Preparing Osteopathic Students for the Single Graduate Medical Education Accreditation System: Evaluating Factors for Match Success in Emergency Medicine.

INTRODUCTION: With the development of and progression toward a single graduate medical education accreditation system combining the current Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) residency programs, the total number of students competing for the same postgraduate training spots will continue to rise. Given this increasing competition for emergency medicine (EM) residency positions, understanding factors that contribute to match success is important to ensure a successful match for osteopathic medical students. METHODS: Our anonymous survey to evaluate factors that led to a successful match was sent out to residents in current ACGME-, AOA-, and dually-accredited programs via the AOA program director listserv and the Council of Residency Directors (CORD) e-mail listserv in 2017. RESULTS: We had 218 responses. Responses showed that osteopathic graduates had less affiliation with EM residencies, their home institutions provided less information regarding standardized letters of evaluations (SLOE), and that successful osteopathic graduates seemed to learn about them while on EM elective rotations. These students also had less direct EM mentorship and were generally unsatisfied with the level of mentorship available. Osteopathic graduates in current ACGME programs were also more likely to have taken the United States Medical Licensing Examination compared to their AOA resident counterparts. CONCLUSION: Osteopathic medical schools can improve their graduates' chances of successfully matching in EM by establishing mentorship programs and educating their students early about SLOEs.

Simulation-based Education to Ensure Provider Competency Within the Health Care System.

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic "Simulation-based education to ensure provider competency within the healthcare system." The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes," held on May 16, 2017, in Orlando, Florida. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, and maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.

Lessons Learned From the Development and Parameterization of a Computer Simulation Model to Evaluate Task Modification for Health Care Providers.

Computer simulation is a highly advantageous method for understanding and improving health care operations with a wide variety of possible applications. Most computer simulation studies in emergency medicine have sought to improve allocation of resources to meet demand or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in health care provider activity and facilitate the progress of future investigators in this field.

The 2017 Academic Emergency Medicine Consensus Conference: Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes.

Over the past decade, emergency medicine (EM) took a lead role in healthcare simulation in part due to its demands for successful interprofessional and multidisciplinary collaboration, along with educational needs in a diverse array of cognitive and procedural skills. Simulation-based methodologies have the capacity to support training and research platforms that model micro-, meso-, and macrosystems of healthcare. To fully capitalize on the potential of simulation-based research to improve emergency healthcare delivery will require the application of rigorous methods from engineering, social science, and basic science disciplines. The Academic Emergency Medicine (AEM) Consensus Conference "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcome" was conceived to foster discussion among experts in EM, engineering, and social sciences, focusing on key barriers and opportunities in simulation-based research. This executive summary describes the overall rationale for the conference, conference planning, and consensus-building approaches and outlines the focus of the eight breakout sessions. The consensus outcomes from each breakout session are summarized in proceedings papers published in this issue of Academic Emergency Medicine. Each paper provides an overview of methodologic and knowledge gaps in simulation research and identifies future research targets aimed at improving the safety and quality of healthcare.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 pediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritized and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a near-continuous review of cardiopulmonary resuscitation science that replaces the previous 5-year cyclic batch-and-queue approach process. This is the first of an annual series of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations summary articles that will include the cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation in the previous year. The review this year includes 5 basic life support and 1 paediatric Consensuses on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Each of these includes a summary of the science and its quality based on Grading of Recommendations, Assessment, Development, and Evaluation criteria and treatment recommendations. Insights into the deliberations of the International Liaison Committee on Resuscitation task force members are provided in Values and Preferences sections. Finally, the task force members have prioritised and listed the top 3 knowledge gaps for each population, intervention, comparator, and outcome question.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]. / Interdisziplinär konsentierte Stellungnahme zum Atemwegsmanagement mit supraglottischen Atemwegshilfen in der Kindernotfallmedizin: Larynxmaske ist State-of-the-art.

BACKGROUND: Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. MATERIAL AND METHODS: Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. DISCUSSION: Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

Pharmacist addition to the post-ED visit review of discharge antimicrobial regimens.

OBJECTIVE: Our objective was to evaluate whether pharmacist addition to the postvisit review of discharged adult emergency department (ED) visits' prescriptions/cultures would reduce the prevalence of revised antimicrobial regimen inappropriateness. METHODS: We conducted a retrospective observational study of discharged adult ED visits to a single center with positive cultures requiring antimicrobial regimen revision (May 1 to October 31, 2012, nurse process; February 1 to July 31, 2013, nurse/pharmacist process). Investigators abstracted cohorts' medical records for demographic, ED diagnosis, original/revised antibiotic regimen, culture result, medical history, medications, and patient instruction data and determined whether the revised regimen was inappropriate based on Infectious Diseases Society of America/Centers for Disease Control and Prevention and clinical guidelines. We used the large sample z-test to compare the prevalence of revised antimicrobial regimen inappropriateness between the 2 cohorts. RESULTS: In the prepharmacist cohort, there were 411 positive ED discharge cultures. Seventy-three (17.8%; 95% confidence interval [CI], 14.1%-21.5%) required antimicrobial regimen revision; 34 of these met 1 or more level of inappropriateness (46.6%; 95% CI, 35.1%-58.0%). In the postpharmacist cohort, there were 459 positive ED discharge cultures. Seventy-five (16.3%; 95% CI, 13.0%-19.7%) required revision; 11 of these met 1 or more level of inappropriateness (14.7%; 95% CI, 6.7%-22.7%; z = 4.2; P < .0001 for comparison). CONCLUSION: In this single-center study, pharmacist addition to the postvisit review of discharged adult ED patients' prescriptions/cultures reduced the prevalence of revised antimicrobial regimen inappropriateness.

Correlation of the emergency medicine resident in-service examination with the American Osteopathic Board of Emergency Medicine Part I.

INTRODUCTION: Eligible residents during their fourth postgraduate year (PGY-4) of emergency medicine (EM) residency training who seek specialty board certification in emergency medicine may take the American Osteopathic Board of Emergency Medicine (AOBEM) Part 1 Board Certifying Examination (AOBEM Part 1). All residents enrolled in an osteopathic EM residency training program are required to take the EM Resident In-service Examination (RISE) annually. Our aim was to correlate resident performance on the RISE with performance on the AOBEM Part 1. The study group consisted of osteopathic EM residents in their PGY-4 year of training who took both examinations during that same year. METHODS: We examined data from 2009 to 2012 from the National Board of Osteopathic Medical Examiners (NBOME). The NBOME grades and performs statistical analyses on both the RISE and the AOBEM Part 1. We used the RISE exam scores, as reported by percentile rank, and compared them to both the score on the AOBEM Part 1 and the dichotomous outcome of passing or failing. A receiver operating characteristic (ROC) curve was generated to depict the relationship. RESULTS: We studied a total of 409 residents over the 4-year period. The RISE percentile score correlated strongly with the AOBEM Part 1 score for residents who took both exams in the same year (r=0.61, 95% confidence interval [CI] 0.54 to 0.66). Pass percentage on the AOBEM Part 1 increased by resident percent decile on the RISE from 0% in the bottom decile to 100% in the top decile. ROC analysis also showed that the best cutoff for determining pass or fail on the AOBEM Part 1 was a 65(th) percentile score on the RISE. CONCLUSION: We have shown there is a strong correlation between a resident's percentile score on the RISE during their PGY-4 year of residency training and first-time success on the AOBEM Part 1 taken during the same year. This information may be useful for osteopathic EM residents as an indicator as to how well prepared they are for the AOBEM Part 1 Board Certifying Examination.

Should osteopathic students applying to allopathic emergency medicine programs take the USMLE Exam?

INTRODUCTION: Board scores are an important aspect of an emergency medicine (EM) residency application. Residency directors use these standardized tests to objectively evaluate an applicant's potential and help decide whether to interview a candidate. While allopathic (MD) students take the United States Medical Licensing Examination (USMLE), osteopathic (DO) students take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). It is difficult to compare these scores. Previous literature proposed an equation to predict USMLE based on COMLEX. Recent analyses suggested this may no longer be accurate. DO students applying to allopathic programs frequently ask whether they should take USMLE to overcome this potential disadvantage. The objective of the study is to compare the likelihood to match of DO applicants who reported USMLE to those who did not, and to clarify how important program directors consider it is whether or not an osteopathic applicant reported a USMLE score. METHODS: We conducted a review of Electronic Residency Application Service (ERAS) and National Resident Matching Program (NRMP) data for 2010-2011 in conjunction with a survey of EM residency programs. We reviewed the number of allopathic and osteopathic applicants, the number of osteopathic applicants who reported a USMLE score, and the percentage of successful match. We compared the percentage of osteopathic applicants who reported a USMLE score who matched compared to those who did not report USMLE. We also surveyed allopathic EM residency programs to understand how important it is that osteopathic (DO) students take USMLE. RESULTS: There were 1,482 MD students ranked EM programs; 1,277 (86%, 95% CI 84.3-87.9) matched. There were 350 DO students ranked EM programs; 181 (52%, 95% CI 46.4-57.0) matched (difference=34%, 95% CI 29.8-39.0, p<0.0001). There were 208 DO students reported USMLE; 126 (61%, 95% CI 53.6-67.2) matched. 142 did not report USMLE; 55 (39%, 95% CI 30.7-47.3) matched (difference=22%, 95% CI 11.2-32.5, p<0.0001). Survey results: 39% of program directors reported that it is extremely important that osteopathic students take USMLE, 38% stated it is somewhat important, and 22% responded not at all important. CONCLUSION: DO students who reported USMLE were more likely to match. DO students applying to allopathic EM programs should consider taking USMLE to improve their chances of a successful match.

Quality assurance in military medical research and medical radiation accident management.

The provision of quality radiation-related medical diagnostic and therapeutic treatments cannot occur without the presence of robust quality assurance and standardization programs. Medical laboratory services are essential in patient treatment and must be able to meet the needs of all patients and the clinical personnel responsible for the medical care of these patients. Clinical personnel involved in patient care must embody the quality assurance process in daily work to ensure program sustainability. In conformance with the German Federal Government's concept for modern departmental research, the international standard ISO 9001, one of the relevant standards of the International Organization for Standardization (ISO), is applied in quality assurance in military medical research. By its holistic approach, this internationally accepted standard provides an excellent basis for establishing a modern quality management system in line with international standards. Furthermore, this standard can serve as a sound basis for the further development of an already established quality management system when additional standards shall apply, as for instance in reference laboratories or medical laboratories. Besides quality assurance, a military medical facility must manage additional risk events in the context of early recognition/detection of health risks of military personnel on deployment in order to be able to take appropriate preventive and protective measures; for instance, with medical radiation accident management. The international standard ISO 31000:2009 can serve as a guideline for establishing risk management. Clear organizational structures and defined work processes are required when individual laboratory units seek accreditation according to specific laboratory standards. Furthermore, international efforts to develop health laboratory standards must be reinforced that support sustainable quality assurance, as in the exchange and comparison of test results within the scope of external quality assurance, but also in the exchange of special diagnosis data among international research networks. In summary, the acknowledged standard for a quality management system to ensure quality assurance is the very generic standard ISO 9001.Health Phys. 103(2):221-225; 2012.

Joint policy statement--guidelines for care of children in the emergency department.

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicine's report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems' administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Children's National Medical Center, Family Voices, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

Vulnerable populations: cultural and spiritual direction.

Cultural, spiritual, and religious diversity of emergency department patients is increasing while that of emergency physicians in particular remains predominantly homogeneous. With a discordance of cultural, race, and ethnicity exist, in the case of ethical conflict -resolution becomes that much more difficult. Patients may feel vulnerable when their emergency care provider does not understand his or her cultural, spiritual, and religious uniqueness as it relates to the patient-doctor interaction and health care decision making. This review will examine (1) language differences; (2) cultural, religious, and spiritual differences between patient and provider; (3) differing explanatory models of disease between patient and provider; and (4) diverse bioethical models of decision making of differing cultures in an effort to reduce vulnerabilities.

Physician knowledge of herbal toxicities and adverse herb-drug interactions.

OBJECTIVE: To determine how knowledgeable physicians are regarding the toxic effects and drug interactions of herbal remedies. METHODS: An anonymous voluntary demographic survey and 16-question, multiple-choice quiz was distributed at educational meetings of emergency medicine and internal medicine physicians. The primary outcome measures were to determine whether significant associations existed between quiz scores and the amount of clinical experience, or between quiz scores and self-assessed familiarity with the topic of herbal toxicities and adverse herb-drug interactions. RESULTS: A total of 142 surveys and quizzes were completed by 59 attending physicians, 57 resident physicians, and 26 medical students. The mean subject score on the quiz was only slightly higher than would have occurred from random guessing. Neither the amount of the subjects' clinical experience, nor their self-assessed familiarity with herbal toxicities and drug interactions correlated significantly with the score on the quiz. CONCLUSION: The physicians and medical students surveyed had little training in herbal toxicities and drug interactions. They generally rated their familiarity with these topics as 'poor', and their scores on the quiz bore out this assessment as correct. Educational efforts might improve physician knowledge of the adverse effects of herbal remedies.