Teaching Quality Improvement: The Use of Education Theories Across the Medical Education Spectrum.

It is well recognized that the principles and practices of patient safety and quality improvement (QI) need to be included in medical education. The implementation of patient safety and QI learning experiences at the undergraduate medical education (UME) and graduate medical education (GME) levels has been variable. Consistent teaching of QI across the UME-GME-continuing medical education (CME) spectrum may result in a systemic change of improved patient care and patient safety in clinical practice. We propose using education theories to frame the development of QI curricula for a longitudinal integration in medical education and clinical practice. The basic principles of four education theories, namely, reflective practice, deliberate practice, social constructivism, and organizational learning, are briefly described, and examples of their applications to QI teaching are discussed. The incorporation of education theory into the design and implementation of a longitudinal QI curriculum threaded across the UME-GME-CME spectrum may empower learners with a comprehensive and lasting understanding of QI principles and training in patient safety practice, which are essential prerequisites for the formation of a physician workforce capable of creating sustainable change in patient care.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders.

INTRODUCTION: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. METHODS: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. RESULTS: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. CONCLUSION: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Upper Extremity Hematoma: An Atypical Case of Compartment Syndrome.

Compartment syndrome is a potentially life- or limb-threatening condition that carries high morbidity if not promptly diagnosed and treated. This case is an atypical presentation demonstrating why a high index of suspicion, prompt surgical consultation, and intervention is required if compartment syndrome is suspected.

In Situ Simulation to Promote Residents as Resuscitation Leaders.

Objectives  Our study sought to assess whether perceptions of residents as resuscitation team leaders could be improved by using emergency department (ED) in situ simulations involving ED staff. Secondarily, we monitored changes indicated in overall resuscitation team dynamics. Methods We conducted a prospective experimental study over the 2018-2019 academic year. Data were collected at a community-based ED with an emergency medicine residency program. Prior to starting the education, all ED staff including residents, attending physicians nurses and techs completed a survey of their perceptions of team performance and leadership during medical resuscitations. Throughout the year, residents and ED staff members were exposed to various in situ simulation scenarios. A follow-up survey was administered to reassess resident and ED staff perceptions of team dynamics and, specifically, residents as patient care team leaders. A relational coordination survey analysis was performed, dichotomized by professional domain. Results A total of 20 participants completed surveys before and after the in situ simulations, covering the professional domains with matched pre-simulation and post-simulation data showing significant improvement in communication and team dynamics for residents (p = 0.029) and other ED staff in medical resuscitations. Using residents as the team leaders for the simulation improved perceived leadership during resuscitation (p = 0.006). Conclusions Our study suggests that in situ simulation within the ED leads to improved team dynamics and defined roles while emphasizing the resident as a resuscitation leader.

Continuing Medical Education Delivery Preferences Among Physicians and Advanced Practice Providers in Emergency Medicine.

Study objective We investigate the continuing medical education delivery preferences among emergency medicine providers, both physicians and advanced practice providers (APPs), within a large, national emergency medicine group. Methods A survey was sent via email to all emergency medicine health care providers in the practice group, including questions evaluating both delivery method and topic preference for continuing education. The study was sent to providers whom the group employed from October 2019 through January 2020. Results A total of 2038 providers, 1373 physicians, and 665 APPs completed the survey - a completion rate of 68.7%. In general, practitioners expressed willingness to learn across various platforms, with a strong overall preference towards online and on-demand options, including video, podcast, and written materials. Universally, a larger percentage of APPs identified a desire for more continuing education across all topics than physicians. Conclusion Education preferences among emergency medicine providers vary with a strong trend toward online and on-demand content. Understanding the delivery and topic preferences for providers is important for the optimal creation of continuing education content.

Innovations in Airway Education: 3D Printed Neonatal and Pediatric Needle Cricothyrotomy Trainers.

Audience: Three dimensional printed cricothyrotomy trainers are designed to be used at all levels of training in emergency medicine, both for skill acquisition and to prevent skill atrophy. Introduction: Simulation has long provided a means to train providers on rarely performed procedures.1,2 For example, surgical cricothyrotomy has commonly been practiced in a simulated environment almost exclusively via low-fidelity models.3-6 What seems to be lacking in this training is simulation of needle cricothyrotomy for the pediatric population. Needle cricothyrotomy remains the standard of care for temporary airway management in a "can't intubate, can't oxygenate" scenario for pediatric patients. In order to address this educational deficiency, we designed a 3D printed pediatric needle cricothyrotomy trainer using evidenced-based cadaveric literature demonstrating neonatal cricothyroid membrane dimensions. These trainers will serve as a simulation tool that will help educate emergency medicine residents to perform a rare, high-stakes procedure within a controlled environment. Educational Objectives: By the end of this educational session, participants should be able to:Discuss indications and contraindications for needle cricothyrotomy in the pediatric population.Assemble the equipment needed to complete a needle cricothyrotomy.Describe and perform the steps of neonatal and pediatric needle cricothyrotomy.Discuss post-procedure ventilation options. Educational Methods: Trainers were created to enhance needle cricothyrotomy training in this rarely performed, yet critical procedure. It was felt that this procedure was only discussed in concept. There was no hands-on, procedure-based option available to realistically reproduce the procedure in a controlled training environment, and we felt the creation of a task trainer was ideal to address this deficiency. Once the trainers were created, we curated assigned pre-reading using a flipped classroom approach. The idea was to provide learners with multiple resources including textbook chapters, blogs, and podcasts, so that they could choose one or two resources that matched their learning style. We felt this was the best way to ensure learner retention. Additionally, we created a PowerPoint presentation to illustrate the stepwise procedure, required equipment, indications/contraindications, and ventilation aspect of the procedure, which can be reviewed with learners prior to performing the hands-on portion of the skills station.In order to create such a trainer, we worked in conjunction with the OhioHealth Simulation Department to obtain a 3D printer. Adult cricothyrotomy trainers were previously purchased from The Airway App, a company specializing in airway management education. The company also provides a standard template library (.STL) file that contains code for 3D printing cricothyrotomy trainers. Using this code, we made changes to the scale in order to create a smaller model that would resemble neonatal, school-aged, and adolescent patients (25%, 33%, and 50% of the original adult trainer, respectively). These scale models, particularly the neonatal model, were chosen based on the neonatal cadaveric measurements researched by Navasa, et al.7To prepare the trainer for use, sim skin and sim tape were used to cover and obscure the landmarks. Learners were given the materials previously discussed in preparation of the skills lab. Although all sizes of trainers were used by the learners, particularly attention was paid to the neonatal trainer. Emphasis was placed on the difficulty finding landmarks during this procedure. Instructors were available for the entirety of the skill station in order to answer questions and give direct feedback. Debriefing was performed at the end of the skills session. Research Methods: Post-simulation surveys were completed by PGY 1-4 emergency medicine resident physicians assessing pre- and post-simulation procedural comfortability using a 5-point Likert scale. In this survey, 1 represented "not comfortable at all" while 5 represented "completely comfortable." Two, three, and four showed a gradual increase in comfortability, respectively. Median pre- and post-scores were calculated with interquartile ranges (IQR). A two-tailed Mann-Whitney U test was performed for statistical significance. Realism and future use were also surveyed. Results: Thirty-one emergency medicine resident physicians ranging from PGY1 to PGY4 completed the post-simulation survey. Median pre-simulation score was 2 (IQR 1-2.5) and post-simulation score was 4 (IQR 3-4). The two-tailed Mann-Whitney U test showed statistical significance at p<0.01. Ninety-seven percent of participants felt the trainers were realistic and 100% would recommend them for future simulation use. Discussion: Novel 3D printed needle cricothyrotomy trainers are a much-needed addition to emergency medicine procedural training. Specifically, we focus on the use of low-cost, high-fidelity trainers for educating emergency medicine resident physicians. By using a pre-templated .STL file, we were able to manipulate sizes and dimensions to create several simulation trainers for simulating needle cricothyrotomy. Our results show that these trainers are valuable to emergency medicine procedural training, increasing resident comfortability. Furthermore, participants feel this is realistic and would recommend this for future simulations. Given the relative ease and low-cost nature of these trainers, in addition to their proven benefit with residents, we hope that others will be able to use similar trainers to help develop needle cricothyrotomy skills at all levels of training. Topics: Needle cricothyrotomy, pediatrics, difficult airway, 3D printing, education.

Podcasting in Medicine: The Current Content by Emergency Medicine Subspecialty.

Background Podcasts and their use in medical education, particularly emergency medicine (EM), are growing and becoming more popular. Many podcasts focus on EM, but the number of podcasts on each EM subspecialty remains unknown. Therefore, the goal of this study was to ascertain the number of podcasts available by EM subspecialty and collect the basic characteristics of each podcast. Methods We conducted a Google-based, investigational study of EM podcasts by subspecialty from July 2019 to January 2020. Search terms included "podcasts in ____", where the EM subspecialties of Toxicology, Ultrasound, Wilderness Medicine, Emergency Medicine Services, Medical Education, and Simulation were inserted to identify podcasts. Results  Emergency Medical Services (EMS) and Medical Education subspecialties have the most active podcasts. Toxicology and EMS have the most inactive podcasts, while Medical Education and Simulation were the only subspecialties found to not have any identified inactive podcasts. Conclusions The use of podcasts in EM has been increasing overall, but physicians in specific subspecialties, such as EMS and Medical Education, have access to a larger number of podcasts specific to their subspecialty than others. There is an opportunity for experts in Toxicology, Simulation, and Ultrasound to create podcast content.

Podcasting in Medicine: A Review of the Current Content by Specialty.

Background Podcasts and their use in medical education is growing and becoming more popular, all while not knowing what podcasts are available for each specialty. Objectives To ascertain the number of podcasts available by specialty and collect basic characteristics of each podcast.  Methods This was a Google-based, investigational study of medical podcasts by specialty undertaken by all authors from January to June 2019. Search terms included "podcasts in ____", where various specialties were inserted to identify current podcasts. Results Over the course of a six month period, 19 specialties were investigated for podcasting content. Emergency medicine, internal medicine, and pediatrics had the most active podcasts. Obstetrics and gynecology, ophthalmology, and orthopedic surgery have the most inactive podcasts. Neurosurgery was the only specialty searched without any identifiable active podcasts. Conclusions While emergency medicine has a large number of podcasts, both active and available other specialties have less of a selection.

Utilization of Simulation Techniques to Enhance Quality Improvement Processes in the Emergency Department.

Introduction Quality improvement projects can help improve clinical practice in an emergency department (ED). However, it is difficult to measure outcomes in rare clinical conditions. We used a simulation program to evaluate a new protocol and workflow in the emergency blood transfusion process as well as provide additional trauma training. To determine if implementing a trauma simulation would help improve the self-reported understanding of the emergency blood transfusion process by both the ED and laboratory staff. Methods Emergency medicine residents and nursing staff participated in a high-fidelity trauma simulation. ED nursing and hospital laboratory staff used the simulation to test a new process for notification and transport of blood within the hospital. All of the participants were provided a four-item Likert scale questionnaire immediately after the training to evaluate their understanding of the ED blood process.  Results There was a significant improvement in overall scores based on paired t-tests in the full group (pre 15.0 versus post 17.6, p = 0.0005) and ED group (pre 14.7 versus post 17.8, p = 0.0007) but not in the lab group (pre 15.8 versus post 17.2, p = 0.296).  Conclusion Simulation appears to be helpful to evaluate and implement a new ED protocol or workflow.

The Impact of Advanced Cardiac Life Support Simulation Training on Medical Student Self-reported Outcomes.

INTRODUCTION: Simulation has become a well-recognized and innovative tool in medical education. While there has been tremendous growth of simulation curricula at the level of graduate medical education, there have been few studies looking at simulation as a learning tool for undergraduate medical education. The goal of this study was to determine if high-fidelity simulation training impacts medical student perception of knowledge and confidence regarding comprehension and application of advanced cardiac life support (ACLS) algorithms. METHODS: This is a prospective observational survey study of third and fourth year medical students who participated in an ACLS simulation training during their emergency medicine rotation between January 2018 and October 2018. Cases covered several ACLS topics including unstable bradycardia, supraventricular tachycardia and ventricular tachycardia. After each session, students received a short survey to assess their simulation experience pertaining to knowledge and comfort levels with ACLS topics before and after the simulation experience. RESULTS: A total of 89 students were included in the study with 86.5% of those being fourth year students. There was a significant increase in both knowledge (pre-training 3.17 vs. 4.11 post-training, p<0.001) and comfort scores (pre-training 2.54 vs. 3.74 post-training, p<0.001) after the ACLS simulation training. Overall, 77.5% of students reported an increase in knowledge and 83.1% reported an increase in confidence after the training session.  Conclusions: The study revealed a statistically significant increase in both perceived knowledge and comfort and confidence of medical students after high-fidelity simulation using ACLS scenarios.

Sex, Drugs, and Seizures: Subarachnoid Hemorrhage in a Young Patient.

A 17-year-old male patient presented to the emergency department (ED) with seizures after sexual intercourse. The patient was found to have an intracerebral hemorrhage (ICH) likely secondary to sexual intercourse and concomitant amphetamine use, an extremely rare finding in this patient population. In this case review, we will discuss the presentation, management, and disposition of subarachnoid hemorrhage (SAH), a well-known emergency diagnosis within the ED, while highlighting a case that is clearly uncommon. In addition, we discuss the etiology of ICH in the setting of intercourse and amphetamine use with the ultimate goal of understanding the interdisciplinary care of a complex subject.

State Emergency Department Opioid Guidelines: Current Status.

INTRODUCTION: The purpose of this study was to evaluate and categorize current state-sponsored opioid guidelines for the practice of emergency medicine (EM). METHODS: We conducted a comprehensive search of EM-specific opioid prescribing guidelines and/or policies in each state to determine current state involvement in EM opioid prescribing, as well as to evaluate some of the specifics of each guideline or policy. The search was conducted using an online query and a follow-up email request to each state chapter of ACEP. RESULTS: We found that 17 states had emergency department-specific guidelines. We further organized the guidelines into four categories: limiting prescriptions for opioids with 67 total recommendations; preventing/diverting abuse with 56 total recommendations; addiction-related guidelines with 29 total recommendations; and a community resources section with 24 total recommendations. Our results showed that current state guidelines focus on providers limiting opioid pain prescriptions and vetting patients for possible abuse/diversion. CONCLUSION: This study highlights the 17 states that have addressed opioid prescribing guidelines and categorizes their efforts to date. It is hoped that this study will provide the basis for similar efforts in other states.