Development, Validation, and Implementation of a Guideline to Improve Clinical Event Debriefing at a Level-I Adult and Level-II Pediatric Trauma Center.

OBJECTIVE: Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department. METHOD: This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools. RESULTS: The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements. CONCLUSION: The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.

The Power of an Active Shooter Simulation: Changing Ethical Beliefs.

INTRODUCTION: During a hospital-based active shooter (AS) event, clinicians may be forced to choose between saving themselves or their patients. The Hartford Consensus survey of clinicians and the public demonstrated mixed feelings on the role of doctors and nurses in these situations. Our objective was to evaluate the effect of simulation on ethical dilemmas during a hospital-based AS simulation. The objective was to determine whether a hospital-based AS event simulation and debrief would impact the ethical beliefs of emergency physicians relating to personal duty and risk. METHODS: Forty-eight emergency physicians and physicians-in-training participated in this cohort study based in an urban academic hospital. Simulation scenarios presented ethical dilemmas for participants (eg, they decided between running a code or hiding from a shooter). Surveys based upon the Hartford Consensus were completed before and after the simulation. Questions focused on preparedness and ethical duties of physicians to their patients during an AS incident. We evaluated differences using a chi-squared test. RESULTS: Preparedness for an AS event significantly improved after the simulation (P = 0.0001). Pre-simulation, 56% of participants felt that doctors/nurses have a special duty like police to protect patients who cannot hide/run, and 20% reported that a provider should accept a very high/high level of personal risk to protect patients who cannot hide/run. This was similar to the findings of the Hartford Consensus. Interestingly, post-simulation, percentages decreased to 25% (P = 0.008) and 5% (P = 0.041), respectively. CONCLUSION: Simulation training influenced ethical beliefs relating to the duty of emergency physicians during a hospital-based AS incident. In addition to traditional learning objectives, ethics should be another important design consideration for planning future simulations in this domain.

Skill Proficiency is Predicted by Intubation Frequency of Emergency Medicine Attending Physicians.

INTRODUCTION: Airway management is a fundamental skill of emergency medicine (EM) practice, and suboptimal management leads to poor outcomes. Endotracheal intubation (ETI) is a procedure that is specifically taught in residency, but little is known how best to maintain proficiency in this skill throughout the practitioner's career. The goal of this study was to identify how the frequency of intubation correlated with measured performance. METHODS: We assessed 44 emergency physicians for proficiency at ETI by direct laryngoscopy on a simulator. The electronic health record was then queried to obtain their average number of annual ETIs and the time since their last ETI, supervised and individually performed, over a two-year period. We evaluated the strength of correlation between these factors and assessment scores, and then conducted a receiver operator characteristic (ROC) curve analysis to identify factors that predicted proficient performance. RESULTS: The mean score was 81% (95% confidence interval, 76% - 86%). Scores correlated well with the mean number of ETIs performed annually and with the mean number supervised annually (r = 0.6, p = 0.001 for both). ROC curve analysis identified that physicians would obtain a proficient score if they had performed an average of at least three ETIs annually (sensitivity = 90%, specificity = 64%, AUC = 0.87, p = 0.001) or supervised an average of at least five ETIs annually (sensitivity = 90%, specificity = 59%, AUC = 0.81, p = 0.006) over the previous two years. CONCLUSION: Performing at least three or supervising at least five ETIs annually, averaged over a two-year period, predicted proficient performance on a simulation-based skills assessment. We advocate for proactive maintenance and enhancement of skills, particularly for those who infrequently perform this procedure.

A Randomized Trial of SMART Goal Enhanced Debriefing after Simulation to Promote Educational Actions.

INTRODUCTION: Goal setting is used in education to promote learning and performance. Debriefing after clinical scenario-based simulation is a well-established practice that provides learners a defined structure to review and improve performance. Our objective was to integrate formal learning goal generation, using the SMART framework (Specific, Measurable, Attainable, Realistic, and Time-bound), into standard debriefing processes (i.e., "SMART Goal Enhanced Debriefing") and subsequently measure the impact on the development of learning goals and execution of educational actions. METHODS: This was a prospective multicenter randomized controlled study of 80 emergency medicine residents at three academic hospitals comparing the effectiveness of SMART Goal Enhanced Debriefing to a standard debriefing. Residents were block randomized on a rolling basis following a simulation case. SMART Goal Enhanced Debriefing included five minutes of formal instruction on the development of SMART learning goals during the summary/application phase of the debrief. Outcome measures included the number of recalled learning goals, self-reported executed educational actions, and quality of each learning goal and educational action after a two-week follow-up period. RESULTS: The mean number of reported learning goals was similar in the standard debriefing group (mean 2.05 goals, SD 1.13, n=37 residents), and in the SMART Goal Enhanced Debriefing group (mean 1.93, SD 0.96, n=43), with no difference in learning goal quality. Residents receiving SMART Goal Enhanced Debriefing completed more educational actions on average (Control group actions completed 0.97 (SD 0.87), SMART debrief group 1.44 (SD 1.03) p=0.03). CONCLUSION: The number and quality of learning goals reported by residents was not improved as a result of SMART Goal Enhanced Debriefing. Residents did, however, execute more educational actions, which is consistent with the overarching intent of any educational intervention.

Development of an Emergency Medicine Simulation Fellowship Consensus Curriculum: Initiative of the Society for Academic Emergency Medicine Simulation Academy.

OBJECTIVES: There is currently no consolidated list of existing simulation fellowship programs in emergency medicine (EM). In addition, there are no universally accepted or expected standards for core curricular content. The objective of this project is to develop consensus-based core content for EM simulation fellowships to help frame the critical components of such training programs. METHODS: This paper delineates the process used to develop consensus curriculum content for EM simulation fellowships. EM simulation fellowship curricula were collected. Curricular content was reviewed and compiled by simulation experts and validated utilizing survey methodology, and consensus was obtained using a modified Delphi methodology. RESULTS: Fifteen EM simulation fellowship curricula were obtained and analyzed. Two rounds of a modified Delphi survey were conducted. The final proposed core curriculum content contains 47 elements in nine domains with 14 optional elements. CONCLUSION: The proposed consensus content will provide current and future fellowships a foundation on which to build their own specific and detailed fellowship curricula. Such standardization will ultimately increase the transparency of training programs for future trainees and potential employers.

Emergency medicine residents' self-assessments play a critical role when receiving feedback.

OBJECTIVES: Emergency medicine (EM) faculty often aim to improve resident performance by enhancing the quality and delivery of feedback. The acceptance and integration of external feedback is influenced by multiple factors. However, it is interpreted through the "lens" of the learner's own self-assessment. Ideally, following an educational activity with feedback, a learner should be able to generate and act upon specific learning goals to improve performance. Examining the source of generated learning goals, whether from one's self-assessment or from external feedback, might shed light on the factors that lead to improvement and guide educational initiatives. Using a standard oral board scenario, the objective of this study was to determine the effects that residents' self-assessment and specific feedback from faculty have on not only the generation of learning goals but also the execution of these goals for performance improvement. METHODS: In this cross-sectional educational study at four academic programs, 72 senior EM residents participated in a standardized oral board scenario. Following the scenario, residents completed a self-assessment form. Next, examiners used a standardized checklist to provide both positive and negative feedback. Subsequently, residents were asked to generate "SMART" learning goals (specific, measurable, attainable, realistic, and time-bound). The investigators categorized the learning goals as stemming from the residents' self-assessments, feedback, or both. Within 4 weeks, the residents were asked to recall their learning goals and describe any actions taken to achieve those goals. These were grouped into similar categories. Descriptive statistics were used to summarize the data. RESULTS: A total of 226 learning goals were initially generated (mean ± SD = 3.1 ± 1.3 per resident). Forty-seven percent of the learning goals were generated by the residents' self-assessments only, while 27% were generated by the feedback given alone. Residents who performed poorly on the case incorporated feedback more often than high performers when generating learning goals. Follow-up data collection showed that 62 residents recalled 89 learning goals, of which 52 were acted upon. On follow-up, the numbers of learning goals from self-assessment and feedback were equal (25% each, 13 of 52), while the greatest number of reportedly executed learning goals came from self-assessments and feedback in agreement (40%). CONCLUSIONS: Following feedback on an oral board scenario, residents generated the majority of their learning goals from their own self-assessments. Conversely, at the follow-up period, they recalled an increased number of learning goals stemming from feedback, while the largest proportion of learning goals acted upon stemmed from both feedback and self-assessments in agreement. This suggests that educators need to incorporate residents' self-assessments into any delivered feedback to have the greatest influence on future learning goals and actions taken to improve performance.

A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine.

STUDY OBJECTIVE: We compare prochlorperazine 10 mg intravenously versus metoclopramide 20 mg intravenously for the emergency department (ED) treatment of acute migraine. METHODS: This was a randomized, double-blind, clinical trial comparing 2 parenteral dopamine antagonists. Both drugs were administered during 15 minutes with 25 mg intravenous diphenhydramine. Pain scores on a numeric rating scale were assessed at baseline, every 30 minutes for 2 hours, and by telephone 24 hours after discharge. The primary endpoint was the between-group difference in change in numeric rating scale from baseline to 1 hour postbaseline. Secondary endpoints included mean differences in change in numeric rating scale at 2 and 24 hours, headache relief, adverse effects, and desire to receive the same treatment for future migraines. RESULTS: Of 152 patients screened, 97 were eligible and 77 were randomized. The mean change in numeric rating scale scores at 1 hour was 5.5 and 5.2 in subjects receiving prochlorperazine and metoclopramide, respectively (difference=0.3; 95% confidence interval [CI] -1.0 to 1.6). Findings were similar at 2 hours and 24 hours. Forty-six percent (18/39) of prochlorperazine and 32% (12/38) of metoclopramide subjects reported adverse events (difference=15%; 95% CI -6% to 36%). Seventy-seven percent (26/34) of prochlorperazine and 73% (27/37) of metoclopramide subjects wanted to receive the same medication in future ED visits (difference=4%; 95% CI -16% to 24%). CONCLUSION: Either prochlorperazine 10 mg intravenously or metoclopramide 20 mg intravenously, combined with diphenhydramine 25 mg intravenously, is an efficacious treatment for ED patients with acute migraine. Three quarters of subjects in both arms would want the same medication for their next migraine.