Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety.

BACKGROUND: Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education. OBJECTIVE: The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University. METHODS: A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline. RESULTS: A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described. CONCLUSIONS: We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review.

OBJECTIVE: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Intensity of anticoagulation with warfarin and risk of adverse events in patients presenting to the emergency department.

BACKGROUND: The ability of patients receiving warfarin to maintain an international normalized ratio (INR) within the desired therapeutic range is important for both efficacy and risk of adverse events. It is unclear whether the desired INR is maintained in patients receiving warfarin who present to the emergency department (ED) and whether they have a higher rate of adverse events. OBJECTIVE: To evaluate the intensity of anticoagulation with warfarin and the risk of bleeding and thromboembolic complications in patients in the ED. METHODS: A prospective observational study was performed using a convenience sample of patients receiving warfarin and presenting to the ED over an 18-week period. Data were collected using a standardized form that included chief complaint, history of present illness, past medical history, medication history, and allergy status. Information from the physical examination, laboratory results, and other diagnostic tests obtained as part of routine assessment in the ED, was used as necessary. The primary outcome was the proportion of patients whose INR was within, above, or below the desired therapeutic range. Bleeding complications and thromboembolic events were recorded in an attempt to determine the relationship between the intensity of anticoagulation and adverse outcomes. RESULTS: Two hundred one patients were included, with a mean (SD) age of 74.0 (13.2) years; 53.7% were female. Primary indications for warfarin were atrial fibrillation (75.6%) and venous thromboembolic disease (14.9%). A therapeutic INR was observed in 88 patients (43.8%; 95% CI 37.1 to 50.7), while 45 patients (22.4%; 95% CI 17.2 to 28.7) and 68 patients (33.8%; 95% CI 27.6 to 40.6) had subtherapeutic and supratherapeutic INRs, respectively. Overall, there were 28 (18 major and 10 minor) bleeding complications (13.9%; 95% CI 9.8 to 19.4) and 4 thromboembolic events (2.0%; 95% CI 0.6 to 5.2). Among patients with a bleeding complication, 14 (50.0%) had a supratherapeutic INR, while 2 patients who experienced a thromboembolic event (50.0%) had a subtherapeutic INR. CONCLUSIONS: The majority of patients receiving warfarin on presentation to the ED had INRs outside the desired therapeutic range. By establishing the impact of warfarin-related adverse events in this population, focused interventions can be established in this setting to address factors that can be targeted to reduce these events.

Major traumatic brain injury: time to tertiary care and the impact of a clinical guideline.

BACKGROUND: To achieve timely access to neurosurgical care for adult brain-injured patients, a Head Injury Guideline was implemented to standardize the emergency department evaluation and management of these patients. The goals of this study were to document times to neurosurgical care for patients with major traumatic brain injury presenting to a Provincial emergency room and to evaluate the impact of the Guideline on timely access to definitive care. METHODS: Data collected prospectively and stored in the Nova Scotia Trauma Registry and the Emergency Health Services Communications and Dispatch Centre database were analyzed for patients with head abbreviated injury scale score (AIS)≥3. Several time intervals from admission to a referring hospital to access to tertiary care were determined and compared for the periods before Guideline implementation, the implementation phase, and after implementation. RESULTS: The time elapsed before calling the provincial Trauma Hotline was not statistically different after Guideline implementation for polytrauma patients with head AIS score≥3 (n=388) during the preimplementation (2:34±1:30; median time in hours:minutes±standard deviation), implementation (1:57±2:33) and postimplementation (2:31±4:06) periods. Subset group analysis of patients with isolated head injuries AIS score≥3 (n=99) also showed no statistical difference in preimplementation (1:51±1:42), implementation (2:49±2:57), and postimplementation (3:10±4:58) times. Examination of overall time to tertiary care revealed prolonged transfer times and that the Guideline had no influence on either the polytrauma patient group (preimplementation, 4:20±1:41; implementation, 5:01±2:55; and postimplementation 4:46±4:22) or those with isolated head injuries (preimplementation, 3:39±1:47; implementation, 6:06±4:00; and postimplementation, 5:13±4:59). CONCLUSIONS: Times to tertiary care are lengthy and have not been reduced by Guideline implementation. System changes beyond Guideline implementation are required to provide timely access to tertiary care for patients with major head injury.

Potentially inappropriate prescribing of benzodiazepines for older adults and risk of falls during a hospital stay: a descriptive study.

BACKGROUND: Falls have been identified as a potential adverse event associated with the administration of psychotropic medications to older patients. OBJECTIVE: The objective of this exploratory study was to examine the association between potentially inappropriate prescribing of benzodiazepines, as defined by the Beers criteria, by older adults (at least 65 years of age) and the risk of having a fall during acute inpatient care. METHODS: This 1-year retrospective cross-sectional study of discharges from a tertiary care hospital in Halifax, Nova Scotia, used pharmacy data to identify the prescription of benzodiazepines listed in the updated Beers criteria as being associated with an increased risk of falls. These data were linked with information on in-hospital falls from occurrence report forms. RESULTS: For 5831 (58.1%) of the 10 044 discharges, the patient had received a prescription for at least one benzodiazepine during the hospital stay. A total of 574 falls were reported (for 374 patients), and 226 (39.4%) of the falls resulted in an injury. According to the Beers criteria, for 936 (9.3%) of the discharges, the patient had received a prescription for at least one potentially inappropriate benzodiazepine. However, there was no statistically significant difference between patients with a prescription for a potentially inappropriate benzodiazepine and those receiving an appropriate or no benzodiazepine in terms of occurrence of falls (4.5% versus 3.8%, p = 0.30) or fall-related injuries (2.6% versus 1.8%, p = 0.08). The median length of stay was about 3 days longer for the former group (9 versus 6 days, p < 0.001). CONCLUSIONS: The findings from the current study do not support use of the Beers criteria related to benzodiazepines alone for identifying patients at risk of falls or injuries.

Adverse events in older patients admitted to acute care: a preliminary cost description.

The financial costs associated with Adverse Events (AEs) for older patients (> or = 65 years) in Canadian hospitals are unknown. The objective of this paper is to describe and compare costs between patients who experienced an AE and those who did not during an acute hospital admission to a tertiary care facility. Patients with an AE had twice the hospital length of stay (20.2 versus 9.8 days, p < 0.00001), resulting in 1,400 extra days at a cost of approximately $7,500/patient.

Impact of adverse events on hospital disposition in community-dwelling seniors admitted to acute care.

Older adults (> or =65 years) have been identified as a high-risk group for the occurrence of adverse events (AEs) in hospital. The purpose of this paper is to describe the association between AEs and disposition for a population of hospitalized seniors. All community-dwelling seniors admitted to an acute care in-patient unit were eligible for inclusion in this retrospective cohort study conducted at an adult tertiary care facility in Atlantic Canada between July 1, 2005, and March 31, 2006. AEs were identified from administrative data using validated screening criteria derived from the International Classification of Diseases (ICD) diagnosis and external cause of injury codes. Of the 982 eligible patients, 140 (14%) had evidence of at least one AE. There were 136 in-hospital deaths (14%). There was no significant difference in the proportion of deaths between those who experienced an AE and those who did not. However, of the 29 patients who were discharged to a long-term care facility, a significantly higher proportion had an in-hospital AE (6% versus 2%, p < .009). The potential contribution of an AE to the subsequent placement in a long-term care facility offers a compelling reason to develop prevention strategies for hospitalized seniors.

Out-of-hospital continuous positive airway pressure ventilation versus usual care in acute respiratory failure: a randomized controlled trial.

STUDY OBJECTIVE: Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care. METHODS: Out-of-hospital patients in severe respiratory distress, with failing respiratory efforts, were eligible for the study. The study was approved under exception to informed consent guidelines. Patients were randomized to receive either usual care, including conventional medications plus oxygen by facemask, bag-valve-mask ventilation, or tracheal intubation, or conventional medications plus out-of-hospital CPAP. The primary outcome was need for tracheal intubation during the out-of-hospital/hospital episode of care. Mortality and length of stay were secondary outcomes of interest. RESULTS: In total, 71 patients were enrolled into the study, with 1 patient in each group lost to follow-up after refusing full consent. There were no important differences in baseline physiologic parameters, out-of-hospital scene times, or emergency department diagnosis between groups. In the usual care group, 17 of 34 (50%) patients were intubated versus 7 of 35 (20%) in the CPAP group (unadjusted odds ratio [OR] 0.25; 95% confidence interval [CI] 0.09 to 0.73; adjusted OR 0.16; 95% CI 0.04 to 0.7; number needed to treat 3; 95% CI 2 to 12). Mortality was 12 of 34 (35.3%) in the usual care versus 5 of 35 (14.3%) in the CPAP group (unadjusted OR 0.3; 95% CI 0.09 to 0.99). CONCLUSION: Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.

The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study.

BACKGROUND: The purpose of this paper is to review the population-based epidemiology of surgically treated post-traumatic epidural hematomas (EDHs) and/or subdural hematomas (SDHs) among patients who presented to the single neurosurgical centre in Nova Scotia. METHODS: We included all patients aged 16 years or older who presented to the tertiary care hospital with acute post-traumatic EDHs and/or SDHs between May 23, 1996, and May 22, 2005, and who were surgically treated. We generated an initial cohort from the provincial trauma registry and reviewed a total of 152 charts for possible inclusion; 70 (46%) patients met the study criteria. We performed a blinded, explicit chart review using a standardized data collection form, and we generated descriptive statistics. RESULTS: Of the patients who had surgery, 34 (49%) presented with SDHs, 23 (33%) presented with EDHs and 13 (19%) presented with both conditions. The median age was 45 years, and 80% of the cohort was male. The major mechanisms of injury were falls (51%), motor vehicle collisions (30%) and assault (11%). More than half (61%) of patients were transferred from referring hospitals while the remainder (39%) arrived directly without an intermediate facility. There were 18 postoperative deaths (26%). Forty-four of 70 patients (63%) had associated good outcomes at 6 months (Glasgow Outcome Scale). CONCLUSION: Acute post-traumatic EDHs and/or SDHs are relatively rare (0.83/100,000 population per annum) and are generally associated with good outcomes. Death was more likely among older, more severely injured patients and among those who required surgery for SDH rather than EDH.

Demystifying medication safety: making sense of the terminology.

BACKGROUND: Although there is a growing interest in medication safety, there remains much confusion about the terminology used to describe the problem. Some have described the classification of medication safety terminology as haphazard. OBJECTIVE: The purpose of this commentary is to help provide some direction by clarifying the terminology. METHODS: A review of the medication safety literature was performed. A description of commonly used terms is provided and the implications of the misuse of terminology are discussed. RESULTS: There are inconsistencies in the definitions of commonly used terms that may affect the accuracy of event rates. This may have an adverse impact on the establishment of medication safety priorities and on the validity of cross-jurisdictional comparisons. CONCLUSIONS: As the medication safety literature continues to expand, it is imperative that standardized terminology be adopted and used consistently.

The Role of Emergency Medical Services in Geriatrics: Bridging the Gap between Primary and Acute Care.

Caring for older adults is a major function of emergency medical services (EMS). Traditional EMS systems were designed to treat single acute conditions; this approach contrasts with best practices for the care of frail older adults. Care might be improved by the early identification of those who are frail and at highest risk for adverse outcomes. Paramedics are well positioned to play an important role via a more thorough evaluation of frailty (or vulnerability). These findings may inform both pre-hospital and subsequent emergency department (ED) based decisions. Innovative programs involving EMS, the ED, and primary care could reduce the workload on EDs while improving patient access to care, and ultimately patient outcomes. Some frail older adults will benefit from the resources and specialized knowledge provided by the ED, while others may be better helped in alternative ways, usually in coordination with primary care. Discerning between these groups is a challenge worthy of further inquiry. In either case, care should be timely, with a focus on identifying emergent or acute care needs, frailty evaluation, mobility assessments, identifying appropriate goals for treatment, promoting functional independence, and striving to have the patient return to their usual place of residence if this can be done safely. Paramedics are uniquely positioned to play a larger role in the care of our aging population. Improving paramedic education as it pertains to geriatrics is a critical next step.

How often should peripheral intravenous catheters in ambulatory patients be flushed?

Ambulatory intravenous (IV) treatment is frequently prescribed to be administered every 24 hours. Institutional protocols commonly recommend flushing catheters every 8 hours. The authors sought to identify whether flushing more than once every 24 hours conferred any benefit. A retrospective review compared complication rates of different catheter flushing intervals for patients receiving IV therapy. This study investigated 111 courses of treatment for 63 patients. In 43% of the patients (48/111), complications were identified during the treatment period. Complications were less common with flushing every 24 hours (39/99, 39.4%) than with more frequent flushing (9/12, 75%) (P = .021). Indwelling peripheral IV catheters flushed once every 24 hours appear to have lower complication rates than those flushed 2 or 3 times a day.

Approaches to improving the safety of the medication use system.

Problems associated with medication use have been consistently identified in the patient safety literature internationally. The purpose of this paper is to review components of the medication use process and offer suggestions for transforming it into a safer system. Prevention strategies are suggested for improving medication use at each stage of the system. Decision criteria are proposed that can be used by administrators and healthcare providers to allocate resources for prevention strategies that will improve medication safety.

Medication-related emergency department visits in pediatrics: a prospective observational study.

BACKGROUND AND OBJECTIVE: There are few data on the rate and characterization of medication-related visits (MRVs) to the emergency department (ED) in pediatric patients. We sought to evaluate the frequency, severity, preventability, and classification of MRVs to the ED in pediatric patients. METHODS: We performed a prospective observational study of pediatric patients presenting to the ED over a 12-month period. A medication-related ED visit was identified by using pharmacist assessment, emergency physician assessment, and an independent adjudication committee. RESULTS: In this study, 2028 patients were enrolled (mean age, 6.1 ± 5.0 years; girls, 47.4%). An MRV was found in 163 patients (8.0%; 95% confidence interval [CI]: 7.0%-9.3%) of which 106 (65.0%; 95% CI: 57.2%-72.3%) were deemed preventable. Severity was classified as mild in 14 cases (8.6%; 95% CI: 4.8%-14.0%), moderate in 140 cases (85.9%; 95% CI: 79.6%-90.8%), and severe in 9 cases (5.5%; 95% CI: 2.6%-10.2%). The most common events were related to adverse drug reactions 26.4% (95% CI: 19.8%-33.8%), subtherapeutic dosage 19.0% (95% CI: 13.3%-25.9%), and nonadherence 17.2% (95% CI: 11.7%-23.9%). The probability of hospital admission was significantly higher among patients with an MRV compared with those without an MRV (odds ratio, 6.5; 95% CI: 4.3-9.6) and, if admitted, the median (interquartile range) length of stay was longer (3.0 [5.0] days vs 1.5 [2.5] days, P = .02). CONCLUSIONS: A medication-related cause was found in ∼1 of every 12 ED visits by pediatric patients, of which two-thirds were deemed preventable. Pediatric patients who present to the ED with an MRV are more likely to be admitted to hospital and when admitted have a longer length of stay.

The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with community-acquired pneumonia: a prospective observational study.

STUDY OBJECTIVE: To assess the clinical usefulness of blood cultures (BCs) in the management of patients hospitalized with community-acquired pneumonia (CAP). DESIGN: A prospective, observational study to investigate the contribution of BCs to the management and outcomes of adult patients presenting with CAP. SETTING: Nineteen Canadian hospitals. PATIENTS: Adults admitted to the hospital with CAP between January 1, 1998, and July 31, 1998. INTERVENTIONS: The courses of therapy in patients for whom BC results yielded organisms considered to be clinically significant were analyzed to determine whether the BCs had contributed to management or outcome. MEASUREMENTS AND RESULTS: Forty-three of 760 patients had significantly positive BC results. Patients with CAP who had BCs performed had a 1.97% chance (15 of 760 patients) of having a change of therapy directed by BC results. Patients in whom BCs yielded positive results had a 34.8% chance (15 of 43 patients) of having a change in therapy determined by BC results, and had a 58.1% chance (25 of 43 patients) of having a course of therapy contraindicated by BC results. Severity of illness, as measured by the pneumonia severity index, correlated poorly with the yield of BCs. BC results were positive in 8.0% of patients in risk classes I and II, 6.2% of patients in risk class III, 4.6% of patients in risk class IV, and 5.2% of patients in risk class V. CONCLUSION: BCs have limited usefulness in the routine management of patients admitted to the hospital with uncomplicated CAP.

Emergency department utilization by older adults: a descriptive study.

BACKGROUND: Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. METHODS: In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. RESULTS: We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U; p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ(2); p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. CONCLUSIONS: Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.

Validating administrative data for the detection of adverse events in older hospitalized patients.

UNLABELLED: Older hospitalized patients are at risk of experiencing adverse events including, but not limited to, hospital-acquired pressure ulcers, fall-related injuries, and adverse drug events. A significant challenge in monitoring and managing adverse events is lack of readily accessible information on their occurrence. PURPOSE: The objective of this retrospective cross-sectional study was to validate diagnostic codes for pressure ulcers, fall-related injuries, and adverse drug events found in routinely collected administrative hospitalization data. METHODS: All patients 65 years of age or older discharged between April 1, 2009 and March 31, 2011 from a provincial academic health sciences center in Canada were eligible for inclusion in the validation study. For each of the three types of adverse events, a random sample of 50 patients whose records were positive and 50 patients whose records were not positive for an adverse event was sought for review in the validation study (n=300 records in total). A structured health record review was performed independently by two health care providers with experience in geriatrics, both of whom were unaware of the patient's status with respect to adverse event coding. A physician reviewed 40 records (20 reviewed by each health care provider) to establish interrater agreement. RESULTS: A total of 39 pressure ulcers, 56 fall-related injuries, and 69 adverse drug events were identified through health record review. Of these, 34 pressure ulcers, 54 fall-related injuries, and 47 adverse drug events were also identified in administrative data. Overall, the diagnostic codes for adverse events had a sensitivity and specificity exceeding 0.67 (95% confidence interval [CI]: 0.56-0.99) and 0.89 (95% CI: 0.72-0.99), respectively. CONCLUSION: It is feasible and valid to identify pressure ulcers, fall-related injuries, and adverse drug events in older hospitalized patients using routinely collected administrative hospitalization data. The information is relatively inexpensive and easy to access with no impact on clinical staff.

Use of an electronic information system to identify adverse events resulting in an emergency department visit.

OBJECTIVE: There is limited information about the nature of adverse events (AEs) that necessitate an emergency department (ED) visit. The objective of the current study was to demonstrate the feasibility of using routinely collected electronic data to identify AEs in patients presenting to EDs in one Canadian health authority. METHODS: This retrospective cross-sectional study occurred in EDs in two community hospitals, an outpatient community health centre and a tertiary care facility in the Capital District Health Authority in Nova Scotia, Canada between 1 November 2007 and 31 October 2008. The primary outcome was identification of an AE as the main reason for the ED visit. AEs were identified from electronic diagnostic data using previously validated screening criteria. RESULTS: There were 142,433 patient visits to the four EDs during the study period. A total of 1870 (1.3%) AEs were identified using the screening criteria. This included 1133 (0.8%) procedure-related, 673 (0.5%) drug-related, 63 (0.04%) device-related and one radiation-related AE. The AEs identified using this method were most likely the manifestation of treatment decisions made prior to the ED visit and/or related to care in other settings (eg, primary or long-term care, acute hospital care) including previous ED visits. INTERPRETATION: Although the use of electronic data significantly underestimates AEs treated in the ED, for relatively low cost, it provides new information on AEs arising from a variety of care settings that may otherwise not be captured. Significant and clinically important differences in healthcare utilisation underscore the value in identifying these AEs.

Identifying bioethics learning needs: a survey of Canadian emergency medicine residents.

OBJECTIVES: Emergency medicine (EM) postgraduate training programs must prepare residents for the ethical challenges of clinical practice. Bioethics curricula have been developed for EM residents, but they are based on expert opinion rather than resident learning needs. Educational interventions based on identified learning needs are more effective at changing practice than interventions that are not. The goal of this study was to identify the bioethics learning needs of Canadian EM residents. METHODS: A survey-based needs assessment of Canadian EM residents was performed between July 2000 and June 2001. Residents were asked to identify their learning needs by rating bioethics topics and by relating their clinical experiences. Physicians and nurses who work with residents were surveyed in a similar manner and also asked to identify the residents' bioethics learning needs. RESULTS: A total of 129 EM residents (77% of eligible residents), 94 physicians, and 87 nurses responded. Residents, physicians, and nurses all identified issues in end-of-life care as the greatest bioethics learning needs of the residents. Other areas identified as learning needs included negotiating consent, capacity assessment, truth telling, and breaking bad news. A learning need identified by nurses, but not residents, was the manner in which residents interact with patients and colleagues. CONCLUSIONS: This needs assessment provides valuable information about the ethical challenges EM residents encounter and the ethical issues they believe they have not been prepared to face. This information should be used to direct and shape ethics education interventions for EM residents.