Weapons Retrieved After the Implementation of Emergency Department Metal Detection.

BACKGROUND: Several high-profile violent incidents have occurred within emergency departments (EDs). There are no recent studies reporting the effectiveness of ED metal detection. OBJECTIVE: Our aim was to assess the effect of metal detection on ED weapons retrieval. METHODS: In September 2011, a metal detector was installed at the entrance of an urban, high-volume teaching hospital ED. The security company recorded retrieved firearms, knives, chemical sprays, and other weapons. We performed qualitative analysis of weapons retrieval data for a 26-month period. RESULTS: A total of 5877 weapons were retrieved, an average of 218 per month: 268 firearms, 4842 knives, 512 chemical sprays, and 275 other weapons, such as brass knuckles, stun guns, and box cutters. The number of retrieved guns decreased from 2012 to 2013 (from 182 to 47), despite an increase in metal detection hours from 8 h per day to 16 h per day. The number of retrieved knives, chemical sprays, and other weapons increased. Recovered knives increased from 2062 in 2012 to 2222 in 2013, chemical sprays increased from 170 to 305, and other weapons increased from 51 to 201. CONCLUSIONS: A large number of weapons were retrieved after the initiation of metal detection in the ED entrance. Increasing hours of metal detection increased the number of retrieved knives, chemical sprays, and other weapons. Retrieved firearms decreased after increasing metal detection hours. Metal detection in the ED entrance is effective in reducing entrance of weapons into the ED. Metal detectors may offer additional benefit in reducing attempts to enter with firearms.

A task analysis of emergency physician activities in academic and community settings.

STUDY OBJECTIVE: We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error. METHODS: This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions. RESULTS: There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients). CONCLUSION: Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality.

STUDY OBJECTIVE: The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record. METHODS: This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records. RESULTS: The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time. CONCLUSION: Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.

Physician Time Management.

Introduction: Time management is an essential skill set for physicians. The importance of time management is not routinely emphasized in undergraduate or graduate medical education curricula, often resulting in the development of poor time-management practices early in training. Improving time-management practices may lead to decreased stress, increased productivity, and improved well-being for physicians. Methods: This interactive workshop targeted trainees and junior faculty. It aimed to highlight common physician knowledge gaps with respect to cognitive limitations and to teach effective time-management strategies. It also aimed to educate learners about how time management may increase physician career satisfaction. The workshop included a detailed presentation with structured resources to reinforce skill development. Results: This workshop was given four times to 54 residents in two different training paradigms. Evaluations were based on a 4-point Likert scale (1 = Strongly Disagree, 4 = Strongly Agree). Overall, participants indicated that the workshop addressed an educational need (M = 3.72) and would recommend this workshop to a colleague (M = 3.83). Follow-up survey results at 4 months indicated that most workshop participants had noticed some degree of improved productivity and well-being, that only a small minority had not incorporated new elements of time management into routine practices. Discussion: This workshop offers an effective way to teach time-management strategies to physicians. Our results imply that this workshop meets an early career physician need by addressing a necessary skill set. Effective time-management skills may promote physician career sustainability.

Conflict of interest in the physician interface with the biomedical industry.

The physician interface with the pharmaceutical industry stands at the forefront of a debate about the effect this relationship has on the behavior of both researchers and clinicians. The authors explore the basis for this conflict of interest and show how it affects physician judgment and behavior. These effects lead to negative consequences for patients and threaten the professional status that society accords physicians. In view of the potential for ethical compromise, physicians should refrain from contact with pharmaceutical marketing representatives.

A case study in medical error: the use of the portfolio entry.

The Accreditation Council for Graduate Medical Education (ACGME) Practice-Based Learning and Improvement competency incorporates lifelong learning techniques and self-reflection. Resident portfolios have received attention as a useful method for addressing this competency. A recent patient encounter provided an experienced clinical educator with the opportunity to develop a portfolio entry that was distributed to all of the residents and faculty in an emergency medicine residency. This report may assist educators in explaining how one could approach the development of the portfolio as a tool for self-assessment. A candid discussion by a senior faculty member about issues that contributed to medical error has been underreported in the medical literature.

Quality and education.

Juxtaposing quality with education in emergency medicine (EM) generates two distinct issues: 1) the quality of education in EM, and 2) educating about quality in EM. There is considerable overlap between the two, and neither should be considered without the other. This paper focuses on education about quality in EM, with some discussion of the quality of EM education. Despite its apparent importance, there is a relative paucity of research on this topic.

An evaluation of emergency medicine resident interaction time with faculty in different teaching venues.

OBJECTIVES: To measure actual emergency medicine (EM) resident interaction time with faculty and to investigate the potential to use direct observation as an assessment tool for the core competencies. By 2006 all EM residencies must implement resident assessment techniques of the six Accreditation Council for Graduate Medical Education core competencies. Emergency medicine educators recommend direct observation as the optimal evaluation tool for patient care, systems-based practice, interpersonal and communication skills, and professionalism. Continuous faculty presence in the emergency department (ED) is widely believed to facilitate direct observation as an assessment technique. METHODS: Observational study of EM resident-faculty interaction time during two-hour periods. Study venues included two EDs, two trauma services, inpatient medicine, adult and pediatric intensive care units (ICUs), and a pediatric outpatient clinic. Using a priori definitions, the authors categorized faculty-EM resident interaction time as direct observation of patient care, indirect patient care, or non-patient care activities, and calculated total faculty interaction time. Subjects were blinded to the nature of the study, and data gathering was encrypted. RESULTS: Two hundred seventy observation periods of two hours each were conducted, sampling 32 EMR1, 33 EMR2-3, 41 EM, and 38 non-EM faculty. The mean total faculty interaction time ranged from a high of 30% (95% CI = 20% to 41%) in the pediatric ICU to a low of 10% (95% CI = 3% to 16%) on internal medicine wards. Overall, EM faculty interaction time was 20% (95% CI = 18% to 22%). Direct observation by faculty ranged from a high of 6% for EMR2-3s in the critical care areas of the ED (95% CI = 3% to 9%) to a low of 1% (95% CI = 0% to 2%) on internal medicine wards. Overall ED direct observation time was 3.6% (95% CI = 2.6% to 4.7%). Emergency department direct observation did not vary within EM resident training level or by ED site. Direct observation varied by treatment area within the EDs, with the critical care areas being substantially higher (6%) than the noncritical care areas (1%). CONCLUSIONS: Faculty direct observation time of EM residents was low in all training venues studied. Direct observation was the highest in ED critical care areas and lowest on medicine ward rotations. Emergency medicine faculty involved simultaneously in routine ED teaching, supervision, and patient care rarely performed direct observation, despite their continuous physical presence. This finding suggests that alternative strategies may be required to assess core competencies through direct observation in the ED.

Droperidol vs prochlorperazine for the treatment of acute headache.

To determine if droperidol i.v. is as effective as prochlorperazine i.v. in the emergency department (ED) treatment of uncomplicated headache, a randomized, controlled, blinded study was conducted in the Emergency Departments of two urban teaching hospitals. Patients >or= 18 years old with crescendo-onset headache were eligible for inclusion. Ninety-six patients (48 in each group) were randomized to receive droperidol 2.5 mg i.v. or prochlorperazine 10 mg i.v. Baseline characteristics were similar between the two study groups. For the main study outcome, 83.3% in the droperidol group and 72.3% in the prochlorperazine group reported 50% pain reduction at 30 min (p <.01; one-sided test of equivalence). The mean decrease in headache intensity was 79.1% (SD 28.5%) in the droperidol group and 72.1% (SD 28.0%) in the prochlorperazine group (p =.23). It is concluded that droperidol i.v. provided a similar reduction of headache as achieved with prochlorperazine i.v. with a similar incidence of akathisia.

The 2013 Model of the Clinical Practice of Emergency Medicine.

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

Reporting for duty during mass casualty events: a survey of factors influencing emergency medicine physicians.

BACKGROUND: Academic medical centers play a major role in disaster response, and residents frequently serve as key resources in these situations. Studies examining health care professionals' willingness to report for duty in mass casualty situations have varying response rates, and studies of emergency medicine (EM) residents' willingness to report for duty in disaster events and factors that affect these responses are lacking. OBJECTIVE: We sought to determine EM resident and faculty willingness to report for duty during 4 disaster scenarios (natural, explosive, nuclear, and communicable), to identify factors that affect willingness to work, and to assess opinions regarding disciplinary action for physicians unwilling to work in a disaster situation. METHODS: We surveyed residents and faculty at 7 US teaching institutions with accredited EM residency programs between April and November 2010. RESULTS: A total of 229 faculty and 259 residents responded (overall response rate, 75.4%). Willingness to report for duty ranged from 54.1% for faculty in a natural disaster to 94.2% for residents in a nonnuclear explosive disaster. The 3 most important factors influencing disaster response were concern for the safety of the family, belief in the physician's duty to provide care, and availability of protective equipment. Faculty and residents recommended minimal or no disciplinary action for individuals unwilling to work, except in the infectious disease scenario. CONCLUSIONS: Most EM residents and faculty indicated they would report for duty. Residents and faculty responses were similar in all but 1 scenario. Disciplinary action for individuals unwilling to work generally was not recommended.

The 2011 model of the clinical practice of emergency medicine.

The 2011 Model of the Clinical Practice of Emergency Medicine.

ACGME outcome project: phase 3 in emergency medicine education.

In this article we present a summary of two interactive panel discussions held at the 2008 Council of Emergency Medicine Residency Directors (CORD) annual meeting. Attendees attempted to identify measurable outcomes for resident performance that could be used to evaluate program effectiveness.