A task analysis of emergency physician activities in academic and community settings.

STUDY OBJECTIVE: We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error. METHODS: This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions. RESULTS: There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients). CONCLUSION: Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality.

STUDY OBJECTIVE: The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record. METHODS: This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records. RESULTS: The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time. CONCLUSION: Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.

Conflict of interest in the physician interface with the biomedical industry.

The physician interface with the pharmaceutical industry stands at the forefront of a debate about the effect this relationship has on the behavior of both researchers and clinicians. The authors explore the basis for this conflict of interest and show how it affects physician judgment and behavior. These effects lead to negative consequences for patients and threaten the professional status that society accords physicians. In view of the potential for ethical compromise, physicians should refrain from contact with pharmaceutical marketing representatives.

A case study in medical error: the use of the portfolio entry.

The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and self-reflection. Resident portfolios have received attention as a useful method for addressing this competency. A recent patient encounter provided an experienced clinical educator with the opportunity to develop a portfolio entry that was distributed to all of the residents and faculty in an emergency medicine residency. This report may assist educators in explaining how one could approach the development of the portfolio as a tool for self-assessment. A candid discussion by a senior faculty member about issues that contributed to medical error has been underreported in the medical literature.

An evaluation of emergency medicine resident interaction time with faculty in different teaching venues.

OBJECTIVES: To measure actual emergency medicine (EM) resident interaction time with faculty and to investigate the potential to use direct observation as an assessment tool for the core competencies. By 2006 all EM residencies must implement resident assessment techniques of the six Accreditation Council for Graduate Medical Education core competencies. Emergency medicine educators recommend direct observation as the optimal evaluation tool for patient care, systems-based practice, interpersonal and communication skills, and professionalism. Continuous faculty presence in the emergency department (ED) is widely believed to facilitate direct observation as an assessment technique. METHODS: Observational study of EM resident-faculty interaction time during two-hour periods. Study venues included two EDs, two trauma services, inpatient medicine, adult and pediatric intensive care units (ICUs), and a pediatric outpatient clinic. Using a priori definitions, the authors categorized faculty-EM resident interaction time as direct observation of patient care, indirect patient care, or non-patient care activities, and calculated total faculty interaction time. Subjects were blinded to the nature of the study, and data gathering was encrypted. RESULTS: Two hundred seventy observation periods of two hours each were conducted, sampling 32 EMR1, 33 EMR2-3, 41 EM, and 38 non-EM faculty. The mean total faculty interaction time ranged from a high of 30% (95% CI = 20% to 41%) in the pediatric ICU to a low of 10% (95% CI = 3% to 16%) on internal medicine wards. Overall, EM faculty interaction time was 20% (95% CI = 18% to 22%). Direct observation by faculty ranged from a high of 6% for EMR2-3s in the critical care areas of the ED (95% CI = 3% to 9%) to a low of 1% (95% CI = 0% to 2%) on internal medicine wards. Overall ED direct observation time was 3.6% (95% CI = 2.6% to 4.7%). Emergency department direct observation did not vary within EM resident training level or by ED site. Direct observation varied by treatment area within the EDs, with the critical care areas being substantially higher (6%) than the noncritical care areas (1%). CONCLUSIONS: Faculty direct observation time of EM residents was low in all training venues studied. Direct observation was the highest in ED critical care areas and lowest on medicine ward rotations. Emergency medicine faculty involved simultaneously in routine ED teaching, supervision, and patient care rarely performed direct observation, despite their continuous physical presence. This finding suggests that alternative strategies may be required to assess core competencies through direct observation in the ED.

Droperidol vs prochlorperazine for the treatment of acute headache.

To determine if droperidol i.v. is as effective as prochlorperazine i.v. in the emergency department (ED) treatment of uncomplicated headache, a randomized, controlled, blinded study was conducted in the Emergency Departments of two urban teaching hospitals. Patients >or= 18 years old with crescendo-onset headache were eligible for inclusion. Ninety-six patients (48 in each group) were randomized to receive droperidol 2.5 mg i.v. or prochlorperazine 10 mg i.v. Baseline characteristics were similar between the two study groups. For the main study outcome, 83.3% in the droperidol group and 72.3% in the prochlorperazine group reported 50% pain reduction at 30 min (p <.01; one-sided test of equivalence). The mean decrease in headache intensity was 79.1% (SD 28.5%) in the droperidol group and 72.1% (SD 28.0%) in the prochlorperazine group (p =.23). It is concluded that droperidol i.v. provided a similar reduction of headache as achieved with prochlorperazine i.v. with a similar incidence of akathisia.

The 2013 Model of the Clinical Practice of Emergency Medicine.

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

The 2011 model of the clinical practice of emergency medicine.

The 2011 Model of the Clinical Practice of Emergency Medicine.

ACGME outcome project: phase 3 in emergency medicine education.

In this article we present a summary of two interactive panel discussions held at the 2008 Council of Emergency Medicine Residency Directors (CORD) annual meeting. Attendees attempted to identify measurable outcomes for resident performance that could be used to evaluate program effectiveness.