Screening for delirium in the emergency department: a systematic review.

Older adults who visit emergency departments (EDs) often experience delirium, but it is infrequently recognized. A systematic review was therefore conducted to identify what delirium screening tools have been used in ED-based epidemiologic studies of delirium, whether there is a validated set of screening instruments to identify delirium among older adults in the ED or prehospital environments, and an ideal schedule during an older adult's visit to perform a delirium evaluation. MEDLINE/EMBASE, Cochrane, PsycINFO, and CINAHL databases were searched from inception through February 2013 for original, English-language research articles reporting on the assessment of older adults' mental status for delirium. Twenty-two articles met all study inclusion criteria. Overall, 7 screening instruments were identified, though only 1 has undergone initial validation for use in the ED environment and a second instrument is currently undergoing such validation. Minimal information was identified to suggest the ideal scheduling of a delirium assessment process to maximize the recognition of this condition in the ED. Study results indicate that several delirium screening tools have been used in investigations in the ED, though validation of these instruments for this particular environment has been minimal to date. The ideal interval(s) during which a delirium screening process should take place has yet to be determined. Research will be needed both to validate delirium screening instruments to be used for investigation and clinical care in the ED and to define the ideal timing and form of the delirium assessment process for older adults.

Evaluation of radiation exposure to pediatric trauma patients.

BACKGROUND: Pediatric trauma patients pose a diagnostic challenge to physicians. Computed tomography (CT) imaging identifies life-threatening injuries quickly and efficiently. CT radiation dose in pediatric trauma patients is a concern. STUDY OBJECTIVES: We evaluated the cumulative effective dose of radiation received by pediatric blunt trauma patients and assessed characteristics of patients and studies received. METHODS: We retrospectively identified pediatric blunt trauma patients at a Level I trauma center between January 1 and December 31, 2006 utilizing the North Carolina Trauma Registry. We searched the patient radiographic history for images in the 7 days after their trauma event. We calculated cumulative effective radiation dose using dose length product and age coefficients. We collected demographic information including age, sex, mechanism of injury, hospital length of stay, and discharge status. RESULTS: Seventy-five pediatric blunt trauma patients with available radiographic records were included. The median age was 11.7 years; males comprised 64% of patients; median Injury Severity Score was 13.8; 64% were transfer patients; median number of CT scans during initial evaluation was 3.4 for directly seen patients and two for transferred patients. Mean effective ionizing radiation dose was 11.4 mSv for CT scans performed in the first 24 h. Sixteen percent of admitted patients had CT scans in the subsequent 6 days, with an average additional CT dose of 4 mSv. Average number of plain radiographs was five. CONCLUSIONS: Pediatric blunt trauma patients receive a major radiation burden in their initial evaluation. Patients who are transferred from an outside facility endure an even higher dose of radiation.

Resilience Building Practices for Women Physicians.

Women now make up more than half of the physician workforce, but they are disproportionately plagued by burnout. Medicine is a fast-paced stressful field, the practice of which is associated with significant chronic stress due to systems issues, crowding, electronic medical records, and patient case mix. Hospitals and health care systems are responsible for mitigating system-based burnout-prone conditions, but often their best efforts fail. Physicians, particularly women, must confront their stressors and the daily burden of significant system strain when this occurs. Those who routinely exceed their cumulative stress threshold may experience burnout, career dissatisfaction, and second victim syndrome and, ultimately, may prematurely leave medicine. These conditions affect women in medicine more often than men and may also produce a higher incidence of health issues, including depression, substance use disorder, and suicide. The individual self-care required to maintain health and raise stress thresholds is not widely ingrained in provider practice patterns or behavior. However, the successful long-term practice of high-stress occupations, such as medicine, requires that physicians, especially women physicians, attend to their wellness. In this article, we address one aspect of health, resilience, and review six practices that can create additional stores of personal resilience when proactively integrated into a daily routine.

Barriers, Challenges, and Solutions: What Can We Learn About Leadership in Academic Medicine From a Qualitative Study of Emergency Medicine Women Chairs?

PURPOSE: Women have made significant gains in leadership across all disciplines in academic medicine but have not yet achieved leadership parity as department chairs. The authors investigated the challenges experienced by one cohort of women department chairs in emergency medicine (EM) and the solutions they proposed to address these challenges. METHOD: The authors conducted a qualitative descriptive study of 19 of 20 possible current and emeritus emergency medicine women department chairs at academic medical centers between April and December 2020. Participant interviews elicited self-reported demographic characteristics and narrative responses to a semistructured interview template that focused on the role of gender in their leadership and career trajectories. Interviews were transcribed, blinded, and iteratively coded and categorized. RESULTS: The analysis demonstrated 4 common challenges and 5 enacted or proposed solutions. The challenges discussed by the participants were: feeling unprepared for the role of department chair, being one of few women in leadership, inheriting unhealthy department cultures, and facing negative faculty reactions. The individual- and institutional-level solutions discussed by the participants were: gaining and maintaining confidence (individual), maintaining accountability and mission alignment (individual), facilitating teamwork (individual), supporting women's leadership (institution), and creating safe leadership cultures (institution). CONCLUSIONS: Women department chairs in EM were successful academic leaders despite confronting several challenges to their leadership. Considering the study findings through the lens of the concept of second-generation gender bias further illuminates the influence of gender on leadership in academic medicine. These findings suggest several possible strategies that can combat gender bias, increase gender parity among academic medicine's leadership, and improve the leadership experience for women leaders.

The pivotal plan: a 3-step approach to decrease staffing costs and improve quality.

This article reviews how the nurse leaders of a 136-bed medical/surgical service developed and implemented a methodical plan to fill RN vacancies, decrease labor costs, and improve quality. This simple, straight-forward approach was designed to rapidly fill core staff positions while minimizing the impact of the vacancies and ultimately eliminate the use of temporary nursing staff. The detailed components of the plan provided a way to assess vacancy data, time temporary replacements, and structure beneficial hospital partnerships, all of which were instrumental in the success of the plan. The plan was implemented throughout the facility because of proven success in the medical/surgical service. The leaders' focus on decreasing labor costs resulted in hiring a stable core staff that was able to attain established quality initiatives. The financial and quality outcomes of the service demonstrate the ability to sustain excellent results over time.

The future of emergency medicine.

BACKGROUND: The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care. SUMMARY: In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to-and will continue to contribute to-a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EM's future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

The future of emergency medicine.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.

Griev_Ing: death notification skills and applications for fourth-year medical students.

BACKGROUND AND PURPOSE: Our study examined whether GRIEV_ING improved death notification skills of medical students, whether pretesting with simulated survivors primed learners and improved results of the intervention, and whether feedback on the simulated encounter improved student performance. METHODS: GRIEV_ING training was given to 138 fourth-year medical students divided into three groups: exposure to simulated survivor (SS) with written feedback, exposure to SS but no feedback, and no exposure to SS before the training. Students were tested on self-confidence before and after the intervention and were rated by SSs on interpersonal communication and death notification skills. ANCOVA was performed, with gender and race covariates. RESULTS: All groups improved on death notification competence and confidence at about the same rate. Competence significantly (p =.037) improved for the feedback group. Interpersonal communication scores declined for all groups. CONCLUSIONS: GRIEV_ING provides an effective model medical educators can use to train medical students to provide competent death notifications. Senior medical students are primed to learn death notification and do not require a preexposure.

Effect of an Educational Intervention on Medical Student Scripting and Patient Satisfaction: A Randomized Trial.

INTRODUCTION: Effective communication between clinicians and patients has been shown to improve patient outcomes, reduce malpractice liability, and is now being tied to reimbursement. Use of a communication strategy known as "scripting" has been suggested to improve patient satisfaction in multiple hospital settings, but the frequency with which medical students use this strategy and whether this affects patient perception of medical student care is unknown. Our objective was to measure the use of targeted communication skills after an educational intervention as well as to further clarify the relationship between communication element usage and patient satisfaction. METHODS: Medical students were block randomized into the control or intervention group. Those in the intervention group received refresher training in scripted communication. Those in the control group received no instruction or other intervention related to communication. Use of six explicit communication behaviors were recorded by trained study observers: 1) acknowledging the patient by name, 2) introducing themselves as medical students, 3) explaining their role in the patient's care, 4) explaining the care plan, 5) providing an estimated duration of time to be spent in the emergency department (ED), and 6) notifying the patient that another provider would also be seeing them. Patients then completed a survey regarding their satisfaction with the medical student encounter. RESULTS: We observed 474 medical student-patient encounters in the ED (231 in the control group and 243 in the intervention group). We were unable to detect a statistically significant difference in communication element use between the intervention and control groups. One of the communication elements, explaining steps in the care plan, was positively associated with patient perception of the medical student's overall communication skills. Otherwise, there was no statistically significant association between element use and patient satisfaction. CONCLUSION: We were unable to demonstrate any improvement in student use of communication elements or in patient satisfaction after refresher training in scripted communication. Furthermore, there was little variation in patient satisfaction based on the use of scripted communication elements. Effective communication with patients in the ED is complicated and requires further investigation on how to provide this skill set.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

OBJECTIVE: We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. METHODS: Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. RESULTS: We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%). CONCLUSION: The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing. PRACTICE IMPLICATIONS: Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

Emergency medical service, nursing, and physician providers' perspectives on delirium identification and management.

Purpose of the study The study objective was to understand providers' perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient's home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients' baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified.

Effect of Socioeconomic Status Bias on Medical Student-Patient Interactions Using an Emergency Medicine Simulation.

OBJECTIVES: Implicit bias in clinical decision making has been shown to contribute to healthcare disparities and results in negative patient outcomes. Our objective was to develop a high-fidelity simulation model for assessing the effect of socioeconomic status (SES) on medical student (MS) patient care. METHODS: Teams of MSs were randomly assigned to participate in a high-fidelity simulation of acute coronary syndrome. Cases were identical with the exception of patient SES, which alternated between a low-SES homeless man and a high-SES executive. Students were blinded to study objectives. Cases were recorded and scored by blinded independent raters using 24 dichotomous items in the following domains: 13 communication, six information gathering, and five clinical care. In addition, quantitative data were obtained on the number of times students performed the following patient actions: acknowledged patient by name, asked about pain, generally conversed, and touching the patient. Fisher's exact test was used to test for differences between dichotomous items. For continuous measures, group differences were tested using a mixed-effects model with a random effect for case to account for multiple observations per case. RESULTS: Fifty-eight teams participated in an equal number of high- and low-SES cases. MSs asked about pain control more often (p = 0.04) in patients of high SES. MSs touched the low-SES patient more frequently (p = 0.01). There were no statistically significant differences in clinical care or information gathering measures. CONCLUSIONS: This study demonstrates more attention to pain control in patients with higher SES as well as a trend toward better communication. Despite the differences in interpersonal behavior, quantifiable differences in clinical care were not seen. These results may be limited by sample size, and larger cohorts will be required to identify the factors that contribute to SES bias.

Emergency physicians and disclosure of medical errors.

Error in medicine is a subject of continuing interest among physicians, patients, policymakers, and the general public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems, patients, physicians, and the law; suggests system changes to address the issue of medical error; offers practical guidelines to promote the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician.

Latent tuberculosis infection among undergraduate medical students in Rio de Janeiro State, Brazil.

SETTING: Five medical schools in three cities with different tuberculosis (TB) incidence rates in Rio de Janeiro State, Brazil. OBJECTIVE: To estimate prevalence of and associated factors for latent tuberculosis infection (LTBI) among medical students. DESIGN: A cross-sectional survey was conducted among undergraduate students in pre-clinical, early and late clinical years from schools in cities with low (28/100,000), intermediate (63/100,000) and high (114/100,000) TB incidence rates. Information on socio-demographic profile, previous BCG vaccination, potential TB exposure, co-morbidity and use of respiratory protective masks was obtained. A tuberculin skin test (TST) was performed using the Mantoux technique by an experienced professional. A positive TST, defined as induration > or = 10 mm, was considered LTBI. RESULTS: LTBI prevalence was 6.9% (95%CI 5.4-8.6). In multivariate analysis, male sex (adjusted odds ratio [aOR] 1.8; 95% CI 1.1-3.0), late clinical years (aOR 1.9; 95% CI 1.01-3.5), intermediate TB incidence (aOR 4.3; 95% CI 1.3-14.6) and high TB incidence in the city of medical school (aOR 5.1; 95% CI 1.6-16.8) were significantly associated with LTBI. CONCLUSIONS: The higher prevalence of LTBI in late clinical years suggests that medical students are at increased risk for nosocomial Mycobacterium tuberculosis infection. The implementation of a TB control program may be necessary in medical schools, particularly in cities with higher TB incidence.

Assessment of communication and interpersonal skills competencies.

Excellent communication and interpersonal (C-IP) skills are a universal requirement for a well-rounded emergency physician. This requirement for C-IP skill excellence is a direct outgrowth of the expectations of our patients and a prerequisite to working in the increasingly complex emergency department environment. Directed education and assessment of C-IP skills are critical components of all emergency medicine (EM) training programs and now are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. In keeping with its mission to improve the quality of EM education and in response to the ACGME Outcome Project, the Council of Emergency Medicine Residency Directors (CORD-EM) hosted a consensus conference focusing on the application of the six core competencies to EM. The objective of this article is to report the results of this consensus conference as it relates to the C-IP competency. There were four primary goals: 1) define the C-IP skills competency for EM, 2) define the assessment methods currently used in other specialties, 3) identify the methods suggested by the ACGME for use in C-IP skills, and 4) analyze the applicability of these assessment techniques to EM. Ten specific communication competencies are defined for EM. Assessment techniques for evaluation of these C-IP competencies and a timeline for implementation are also defined. Standardized patients and direct observation were identified as the criterion standard assessment methods of C-IP skills; however, other methods for assessment are also discussed.

Faculty development: academic opportunities for emergency medicine faculty on education career tracks.

Medical school faculty members who specialize in the scholarship of teaching have unique requirements for academic advancement in universities with clinician-educator series. While excellence in teaching is the cornerstone of achievement, attention to traditional academic pursuits improves the likelihood of a favorable review by the institution's promotion and tenure committee. The teaching portfolio is an effective means to document performance. Ongoing faculty development and sound mentoring relationships facilitate the academic advancement of clinician-educators.

Engaging senior residents as leaders: a novel structure for multiple chief roles.

BACKGROUND: The chief resident's role encompasses administrative, academic, educational, and social responsibilities and is traditionally filled by a small number of residents who are charged with various administrative and educational duties. These duties lay the groundwork that prepares chief residents to assume future leadership positions. INTERVENTION: We propose a new model for multiple chief residents. In this system, there are leadership roles for resident and medical student education, ultrasonography, resident research, and high-fidelity simulation in addition to the traditional administrative roles. This model can be modified to match the needs of a given program and the aptitudes of the senior residents. RESULTS: We describe the successful implementation of this model at our program, which has resulted in a progressive curriculum, increased resident leadership, and program ownership among the residents. CONCLUSIONS: Our intervention offers an alternative model for overcoming some of the limitations of the traditional chief resident model, including some chief residents who become overwhelmed by their duties and are discouraged from pursuing future leadership roles. It also has the potential to offer other senior residents with various skills and leadership abilities the opportunities to contribute to their program.