas, Nevada, resident participants from 31 programs collaborated in the Educator Toolkit workgroup. Over a seven-month period leading up to the summit, this workgroup convened virtually in the Wellness Think Tank, an online resident community, to perform a literature review and draft curricular plans on three core wellness topics. These topics were second victim syndrome, mindfulness and meditation, and positive psychology. At the live summit event, the workgroup expanded to include residents outside the Wellness Think Tank to obtain a broader consensus of the evidence-based toolkits for these three topics. Results: Three educator toolkits were developed. The second victim syndrome toolkit has four modules, each with a pre-reading material and a leader (educator) guide. In the mindfulness and meditation toolkit, there are three modules with a leader guide in addition to a longitudinal, guided meditation plan. The positive psychology toolkit has two modules, each with a leader guide and a PowerPoint slide set. These toolkits provide educators the necessary resources, reading materials, and lesson plans to implement didactic sessions in their residency curriculum. Conclusion: Residents from across the world collaborated and convened to reach a consensus on high-yield-and potentially high-impact-lesson plans that programs can use to promote and improve resident wellness. These lesson plans may stand alone or be incorporated into a larger wellness curriculum.
    • Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates

      Stowell, Jeffrey R; Pugsley, Paul; Jordan, Heather; Akhter, Murtaza; Univ Arizona, Coll Med, Dept Emergency Med (WESTJEM, 2019-07-01)
      Introduction: The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates. Methods: This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015-March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patients specimen vs not. Results: Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%-5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%-3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%-5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%-63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%-0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters. Conclusion: ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.
    • Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

      Sakles, John C; Augustinovich, Cassidy C; Patanwala, Asad E; Pacheco, Garrett S; Mosier, Jarrod M; Univ Arizona, Coll Med, Dept Med, Div Pulm Allergy Crit Care & Sleep Med; Univ Arizona, Coll Med, Dept Emergency Med (WESTJEM, 2019-07-01)
      Introduction: Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period. Methods: An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means. Results: EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = -7.9%, 95% CI -13.4% to -2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%). Conclusion: The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.
    • Innovative Approaches to Emergency Medical Services Fellowship Challenges

      Weston, Benjamin; Gaither, Joshua; Schulz, Kevin; Srinivasan, Saranya; Smith, Jennifer; Colella, M. Riccardo; Univ Arizona, Coll Med, Dept Emergency Med (WESTJEM, 2020-02-21)
      Introduction: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum. Methods: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows' rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician. Results: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system. Conclusion: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.
    • The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM)

      Jung, Julianna; Franzen, Douglas; Lawson, Luan; Manthey, David; Tews, Matthew; Dubosh, Nicole; Fisher, Jonathan; Haughey, Marianne; House, Joseph; Trainor, Arleigh; et al. (WESTJEM, 2018-01)
      Introduction: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. Methods: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. Results: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. Conclusion: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.
    • A Roadmap for the Student Pursuing a Career in Pediatric Emergency Medicine

      Leetch, Aaron N; Glasser, Joshua A; Woolridge, Dale P; Univ Arizona, Dept Emergency Med & Pediat, Coll Med (WESTJEM, 2019-12-09)
      Introduction: Three pathways are available to students considering a pediatric emergency medicine (PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicine residency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency (EM&Peds). Questions regarding differences between the training pathways are common among medical students. We present a comparative analysis of training pathways highlighting major curricular differences to aid in students' understanding of these training options. Methods: All currently credentialed training programs for each pathway with curricula published on their websites were included. We analyzed dedicated educational units (EU) core to all three pathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimum requirements for primary residencies were assumed for fellowship trainees. Results: Of the 75 Peds-PEM, 34 EM-PEM, and 4 EM&Peds programs screened, 85% of Peds-PEM and EM-PEM and all EM&Peds program curricula were available for analysis. Average Peds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. Average EM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. Average EM&Peds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research. Conclusion: All three pathways exceed pediatric-focused training required for EM or pediatric residency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EM&Peds the most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the best pathway for their own careers.
    • Ruling out Pulmonary Embolism in Patients with High Pretest Probability

      Akhter, Murtaza; Kline, Jeffrey; Bhattarai, Bikash; Courtney, Mark; Kabrhel, Christopher; Univ Arizona, Coll Med Phoenix, Maricopa Integrated Hlth Syst, Dept Emergency Med; Univ Arizona, Coll Med Phoenix, Maricopa Integrated Hlth Syst, Dept Med Adm (WESTJEM, 2018-05)
      Introduction: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients. Methods: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%. Results: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells > 6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%-40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up. Conclusion: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients.