Early, awake proning in emergency department patients with COVID-19.

OBJECTIVE: Proning has been shown to improve oxygenation and mortality in certain populations of intubated patients with acute respiratory distress syndrome. Small observational analyses of COVID-19 patients suggest awake proning may lead to clinical improvement. Data on safety and efficacy is lacking. We sought to describe the effect of proning on oxygenation in nonintubated COVID-19 patients. We also evaluated feasibility, safety, and other physiological and clinical outcomes associated with this intervention. METHODS: We conducted a prospective, observational cohort study of nonintubated patients with COVID-19 who underwent proning per an Emergency Department (ED) clinical protocol. Patients with mild to moderate respiratory distress were included. We calculated change in oxygenation by comparing the oxygen saturation to fraction of inspired oxygen ratio (SpO2:FiO2) during the five minutes prior to proning and first 30 min of proning. We also captured data on respiratory rate, duration of proning, need for intubation, intensive care unit admission, survival to discharge. RESULTS: Fifty-two patients were enrolled. Thirty were excluded for not meeting protocol inclusion criteria or missing baseline oxygenation data, leaving 22 for analysis. The SpO2:FiO2 ratio increased by a median of 5 (IQR: 0-15) in the post-proning period compared to the pre-proning period (median: 298 (IQR: 263-352) vs 295 (IQR: 276-350), p = 0.01). Respiratory rate did not change significantly between time periods. No immediate adverse events occurred during proning. Five patients (23%) were intubated within 48 h of admission. CONCLUSION: Early, awake proning may be feasible in select COVID-19 patients and was associated with improved oxygenation.

Gender differences in funding among grant recipients in emergency medicine: A multicenter analysis.

OBJECTIVE: To describe differences in funded grants between male and female faculty in two academic emergency departments. METHODS: This was a retrospective analysis of grant funding at two academic emergency departments from January 2012-September 2018. We queried the grants department databases at each institution and obtained records of all funded grants for emergency medicine (EM) faculty. We extracted the following information for each award: gender of the principal investigator (PI), PI academic rank, grant mechanism (government, institutional, industry, organizational), and percent effort. Differences by gender were compared using Chi-square or Fisher's exact test and Wilcoxon-rank sum. RESULTS: One-hundred and thirty grants were awarded to EM faculty at the two institutions during the study period. Of the funded grants, 35 (27%) of recipients were female. Among grant recipients, females held lower academic ranking than males (p-value < 0.001): Instructor (49% vs 51%), Assistant Professor (36% vs 64%), Associate Professor (9% vs 91%), and Professor (0% vs 100%), respectively. Organizational grants were dispersed equally between funded faculty, but females received a fewer government, industry, and institutional grants (p-value = 0.007). Female grant recipients were awarded a higher median percent of effort compared to males (14% [IQR: 3-51] vs 8% [IQR: 1-15], respectively, p-value = 0.023). CONCLUSION: In this multicenter analysis, gender discrepancies exist among funded grants of EM faculty. Male recipients had higher academic ranking than their female counterparts. Female recipients were less likely to have government, institutional, and industry grants but received a greater percent effort on funding that was awarded.

Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain.

STUDY OBJECTIVE: Serious neurologic conditions can be missed on initial emergency department (ED) visit and discharge diagnosis oftentimes remains a nonspecific symptom. We aim to examine the incidence of potential harm from serious neurologic conditions in ED patients discharged with a nonspecific diagnosis of headache or back pain, identify specific missed conditions, and determine risk factors for potential misdiagnosis-related harm. METHODS: This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012. We identified adults (≥18 years) discharged from the ED with a diagnosis of atraumatic headache or back pain. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge. RESULTS: There were 2,101,081 ED discharges with a nonspecific diagnosis of headache and 1,381,614 discharges with a nonspecific diagnosis of back pain. Overall, 0.5% of the headache patients and 0.2% of back pain patients had a primary outcome. The most common missed condition for headache was ischemic stroke (18.1%). The most common missed condition for back pain was intraspinal abscess (41%). In both populations, advanced age, male sex, non-Hispanic white, and comorbidities (eg, neurologic disorders, HIV/AIDS, malignancy) were associated with higher odds of outcome. CONCLUSION: A small proportion of ED patients discharged with nonspecific diagnoses of headache or back pain returned with a serious neurologic condition or inhospital death within 30 days.

The Effect of Signed-Out Emergency Department Patients on Resident Productivity.

BACKGROUND: Transitions of care and patient hand-offs between physicians have important implications for patient care. However, what effect caring for signed-out patients has on providing care to new patients and education is unclear. OBJECTIVE: We sought to determine whether the number of patients a physician receives in sign-out affects productivity. METHODS: This was a retrospective cohort study, conducted at an emergency medicine residency program. A general estimation equation was constructed to model productivity, defined as new patients evaluated and relative value units (RVUs) generated per shift, relative to the number of sign-outs received, and training year. A secondary analysis evaluated the effect of signed-out patients in observation. RESULTS: We evaluated 19,389 shifts from July 1, 2010 to July 1, 2017. Postgraduate year (PGY)-1 residents without sign-out evaluated 10.3 patients (95% confidence interval [CI] 9.83 to 10.7), generating 31.6 RVUs (95% CI 30.5 to 32.7). Each signed-out patient was associated with -0.07 new patients (95% CI -0.12 to -0.01), but no statistically significant decrease in RVUs (95% CI -0.07 to 0.28). PGY-2 residents without sign-out evaluated 13.6 patients (95% CI 12.6 to 14.6), generating 47.7 RVUs (95% CI 45.1 to 50.3). Each signed-out patient was associated with -0.25 (95% CI -0.40 to -0.10) new patients, and -0.89 (95% CI -1.22 to -0.55) RVUs. For all residents, observation patients were associated with more substantial decreases in new patients (-0.40; 95% CI -0.47 to -0.33) and RVUs (-1.11; 95% CI -1.40 to -0.82). CONCLUSIONS: Overall, sign-out burden is associated with a small decrease in resident productivity, except for observation patients. Program faculty should critically examine how signed-out patients are distributed to address residents' educational needs, throughput, and patient safety.

Hospital ward transfer to intensive care unit as a quality marker in emergency medicine.

BACKGROUND: Minimizing and preventing adverse events and medical errors in the emergency department (ED) is an ongoing area of quality improvement. Identifying these events remains challenging. OBJECTIVE: To investigate the utility of tracking patients transferred to the ICU within 24h of admission from the ED as a marker of preventable errors and adverse events. METHODS: From November 2011 through June 2016, we prospectively collected data for all patients presenting to an urban, tertiary care academic ED. We utilized an automated electronic tracking system to identify ED patients who were admitted to a hospital ward and then transferred to the ICU within 24h. Reviewers screened for possible error or adverse event and if discovered the case was referred to the departmental Quality Assurance (QA) committee for deliberations and consensus agreement. RESULTS: Of 96,377 ward admissions, 921 (1%) patients were subsequently transferred to the ICU within 24h of ED presentation. Of these 165 (19%) were then referred to the QA committee for review. Total rate of adverse events regardless of whether or not an error occurred was 2.1%, 19/921 (95% CI 1.4% to 3.0%). Medical error on the part of the ED was 2.2%, 20/921 (95% CI 1.5% to 3.1%) and ED Preventable Error in 1.1%, 10/921 (95% CI 0.6% to 1.8%). CONCLUSION: Tracking patients admitted to the hospital from the ED who are transferred to the ICU <24h after admission may be a valuable marker for adverse events and preventable errors in the ED.

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship.

BACKGROUND: Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear. OBJECTIVE: We sought to correlate faculty clinical evaluations with medical student performance on a written, standardized EM examination of medical knowledge. METHODS: This is a retrospective study of fourth-year medical students in a 4-week EM elective at one academic medical center. EM faculty performed end of shift evaluations of students via a blinded online system using a 5-point Likert scale for 8 domains: data acquisition, data interpretation, medical knowledge base, professionalism, patient care and communication, initiative/reliability/dependability, procedural skills, and overall evaluation. All students completed the National EM M4 Examination in EM. Means, medians, and standard deviations for end of shift evaluation scores were calculated, and correlations with examination scores were assessed using a Spearman's rank correlation coefficient. RESULTS: Thirty-nine medical students with 224 discrete faculty evaluations were included. The median number of evaluations completed per student was 6. The mean score (±SD) on the examination was 78.6% ± 6.1%. The examination score correlated poorly with faculty evaluations across all 8 domains (ρ 0.074-0.316). CONCLUSION: Faculty evaluations of medical students across multiple domains of competency correlate poorly with written examination performance during an EM clerkship. Educators need to consider the limitations of examination score in assessing students' ability to provide quality patient clinical care.

Cultural Competency Training in Emergency Medicine.

BACKGROUND: The Emergency Department is widely regarded as the epicenter of medical care for diverse and largely disparate types of patients. Physicians must be aware of the cultural diversity of their patient population to appropriately address their medical needs. A better understanding of residency preparedness in cultural competency can lead to better training opportunities and patient care. OBJECTIVE: The objective of this study was to assess residency and faculty exposure to formal cultural competency programs and assess future needs for diversity education. METHODS: A short survey was sent to all 168 Accreditation Council for Graduate Medical Education program directors through the Council of Emergency Medicine Residency Directors listserv. The survey included drop-down options in addition to open-ended input. Descriptive and bivariate analyses were used to analyze data. RESULTS: The response rate was 43.5% (73/168). Of the 68.5% (50/73) of residency programs that include cultural competency education, 90% (45/50) utilized structured didactics. Of these programs, 86.0% (43/50) included race and ethnicity education, whereas only 40.0% (20/50) included education on patients with limited English proficiency. Resident comfort with cultural competency was unmeasured by most programs (83.6%: 61/73). Of all respondents, 93.2% (68/73) were interested in a universal open-source cultural competency curriculum. CONCLUSIONS: The majority of the programs in our sample have formal resident didactics on cultural competency. Some faculty members also receive cultural competency training. There are gaps, however, in types of cultural competency training, and many programs have expressed interest in a universal open-source tool to improve cultural competency for Emergency Medicine residents.

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients. METHODS: After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). RESULTS: A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients. Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971-0.994) and specificity was 0.999 (95% confidence intervals, 0.993-1.0). The pooled likelihood ratio of a negative CT was 0.010 (95% confidence intervals, 0.003-0.034). CONCLUSIONS: In patients presenting with thunderclap headache and normal neurological examination, normal brain CT within 6 hours of headache is extremely sensitive in ruling out aneurysmal SAH.

Implementation of an emergency department sign-out checklist improves transfer of information at shift change.

BACKGROUND: Transitions of care are ubiquitous in the emergency department (ED) and inevitably introduce the opportunity for errors. Few emergency medicine residency programs provide formal training or a standard process for patient handoffs. Checklists have been shown to be effective quality-improvement measures in inpatient settings and may be a feasible method to improve ED handoffs. OBJECTIVE: To determine if the use of a sign-out checklist improves the accuracy and efficiency of resident sign-out in the ED. METHODS: A prospective pre-/postinterventional study of residents rotating in the ED at a tertiary academic medical center. Trained research assistants observed resident sign-out during shift change over a 2-week period and completed a data collection tool to indicate whether or not key components of sign-out occurred and time to sign out each patient. An electronic sign-out checklist was implemented using a multi-faceted educational effort. A 2-week postintervention observation phase was conducted. Proportions, means, and nonparametric comparison tests were calculated using STATA. RESULTS: One hundred fifteen sign-outs were observed prior to checklist implementation and 114 were observed after. Significant improvements were seen in four sign-out components: reporting of history of present illness increased from 81% to 99%, ED course increased from 75% to 86%, likely diagnosis increased from 60% to 77%, and team awareness of plan increased from 21% to 41%. Use of the repeat-back technique decreased from 13% to 5% after checklist implementation and time to sign-out showed no significant change. CONCLUSION: Implementation of a checklist improved the transfer of information without increasing time to sign-out.

Teaching Trainees Effective Patient Communication Skills in the Clinical Environment: Best Practices Under Crisis Conditions.

ABSTRACT: Communication within the health care setting has significant implications for the safety, engagement, and well-being of patients and physicians. Evidence shows that communication training is variable or lacking in undergraduate and graduate medical education. Physician-patient communication presents a vulnerable point in patient care, which was heightened by the COVID-19 pandemic and its aftermath. Physicians have to adapt their strategies to meet new challenges, including communicating through the necessary barriers of personal protective equipment and telecommunication platforms. They also face uncharted challenges of facilitating discussions around proactive planning and scarce resources. Medical educators must be equipped to provide trainees with the skills needed to maintain empathy, facilitate trust and connection, and adapt communication behaviors under such crisis conditions. Using the Calgary-Cambridge model as a framework, the authors describe 3 new challenges to effective physician-patient communication for which COVID-19 was the impetus-face masks, visitor restrictions, and resource allocation/proactive planning discussions-and propose educational solutions.

Measuring and Predicting Faculty Consensus Rankings of Standardized Letters of Evaluation.

Background Standardized letters of evaluation (SLOE) are becoming more widely incorporated into the residency application process to make the letter of recommendation, an already critical component in a residency application packet, more objective. However, it is not currently known if the reviewers of these letters share consensus regarding the strength of an applicant determined by their SLOE. Objective We measured the level of faculty agreement regarding applicant competitiveness as determined by SLOEs and the ability of 2 algorithms to predict faculty consensus rankings. Methods Using data from the 2021-2022 Match cycle from the Council of Residency Directors in Emergency Medicine SLOE Database as a blueprint, authors created 50 fictional SLOEs representative of the national data. Seven faculty then rated these SLOEs in order of applicant competitiveness, defined as suggested rank position. Consensus was evaluated using cutoffs established a priori, and 2 prediction models, a point-based system and a linear regression model, were tested to determine their ability to predict consensus rankings. Results There was strong faculty consensus regarding the interpretation of SLOEs. Within narrow windows of agreement, faculty demonstrated similar ranking patterns with 83% and 93% agreement for "close" and "loose" agreement, respectively. Predictive models yielded a strong correlation with the consensus ranking (point-based system r=0.97, linear regression r=0.97). Conclusions Faculty displayed strong consensus regarding the competitiveness of applicants via SLOEs, adding further support to the use of SLOEs for selection and advising. Two models predicted consensus competitiveness rankings with a high degree of accuracy.

Racial disparities in emergency medicine: Implementation of a novel educational module in the emergency medicine clerkship.

Objectives: Despite decades of literature recognizing racial disparities (RDs) in emergency medicine (EM), published curricula dedicated to addressing them are sparse. We present details of our novel RD curriculum for EM clerkships and its educational outcomes. Methods: We created a 30-min interactive didactic module on the topic designed for third- and fourth-year medical students enrolled in our EM clerkships. Through a modified Delphi process, education faculty and content experts in RD developed a 10-question multiple-choice test of knowledge on RD that the students completed immediately prior to and 2 weeks following the activity. Students also completed a Likert-style learner satisfaction survey. Median pre- and posttest scores were compared using a paired Wilcoxon signed-rank test and presented using medians and 95% confidence intervals (CIs). Satisfaction survey responses were dichotomized into favorable and neutral/not favorable. Results: For the 36 students who completed the module, the median pretest score was 40% (95% CI 36%-50%) and the posttest score was 70% (95% CI 60%-70%) with a p-value of <0.001. Thirty-five of the 36 students improved on the posttest with a mean increase of 24.2% (95% CI 20.2-28.2). The satisfaction survey also showed a positive response, with at least 83% of participants responding favorably to all statements (overall mean favorable response 93%, 95% CI 90%-96%).ConclusionsThis EM-based module on RD led to improvement in students' knowledge on the topic and positive reception by participants. This is a feasible option for educating students in EM on the topic of RD.

Design and Evaluation of a Curriculum on Intimate Partner Violence for Medical Students in an Emergency Medicine Clerkship.

Purpose: Intimate partner violence (IPV) is a widespread public health issue that is relevant to all areas of medicine. Patients who suffer from IPV often contact the health care system via the emergency department, making this a particularly important but too often overlooked issue in this setting. Education on IPV varies in medical schools and emergency medicine (EM) educational programs, and evidence suggests that a barrier to assessing for IPV is a lack of adequate training of clinicians. In this study, we sought to design, implement and evaluate the efficacy of a curriculum on IPV geared towards medical students on an EM clerkship. Methods: We assembled a multi-disciplinary team of EM education faculty, a resident content expert on IPV, and social workers to design a two-part curriculum that was administered to medical students on an EM clerkship. The curriculum involved a 20-minute narrated slide presentation viewed asynchronously, followed by a 1-hour case-based discussion session. The curriculum was evaluated using a 13-item self-assessment survey on knowledge, comfort level and skill in managing victims of IPV, administered electronically before and after the curriculum. Survey results were compared pre- and post-curriculum using Wilcoxon signed-rank test. Results: Thirty-four students completed the curriculum and 26 completed both the pre and post self-assessment surveys. A statistically significant improvement in knowledge, comfort level and skills was observed in 11 of the 13 survey elements. Conclusion: Based on the self-assessment survey results, this curriculum was well received and successfully increased participants' comfort, knowledge and skill level regarding assessment of patients for IPV. This is a focused and feasible curriculum that can be easily incorporated into an EM clerkship to provide effective education on a relevant but often overlooked topic.

Sensitivity of diffusion-weighted magnetic resonance imaging in transient global amnesia as a function of time from symptom onset.

BACKGROUND: The objective was to systematically evaluate the sensitivity of diffusion-weighted magnetic resonance imaging (DW-MRI) for transient global amnesia (TGA) across various time frames compared to the reference-standard clinical criteria. METHODS: All indexed publications related to TGA and MRI through June 2020 were retrieved by a medical librarian. Two independent reviewers identified original research studies of adults with a clinical diagnosis of TGA using Caplan and Hodges and Warlow criteria (reference standard) who were evaluated with DW-MRI. Pooled estimates and its 95% confidence intervals (CI) for the proportion of acute TGA patients with positive DW-MRI (i.e., sensitivity) were obtained using random-effects meta-analysis for various time frames. Quality assessment was performed using the revised Quality of Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: After screening 665 reports, we identified 81 potentially relevant studies. Twenty-three studies representing 1688 patients met eligibility criteria, but not all studies had data available for meta-analysis. The pooled sensitivity (also described as positivity rate) of DW-MRI was 15.6% (95% CI = 2.6%-35.0%) between 0 and 12 h from symptom onset, 23.1% (95% CI = 6.1%-45.7%) at 0-24 h, 72.8% (95% CI = 40.8%-96.3) at 12-24 h, 68.8% (95% CI = 44.8%-88.8%) at 24-36 h, 72.4% (95% CI = 59.8%-83.5%) at 36-48 h, 82.8% (95% CI = 54.7%-99.6%) at 48-60 h, 66.9% (95% CI = 47.5%-83.9%) at 60-72 h, and 72.0% (95% CI = 30.1%-100.0%) at 72-96 h. There was significant concern for risk of bias in the QUADAS-2 domains of patient selection and index test, yielding a low level of certainty in the pooled estimates. CONCLUSION: DW-MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW-MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW-MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low-yield test.

The next generation of researchers: One-year outcome data from the SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program.

Introduction: As the field of medical education evolves, there is a need to increase the quality of education scholarship and develop a cadre of research scholars; however, clinician educators (CEs) considering this career transition have limited formal training in education research methodology to heed this call. Therefore, a program that provides more advanced training in education scholarship for CEs without the financial and resource barriers of fellowships and masters programs is needed. Methods: The SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program is a longitudinal program for the beyond-beginner CE, seeking advanced training in education research. The program was created using a comprehensive needs assessment and included longitudinal training; small-group projects; dedicated project mentors; and integrated diversity, equity, and inclusion initiatives. Program participants applied for a grant upon program completion. Results: Twenty-one participants completed the course with 100% completing the baseline survey and 67% (14/21) completing the end-of-program survey. Participants reported improved perception of knowledge across all of the topics with a medium to large effect size, ranging from 0.40 to 0.62. When asked about impact on their network of potential collaborators, participants reported a median of 7 (interquartile range [IQR] 5-8) out of 9. When asked about the impact on their community of practice, participants reported a median of 7 (IQR 5-7) out of 9. When asked about the impact on their professional identity, participants reported a median of 7 (IQR 4-9) out of 9. Participants also reported an increase in both the quantity (mean of 2 ± 1 new mentors) and the quality (median score 7 [IQR 5-8] out of 9) of new research mentorship as a result of the program. Open-ended feedback was generally positive, with 100% reporting they would advise others to take this program. Conclusions: The SAEM ARMED MedEd program represents a proof of concept for an advanced education research program seeking to fill the research training gap for the beyond-beginner Clinician educators.

Guidelines on the use of race as patient identifiers in clinical presentations.

The value of including race as part of the patient identifier in care and medical education has been a topic of debate among clinicians, medical educators, and sociologists.1,2,6,7,8 The perceived benefit of using racial identifiers is that it may allow physicians to predict the risk of disease and inform drug therapy.9 This association is thought to be useful to medical students and trainees as they form their clinical knowledge base. However, there is a larger body of evidence that the use of race leads to bias and stereotyping by physicians. In many cases, patients are assigned to racial categorizations that are inconsistent with their self-reported identities.1,15 It is unclear which medical schools have a policy that explicitly detail their stance on this topic. In this article, we propose a frame of thinking to guide medical educators as they develop policies on race as patient identifiers.

Diagnosis and Initial Emergency Department Management of Subarachnoid Hemorrhage.

Atraumatic subarachnoid hemorrhage represents a small proportion of strokes, but is a true medical emergency that results in significant morbidity and mortality. Making the diagnosis can be challenging and misdiagnosis can result in devastating consequences. There are several time-dependent diagnostic and management considerations for emergency physicians and other frontline providers. This article reviews the most up-to-date literature on the diagnostic workup of subarachnoid hemorrhage, avoiding misdiagnosis, and initial emergency department management recommendations.

Correlation of attending and patient assessment of resident communication skills in the emergency department.

BACKGROUND: Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills. METHODS: This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement. RESULTS: During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26). CONCLUSIONS: Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills.

A Simulation-Based Prospective Cohort Study on Teaching Best Practices in Firearms Safety.

BACKGROUND: Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms. METHODS: This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared. RESULTS: Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it. CONCLUSIONS: This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.

Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine.

Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute gender-specific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.