Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents.

PURPOSE: Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). METHODS: First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. RESULTS: Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. CONCLUSIONS: A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Emergency Department Grief Support: A Multidisciplinary Intervention to Provide Bereavement Support After Death in the Emergency Department.

BACKGROUND: The nature of death in the emergency department (ED) may put survivors at higher risk for complicated bereavement. Access to bereavement care could mitigate this, but many EDs do not include bereavement follow-up as part of their routine practice. OBJECTIVE: We describe the implementation at our institution of ED Grief Support, a program developed to extend care to the bereaved through in-person, telephone, and e-mail follow-up for 1 year after the death of a loved one. METHODS: Bereavement follow-up was preferentially extended to survivors of patients <45 years of age who were chosen because of the higher likelihood of unexpected death in this age group. Detailed records of each case were collected prospectively using online data management software and outcomes were recorded. Successful strategies to navigate communication and resource referrals are discussed. RESULTS: We enrolled 192 patients during our 2-year period of observation. The majority died from trauma and parents were the most common next-of-kin to be contacted. Commonly requested services included: clarification of the circumstances of death, the interpretation of autopsy reports, referral to community bereavement resources, and family meetings. Challenges included supporting the emotional well-being of staff and the resource-intensive nature of the follow-up. Staff members who worked with ED Grief Support find it meaningful and note a positive influence on their well-being as providers. CONCLUSIONS: Longitudinal bereavement follow-up from the ED is feasible and had a perceived positive impact on the bereaved as well as ED staff.

Effect of an automated chest radiograph at triage protocol on time to antibiotics in patients admitted with pneumonia.

OBJECTIVE: We derived and tested a protocol to automatically order a chest radiograph (CXR) at emergency department triage for patients with signs and symptoms of pneumonia to reduce time to antibiotics. METHODS: We derived a protocol using a retrospective study of admitted adult patients with pneumonia then prospectively tested the protocol on time to antibiotics. The protocol included patients with a chief complaint of chest pain, shortness of breath, upper respiratory tract infection, hemoptysis, fever, and cough. Of those, patients 50 years or older with any vital sign abnormality and patients younger than 50 with a comorbidity of immunocompromise, cancer, diabetes, transplant, or chronic alcoholism had a CXR ordered automatically. RESULTS: Although the protocol was only 35% (95% confidence interval, 28%-43%) sensitive in identifying patients admitted with pneumonia, time to antibiotics (in hours) (3.4 vs 4.2, P = .01) and time to CXR (3.0 vs 2.0, P = .01) for patients admitted with pneumonia were lower during the study period. CONCLUSION: Automated CXR at triage reduces time to antibiotics in patients admitted with pneumonia.

Dissociation of event-related potentials indexing arousal and semantic cohesion during emotional word encoding.

Event-related potential (ERP) studies have shown that emotional stimuli elicit greater amplitude late positive-polarity potentials (LPPs) than neutral stimuli. This effect has been attributed to arousal, but emotional stimuli are also more semantically coherent than uncategorized neutral stimuli. ERPs were recorded during encoding of positive, negative, uncategorized neutral, and categorized neutral words. Differences in LPP amplitude elicited by emotional versus uncategorized neutral stimuli were evident from 450 to 1000 ms. From 450 to 700 ms, LPP effects at midline and right hemisphere frontal electrodes indexed arousal, whereas LPP effects at left hemisphere centro-parietal electrodes indexed semantic cohesion. This dissociation helps specify the processes underlying emotional stimulus encoding, and suggests the need to control for semantic cohesion in emotional information processing studies.

Co-activation of the amygdala, hippocampus and inferior frontal gyrus during autobiographical memory retrieval.

Functional MRI was used to investigate the role of medial temporal lobe and inferior frontal lobe regions in autobiographical recall. Prior to scanning, participants generated cue words for 50 autobiographical memories and rated their phenomenological properties using our autobiographical memory questionnaire (AMQ). During scanning, the cue words were presented and participants pressed a button when they retrieved the associated memory. The autobiographical retrieval task was interleaved in an event-related design with a semantic retrieval task (category generation). Region-of-interest analyses showed greater activation of the amygdala, hippocampus, and right inferior frontal gyrus during autobiographical retrieval relative to semantic retrieval. In addition, the left inferior frontal gyrus showed a more prolonged duration of activation in the semantic retrieval condition. A targeted correlational analysis revealed pronounced functional connectivity among the amygdala, hippocampus, and right inferior frontal gyrus during autobiographical retrieval but not during semantic retrieval. These results support theories of autobiographical memory that hypothesize co-activation of frontotemporal areas during recollection of episodes from the personal past.