Challenges and Opportunities for Graduate Medical Education: Steps to Keep Physician Training in North Carolina Exceptional.

Changes in health care present many challenges and opportunities to North Carolina's exceptional graduate medical education programs. Steps to keep these programs exceptional include boosting leadership training, championing well-being, expanding rural training, and more described here.

Getting work done: a grounded theory study of resident physician value of nursing communication.

Poor communication between nurses and physicians results in patient injury and increased healthcare costs. While multiple attempts have been made to improve communication between the two professions, evidence confirms little progress has been made. Previous research focused on standardizing communication processes and protocols between nurses and physicians rather than examining the relational component of these human interactions. The purpose of this study was to explore physician valuing of nursing communication in the context of patient care. Interviews were conducted with 15 internal medicine resident physicians. A constructivist grounded theory approach was used to develop the substantive theory of Getting Work Done. Getting Work Done incorporated three major categories: discerning the team, shifting communication, and accessing nurse knowledge and abilities. Hierarchical behaviors and language, and nurse collusion in both, characterized nurse-physician communication and situated the nurse outside the decision-making team. Complex work environments further devalued nurse-physician communication. Interprofessional education and practice must advance the unique and essential role of all health care professionals such that mutual valuing replaces hierarchical actions with collaborative systems for determining the most effective approaches to patient care.

Optimal Care for All: The Critical Need for Clinician Retention in Rural North Carolina.

Despite its increasing urbanization, North Carolina still has a large rural population that lacks optimal health care. While multiple programs have been successful in recruiting clinicians to rural communities, improving the retention of those clinicians will require the development and implementation of novel strategies along with the evaluation of their effectiveness.

Transforming Medical Education is the Key to Meeting North Carolina's Physician Workforce Needs.

To meet the needs of the population of North Carolina, an epic transformation is under way in health care. This transformation requires that we find new ways to educate and train physicians and other health care professionals. In this commentary, we propose that the success of the Brody School of Medicine in preparing a primary care physician workforce can serve as a model for meeting the state's future physician workforce needs. Other considerations include increasing graduate medical education positions through state funding and providing incentives for medical students who stay in North Carolina.

Mobilization of the obese patient and prevention of injury.

OBJECTIVES AND BACKGROUND: Obese patients are difficult to transport between emergency departments, imaging facilities, operating rooms, intensive care units, acute care units, and rehabilitation facilities. Each move, along with turning, bathing, and access to bathrooms, poses risks of injury to patients and personnel. Similarly, inadequate mobilization raises the risk of pressure ulcers. The costs can be prohibitive. METHODS: On 6 pilot units, mobilization of patients was delegated to trained lift team technicians who covered the units in pairs, 24 hours per day, 7 days per week, to assist with moving and lifting of patients weighing 200 pounds or more, with a Braden Scale score of 18 or less and/or the presence of pressure ulcers. RESULTS: In fiscal year 2012, hospital-acquired pressure ulcers on pilot units decreased by 43% (from 61 to 35). Patient handling-related employee injuries on pilot units decreased by 38.5% (from 13 to 8). Employee satisfaction related to organizational commitment to employee safety and impact on job satisfaction was positively impacted by implementation of the lift team. With the reduction in employee injuries and the fall in the prevalence of pressure ulcers, the adoption of the lift team program decreased costs by $493,293.00. CONCLUSIONS: Implementation of lift teams on pilot nursing units decreased patient handling-related employee injuries, resulting in sharp improvements in quality patient care and reduced costs.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects.

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Injury and death on the farm: improving prevention through improved surveillance.

Work-related injury data suggest that agricultural workers in North Carolina are experiencing high rates of injury and death compared with workers in other occupations. However, current occupational injury data sources are insufficient to calculate accurate injury and mortality rates. We propose recommendations to improve existing farm injury surveillance, to guide prevention.

Is fatality-free travel on North Carolina's streets and highways feasible? It's time to think the unthinkable.

The persistent downward trajectory in the traffic fatality rate during the past 90 years suggests that fatality-free travel on North Carolina's streets and highways may one day be a reality. Multiple interventions, including raising the driving age to 17 years and banning cell phone use, will help North Carolina achieve this vision.

Making the Learning Continuum a Reality: The Critical Role of a Graduate Medical Education-Continuing Medical Education Partnership.

A true continuum of learning in physician education, envisioned as the seamless integration of undergraduate, graduate, and continuing medical education that results in lifelong learning, has yet to be realized. Rapid clinical change, evolving systems of health care, and a shift to competency-based training make the continuum and lifelong learning even more critical. Because they function independently, the efforts of Graduate Medical Education (GME) and Continuing Medical Education (CME) have fallen short of the integrated ideal. The complementary threads of accreditation requirements, expertise, resources, and scholarly activities provide an opportunity for GME and CME to operate in a more integrated and coordinated fashion. Our local GME-CME partnership model demonstrates that these complimentary threads can be tied together to effectively facilitate lifelong learning and promote an integrated learning continuum.

The Teachers of Quality Academy: Evaluation of the Effectiveness and Impact of a Health Systems Science Training Program.

This project aimed to evaluate the effectiveness of a faculty development program in health systems science (HSS)-the Teachers of Quality Academy (TQA). Participants in TQA and a comparison group were evaluated before, during, and 1 year after the program using self-perception questionnaires, tests of HSS knowledge, and tracking of academic productivity and career advancement. Among program completers (n = 27), the mean self-assessed ratings of knowledge and skills of HSS topics immediately after the program, as compared to baseline, increased significantly compared to controls (n = 30). Participants demonstrated progressive improvement of self-perceived skills and attitudes, and retention of HSS knowledge, from baseline to completion of the program. Participants also demonstrated substantially higher HSS scholarly productivity, leadership, and career advancement compared to the comparison group. The TQA effectively created a faculty cadre able to role model, teach, and create a curriculum in HSS competencies for medical students, resident physicians, and other health professionals.

A comprehensive framework for determining the cost of an emergency medical services system.

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Awareness of the bicycle helmet law in North Carolina.

BACKGROUND: One in 3 bicyclists killed in North Carolina is under the age of 16. Since enactment of a mandatory bicycle helmet law for children in 2001, there has been no observed increase in helmet use in North Carolina. The goal of this study was to assess perceptions of helmet effectiveness and the level ofawareness of the North Carolina bicycle helmet law. METHODS: A written survey was distributed to parents, physicians, teachers, and emergency medical services (EMS) personnel throughout Pitt County, North Carolina, to ask their knowledge of the bicycle helmet law, the frequency of their helmet use, their perceptions of the effectiveness of helmets, their opinions of who should be providing education about bicycle helmets, and their knowledge ofpr oper bicycle helmet use. RESULTS: The survey response rate was 72% (n=43). Seventy-five percent of teachers and EMS personnel, 69% ofparents, and 580% of physicians were aware of the North Carolina helmet law. Nineteen percent of parents responded that their children wore helmets "always", 1% answered "often", and 18% answered "never". The effectiveness of helmets in preventing head injuries was underestimated by many respondents with 49% estimating 50%-75% effectiveness. LIMITATIONS: This survey was distributed only in Pitt County and does not reflect helmet awareness for the state as a whole. CONCLUSIONS: The majority ofparents, teachers, physicians, and EMS personnel in Pitt County, North Carolina, are aware of the mandatory bicycle helmet law for children. Enforcement of and education about the bicycle helmet law should be increased .

Economic value of out-of-hospital emergency care: a structured literature review.

STUDY OBJECTIVE: The evaluation of the impact of out-of-hospital emergency care is a relatively new research focus. As such, there is a compelling need to determine how finite health care resources should be used in this setting. The objective of this study is to conduct a structured review of published economic evaluations of out-of-hospital emergency care to assess its economic value. METHODS: A structured literature search and structured review of articles pertaining to the economic value of out-of-hospital care was performed. The bibliographic database MEDLINE was searched for pertinent English-language articles published between 1966 and 2003. The search used the medical subject headings "emergency medical services" and "emergency medical technician" and was limited to the subheading "economics" and crossed with the medical subject heading "economics." The titles generated by this search were systematically reviewed and limited by topic. Abstracts from the identified titles were reviewed to select a final set of pertinent articles. These articles were further limited based on explicit inclusion and exclusion criteria. Authors used a previously published structured evaluation tool to review the final set of identified articles for quality and content. RESULTS: The initial MEDLINE search identified 3,533 citations. From this set, 535 potentially relevant abstracts were reviewed. From the abstract review, 46 articles were identified, along with an additional 14 from searching the secondary references. Of these 60 articles, 32 met the review inclusion criteria and were subjected to a full structured review. These studies predominantly addressed the cost of cardiac arrest (n=13, 41%), major trauma (n=8, 25%), and emergency medical services treatment in general (n=8, 25%). Only 14 studies considered the costs and consequences of competing alternatives. Of these, 2 were cost-benefit and 12 were cost-effectiveness evaluations. Two of the 14 studies met all 10 criteria for high-quality economic evaluation, whereas 2 others met none. CONCLUSION: There is a paucity of out-of-hospital care literature that addresses cost and economic value. The extant literature is limited in scope, poor in quality, and evaluates small subsets of out-of-hospital emergency care costs. Favorable cost-effectiveness has not been firmly established for most aspects of out-of-hospital emergency care.

The Teachers of Quality Academy: A Learning Community Approach to Preparing Faculty to Teach Health Systems Science.

PROBLEM: Although efforts to integrate health systems science (HSS) topics, such as patient safety, quality improvement (QI), interprofessionalism, and population health, into health professions curricula are increasing, the rate of change has been slow. APPROACH: The Teachers of Quality Academy (TQA), Brody School of Medicine at East Carolina University, was established in January 2014 with the dual goal of preparing faculty to lead frontline clinical transformation while becoming proficient in the pedagogy and curriculum design necessary to prepare students in HSS competencies. The TQA included the completion of the Institute for Healthcare Improvement Open School Basic Certificate in Quality and Safety; participation in six 2-day learning sessions on key HSS topics; completion of a QI project; and participation in three online graduate courses. OUTCOMES: Twenty-seven faculty from four health science programs completed the program. All completed their QI projects. Nineteen (70%) have been formally engaged in the design and delivery of the medical student curriculum in HSS. Early into their training, TQA participants began to apply new knowledge and skills in HSS to the development of educational initiatives beyond the medical student curriculum. NEXT STEPS: Important next steps for TQA participants and program planners include further incorporation as faculty advisors and contributors to the full implementation of the longitudinal HSS curriculum; expanded involvement with the Leaders in Innovative Care Scholars student leadership distinction track; continued in-depth evaluation of the impact of TQA participation on patient care, teaching, and role modeling; and the recruitment of the next cohort of TQA participants.

Development of New Methods to Assess the Outcomes of Emergency Care.

This article provides information supporting the need for new outcome measures in emergency care. It also addresses the use of outcome measures in emergency care, the impact of emergency care, identification of at-risk groups, new approaches to measuring patient satisfaction, quality of life and cost-effectiveness, and the unique related implications for emergency medicine. [Cairns CB, Garrison HG, Hedges JR, Schriger DL, Valenzuela TD: Development of new methods to assess the outcomes of emergency care. Ann Emerg Med February 1998;31:166-171.].

Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report.

See editorial, p 274. Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems-such as data incompatibility and high costs of collecting, linking, and using data-can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations. [DEEDS Writing Committee: Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A summary report. Ann Emerg Med February 1998;31:264-273.].

The overcrowded emergency department: a comparison of staff perceptions.

OBJECTIVES: To study perceptions of physicians and nursing staff about real-time demands and capacity of an emergency department (ED). To use ED data to calculate proposed demand ratios called Real-time Emergency Analysis of Demand Indicators (READI) scores. To compare the READI scores with ED staff perceptions of demand and capacity. METHODS: This prospective study used a computerized clinical management system to provide data about ED demand and capacity. Physicians and staff charge nurses were surveyed about perceptions of ED demand and capacity. Results were compared with mathematical READI scores, which are proposed to objectively assess ED demand. Kappa scores were used to measure intrarater reliability between the physicians' and charge nurses' assessment of demand and between the staff assessments and the READI scores. RESULTS: Kappa scores of the perception of excess demand were as follows: between two physician groups, kappa = 0.392; between one physician group and charge nurses, kappa = 0.453; and between a second physician group and charge nurses, kappa = 0.243. Comparing respondents who indicated that demand had or had not exceeded capacity, one of the READI ratios, the Bed Ratio, showed a significant difference in mean, 0.245 (95% confidence interval = 0.153 to 0.336), between groups. CONCLUSIONS: Real-time data may be used to predict ED demand and resource needs. Subjective assessment of excess ED demand did not correlate between physician groups or between physicians and charge nurses. Although there was a trend toward predicting excess demand with one of the READI scores, these scores did not correlate to staff perceptions.

Establishing the scope and methodological approach to out-of-hospital outcomes and effectiveness research.

Outcomes research offers out-of-hospital medicine a valuable methodology for studying the effectiveness of services provided in the out-of hospital setting. A clear understanding of the history and constructs of outcomes research is necessary for its integration into emergency medical services research. This report describes the conceptual framework of outcomes research and key methodological considerations for the successful implementation of out-of-hospital outcomes research. Illustrations of the specific applications of outcomes research and implications to existing methodologies are given, as well as suggestions for improved interdisciplinary research.

Risk adjustment and outcome measures for out-of-hospital respiratory distress.

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work, this group delineated the priority conditions, described conceptual models, suggested core and risk adjustment measures potentially useful to emergency medical services research, and summarized out-of-hospital pain measurement. In this fifth article in the EMSOP series, the authors recommend specific risk-adjustment measures and outcome measures for use in out-of-hospital research on patients presenting with respiratory distress. The methodology included systematic literature searches and a structured review by an expert panel. The EMSOP group recommends use of pulse oximetry, peak expiratory flow rate, and the visual analog dyspnea scale as potential risk-adjustment measures and outcome measures for out-of-hospital research in patients with respiratory distress. Furthermore, using mortality as an outcome measure is also recommended. Future research is needed to alleviate the paucity of validated tools for out-of-hospital outcomes research.

Application of measurement tools to pediatric emergency medicine.

A focus on children and the limited time frame of the emergency care setting makes pediatric emergency medicine (EM) outcomes research a challenging endeavor. To address the challenges, pediatric EM researchers must choose their risk adjustment and outcomes measures carefully. This article provides guidance to those researchers through a series of questions and answers, with an emphasis on present and future measurement tools and the steps needed to further develop the field.