Simulation-Based Mastery Learning Course for Tube Thoracostomy.

Introduction: Tube thoracostomy is a relatively infrequent, high-risk procedure that is a required competency for emergency medicine residents. Simulation-based mastery learning is the gold standard for procedure training and has been used to successfully train residents in high-risk procedures. Methods: We developed a simulation-based mastery learning course for tube thoracostomy for PGY 2 emergency medicine residents. The course included (1) precourse work, (2) baseline assessment using a modified version of the TUBE-iCOMPT checklist, (3) anatomy/radiology review, (4) deliberate practice to master individual aspects of the procedure, and (5) final assessment. If a minimum passing score was not achieved, additional coaching and deliberate practice occurred until the learner was able to achieve a minimum passing score. Results: After piloting the course with a cohort of seven PGY 2 emergency medicine residents, we successfully trained 24 additional PGY 2 residents in the subsequent two classes. Combining all three cohorts (N = 31), there was a statistically significant increase in learners' modified TUBE-iCOMPT scores (pretest M = 61.2, SD = 10.0; posttest M = 75.5, SD = 2.9; p < .001). Learners' confidence in their ability to correctly place a chest tube increased, rated on a 10-point Likert scale (1 = not very confident, 10 = very confident; precourse M = 5.6, SD = 1.8; postcourse M = 8.3, SD = 1.1; p < .001). Discussion: This simulation-based course was well received by learners. Our assessment demonstrated that learners improved directly observed procedural skills in simulation and confidence in tube thoracostomy placement.

Dedicated Shift Wrap-up Time Does Not Improve Resident Sign-out Volume or Efficiency.

OBJECTIVES: Sign-out (SO) is a challenge to the emergency physician. Some training programs have instituted overlapping 9-hour shifts. The residents see patients for eight hours, and have one hour of wrap-up time. This hour helps them complete patient care, leaving fewer patients to sign-out. We examined whether this strategy impacts SO burden. METHODS: This is a retrospective review of patients evaluated by emergency medicine (EM) residents working 9-hour (eight hours of patient care, one hour wrap-up time) and 12-hour shifts (12 hours patient care, no reserved time for wrap-up). Data were collected by reviewing the clinical tracker. A patient was assigned to the resident who initiated care and dictated the chart. SO was defined as any patient in the ED without disposition at change of shift. Patient turn-around-time (TAT) was also recorded. RESULTS: One-hundred sixty-one postgraduate-year-one resident (PGY1), 264 postgraduate-year-two resident (PGY2), and 193 postgraduate-year-three resident (PGY3) shifts were included. PGY1s signed out 1.9 patients per 12-hour shift. PGY2s signed out 2.3 patients on 12-hour shifts and 1.8 patients on 9-hour shifts. PGY3s signed out 2.1 patients on 12-hour shifts and 2.0 patients on 9-hour shifts. When we controlled for patients seen per hour, SO burden was constant by class regardless of shift length, with PGY2s signing out 18% of patients seen compared to 15% for PGY3s. PGY1s signed out 18% of patients seen. TAT for patients seen by PGY1s and PGY2s was similar, at 189 and 187 minutes, respectively. TAT for patients seen by PGY3s was significantly less at 175 minutes. CONCLUSION: The additional hour devoted to wrapping up patients in the ED had no affect on SO burden. The SO burden represented a fixed percentage of the total number of patients seen by the residents. PGY3s sign-out a smaller percentage of patients seen compared to other classes, and have faster TATs.

Resident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department.

OBJECTIVES: We sought to determine if resident productivity changed based on emergency department (ED) volume, shift time of day, or over time during a shift. METHODS: This is a retrospective review of patients evaluated in the ED by emergency medicine residents. Data were collected using the computerized tracker that provides time of physician assignment and daily volume. Regression analysis was used to determine relationship between productivity and volume as well as relationship between productivity and accumulated time in the ED. Analysis of variance was used to assess for productivity differences by shift time of day. RESULTS: One hundred sixty-one postgraduate year-1 (PGY-1), 264 PGY-2, and 193 PGY-3 shifts were included. PGY-1, PGY-2, and PGY-3 residents saw 0.85, 1.13, and 1.25 patients per hour, respectively. PGY-3 and PGY-2 productivity had a weak relationship to ED volume (R = 0.28, P = .03; and R = 0.36, P = .03), whereas PGY-1 productivity had a moderate relationship to ED volume (R = 0.44, P = .0001). There were no differences in productivity based on shift time of day. Accumulated time in the ED had a strongly negative relationship to productivity, with R values from -0.79 to -0.93 (P < .002 for all comparisons). CONCLUSIONS: Resident productivity is not strongly linked to volume or time of day. If specific times have statistically higher volume, they should be staffed with larger numbers of residents. In addition, emergency medicine resident productivity declines reliably over shift time. Therefore, scheduling should be adjusted to create larger shift overlaps to aid in smoother patient flow.