Euglycemic Diabetic Ketoacidosis Secondary to Dapagliflozin Use: A Case Report.

BACKGROUND: Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a novel class of oral antihyperglycemic agents. They are associated with rare cases of euglycemic diabetic ketoacidosis (DKA), which presents a diagnostic challenge in the emergency department (ED) and potentially severe consequences if missed. CASE REPORT: A 53-year-old man with type 2 diabetes mellitus and a recent Roux-en-Y gastric bypass surgery presented to the ED with nausea, vomiting, and generalized abdominal pain. His medications included dapagliflozin. Work-up revealed anion-gap acidosis, which prompted us to send serum ketone levels despite a blood glucose level of 9.8 mmol/L (162 mg/dL). The patient was ultimately diagnosed with euglycemic DKA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients on SGLT2 inhibitors may present in DKA despite having normal blood glucose levels. It is important for emergency physicians to be aware of this phenomenon in all SGLT2-inhibitor users, as a delay in the diagnosis of DKA can be life threatening.

Development and evaluation of a clinical simulation-based educational innovation on sexual orientation and gender identity in emergency medicine.

INTRODUCTION: Sexual orientation and gender identity (SOGI)-diverse patients are marginalized and poorly cared for in the emergency department, yet well-designed educational interventions to meet this gap are lacking. We developed, implemented, and assessed a novel multi-modal SOGI curriculum on health and cultural humility for emergency medicine physician trainees. METHODS: We conducted a prospective, single-arm evaluation of our educational intervention. A convenience sample of emergency medicine resident physicians (n = 21) participated in the facilitated curriculum including didactic and clinical simulation components. Participants completed a pre- and post-curriculum evaluation that assessed clinical skills, preparedness, attitudinal awareness, and basic knowledge in caring for SOGI-diverse patients. The content of the module was based on a scoping literature review and national needs assessment of Canadian emergency physicians, educators, and trainees along with expert collaborator and input from patient/community partners. The curriculum included a facilitated pre-brief, didactic presentation, clinical simulation modules, and a structured de-brief. Participant clinical skills were evaluated before and after the educational intervention. Our primary outcome was change in clinical preparedness, attitudinal awareness, and basic knowledge in caring for SOGI-diverse patients pre- and post-intervention. RESULTS: Our patient-centered, targeted emergency medicine SOGI health and cultural humility training resulted in a significant improvement in resident self-rated clinical preparedness, attitudes, and knowledge in caring for SOGI-diverse patients. This training was valued by participants. CONCLUSION: We have designed an effective, patient-centered curriculum in health and cultural humility for SOGI-diverse patients in EM. Other programs can consider using this model and developed resources in their jurisdictions to enhance provider capacities to care for this marginalized group.

RéSUMé: INTRODUCTION: L'orientation sexuelle et l'identité de genre (OSIG) - des patients de diverses natures sont marginalisés et mal soignés dans les services d'urgence, mais des interventions éducatives bien conçues pour combler cette lacune font défaut. Nous avons élaboré, mis en œuvre et évalué un nouveau programme multimodal de l'OSIG sur la santé et l'humilité culturelle pour les médecins d'urgence stagiaires. MéTHODES: Nous avons effectué une évaluation prospective de notre intervention éducative à un seul bras. Un échantillon pratique de médecins résidents en médecine d'urgence (n = 21) a participé au programme facilité, y compris les composantes didactiques et de simulation clinique. Les participants ont effectué une évaluation avant et après le programme d'études qui évaluait les compétences cliniques, la préparation, la sensibilisation aux attitudes et les connaissances de base en matière de soins aux patients atteints de diverses OSIG. Le contenu du module était fondé sur une analyse documentaire de portée et une évaluation des besoins nationaux des médecins d'urgence, des éducateurs et des stagiaires canadiens, ainsi que sur un collaborateur expert et les commentaires des patients et des partenaires communautaires. Le programme comprenait un pré-briefing animé, une présentation didactique, des modules de simulation clinique et un débriefing structuré. Les compétences cliniques des participants ont été évaluées avant et après l'intervention éducative. Notre résultat principal était un changement dans la préparation clinique, la sensibilisation aux attitudes et les connaissances de base dans les soins aux patients atteints de diverses OSIG avant et après l'intervention. RéSULTATS: Notre formation sur la santé et l'humilité culturelle axée sur le patient et ciblée en médecine d'urgence SOGI a permis d'améliorer considérablement la préparation clinique, les attitudes et les connaissances auto-évaluées des résidents en matière de soins aux patients SOGI-divers. Cette formation a été appréciée par les participants. CONCLUSIONS: Nous avons conçu un programme efficace et centré sur le patient en matière de santé et d'humilité culturelle pour les patients SOGI-divers en EM. D'autres programmes peuvent envisager d'utiliser ce modèle et d'élaborer des ressources dans leur administration pour améliorer les capacités des fournisseurs de soins à ce groupe marginalisé.

Equity-relevant sociodemographic variable collection in emergency medicine: A systematic review, qualitative evidence synthesis, and recommendations for practice.

OBJECTIVES: The objective was to conduct a systematic review and qualitative evidence synthesis (QES) to identify best practices, benefits, harms, facilitators, and barriers to the routine collection of sociodemographic variables in emergency departments (EDs). METHODS: This work is a systematic review and QES. We conducted a comprehensive search of Medline (Ovid), CINAHL (Ebsco), Cochrane Central (OVID), EMBASE (Ovid), and the multidisciplinary Web of Science Core database using peer-reviewed search strategies, complemented by a gray literature search. We included citations containing perspectives on routine sociodemographic variable collection in EDs and recommendations on definitions or processes of collection or benefits, harms, facilitators, or barriers related to the routine collection of sociodemographic variables in EDs. We conducted this systematic review and QES adhering to the Joanna Briggs Institute guidelines. Two reviewers independently selected included studies and extracted data. We conducted a best-fit framework synthesis and paired inductive thematic analysis of the included studies. We generated recommendations based on the QES. RESULTS: We included 21 unique reports that enrolled 10,454 patients or respondents in our systematic review and QES. Publication dates of included studies ranged from 2011 to 2021. Included citations were published in Australia, Canada, and the United States. We synthesized 11 benefits, 14 potential harms, 15 barriers, and 19 facilitators and identified 14 best practice recommendations from included citations. CONCLUSIONS: Health systems should routinely collect sociodemographic variables in EDs guided by recommendations that minimize harms and maximize benefits and consider relevant barriers and facilitators. Our recommendations can serve as a guide for the equity-focused reformation of emergency medicine health information systems.

Ready for practice? National recommendations for emergency medicine transition to practice curriculum.

BACKGROUND: Transition from residency to unsupervised practice represents a critical stage in learning and professional identity formation, yet there is a paucity of literature to inform residency curricula and emergency department transition programming for new faculty. OBJECTIVE: The objective of this study was to develop consensus-based recommendations to optimize the transition to practice phase of emergency medicine training. METHODS: A literature review and results of a survey of emergency medicine (EM) residency program directors informed focus groups of recent (within 5 years) EM graduates. Focus group transcripts were analyzed following conventional content analysis. Preliminary recommendations, based on identified themes, were drafted and presented at the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. Through a live presentation, symposium attendees representing the Canadian national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback to construct a final set of 14 recommendations, 8 targeted toward residency training programs and 6 specific to department leadership. CONCLUSION: The Canadian EM community used a structured process to develop 14 best practice recommendations to enhance the transition to practice phase of residency training as well as the transition period in the career of junior attending physicians.

ABSTRAIT: ARRIèRE-PLAN: La transition de la résidence à la pratique non supervisée représente une étape cruciale de l'apprentissage et de la formation de l'identité professionnelle, mais il y a peu de documentation pour éclairer les programmes de résidence et les programmes de transition des services d'urgence pour les nouveaux professeurs. OBJECTIF: L'objectif de cette étude était d'élaborer des recommandations consensuelles pour optimiser la transition vers la pratique de la formation en médecine d'urgence. MéTHODES: Une recension des écrits et les résultats d'un sondage auprès des directeurs des programmes de résidence en médecine d'urgence (GU) ont informé les groupes de discussion des diplômés récents (moins de cinq ans) en GU. Les transcriptions des groupes de discussion ont été analysées à la suite d'une analyse du contenu classique. Des recommandations préliminaires, fondées sur des thèmes déterminés, ont été rédigées et présentées au Symposium universitaire sur l'éducation de 2022 de l'Association canadienne des médecins d'urgence (ACMU). Au moyen d'une présentation en direct, les participants au symposium représentant la communauté nationale canadienne de la GU ont participé à une discussion dirigée sur les recommandations. Les auteurs ont intégré ces commentaires pour élaborer un ensemble final de 14 recommandations, 8 ciblant les programmes de formation en résidence et 6 ciblant le leadership ministériel. CONCLUSIONS: La communauté canadienne de la GU a utilisé un processus structuré pour élaborer 14 recommandations de pratiques exemplaires afin d'améliorer la transition à la phase de pratique de la formation en résidence ainsi que la période de transition dans la carrière des médecins traitants débutants.

Navigating gaps in practice: consensus recommendations for educational and support structures for emergency physicians returning from gaps in practice.

OBJECTIVE: The purpose of this study was to identify the learning needs of emergency physicians returning to Emergency Medicine (EM) practice after clinical leaves of less than 2 years, summarize existing return to practice programs, and propose recommendations regarding ideal educational and support structures for these physicians both during their practice gaps and upon return to EM. METHODS: A multiple-phased study was conducted to establish recommendations regarding ideal educational and support structures for emergency physicians returning from practice gaps of less than 2 years. The overall design involved an initial environmental scan of existing and exemplar programs and regulatory body positions, followed by interviews with EM Department Heads from across Canada, and then subsequent content analysis and recommendation derivation by EM medical education expert group consensus. These summary recommendations were further revised by consensus at the 2022 CAEP conference academic symposium to derive a final set of consensus recommendations. CONCLUSIONS: We have developed a set of recommendations regarding ideal educational and support structures for physicians experiencing gaps in practice of less than 2 years. This set of recommendations was informed by review of existing and exemplar programs, policies and experience of regulatory bodies, interviews with EM Department Heads across Canada, and a subsequent process of consensus at the 2022 CAEP conference academic symposium. It is hoped that this set of recommendations will inform discussions and potential strategies employed by departments to facilitate the smooth and effective return to EM practice for individuals experiencing gaps.

ABSTRAIT: OBJECTIFS: Le but de cette étude était de déterminer les besoins d'apprentissage des médecins d'urgence qui retournent à la pratique de la médecine d'urgence (ME) après des congés cliniques de moins de deux ans, de résumer les programmes de retour à la pratique existants. et de proposer des recommandations concernant les structures de formation et de soutien idéales pour ces médecins, à la fois pendant leurs lacunes dans la pratique et à leur retour à la GU. MéTHODES: Une étude en plusieurs phases a été menée afin d'établir des recommandations concernant les structures de formation et de soutien idéales pour les médecins d'urgence qui reviennent de lacunes de moins de deux ans. La conception globale comprenait une première analyse de l'environnement des programmes existants et exemplaires et des postes d'organismes de réglementation, suivie d'entrevues avec les chefs des services de GU de partout au Canada. et ensuite l'analyse du contenu et la formulation de recommandations par consensus du groupe d'experts en éducation médicale de la SE. Ces recommandations résumées ont été révisées par consensus lors du symposium universitaire de la conférence 2022 de l'ACMU afin d'en arriver à une série finale de recommandations consensuelles. CONCLUSION: Nous avons élaboré une série de recommandations concernant les structures de formation et de soutien idéales pour les médecins qui connaissent des lacunes dans la pratique depuis moins de deux ans. Cette série de recommandations a été éclairée par l'examen des programmes, des politiques et de l'expérience des organismes de réglementation existants et exemplaires, des entrevues avec les chefs des services de GU partout au Canada et un processus subséquent de consensus au symposium universitaire de la conférence 2022 de la CAEP. On espère que cette série de recommandations éclairera les discussions et les stratégies potentielles employées par les ministères pour faciliter le retour en douceur et efficace à la pratique de GU pour les personnes qui connaissent des lacunes.

Call to action: equity, diversity, and inclusion in emergency medicine resident physician selection.

OBJECTIVES: This call to action seeks to improve emergency care in Canada for equity-deserving communities, enabled by equitable representation among emergency physicians nationally. Specifically, this work describes current resident selection processes and makes recommendations to enhance the equity, diversity, and inclusion (EDI) of resident physician selection in Canadian emergency medicine (EM) residency programs. METHODS: A diverse panel of EM residency program directors, attending and resident physicians, medical students, and community representatives met monthly from September 2021 to May 2022 via videoconference to coordinate a scoping literature review, two surveys, and structured interviews. This work informed the development of recommendations for incorporating EDI into Canadian EM resident physician selection. At the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, these recommendations were presented to symposium attendees composed of national EM community leaders, members, and learners. Attendees were divided into small working groups to discuss the recommendations and address three conversation-facilitating questions. RESULTS: Symposium feedback informed a final set of eight recommendations to promote EDI practices during the resident selection process that address recruitment, retention, mitigating inequities and biases, and education. Each recommendation is accompanied by specific, actionable sub-items to guide programs toward a more equitable selection process. The small working groups also described perceived barriers to the implementation of these recommendations and outlined strategies for success that are incorporated into the recommendations. CONCLUSION: We call on Canadian EM training programs to implement these eight recommendations to strengthen EDI practices in EM resident physician selection and, in doing so, help to improve the care that patients from equity-deserving groups receive in Canada's emergency departments (EDs).

ABSTRAIT: OBJECTIFS: Cet appel à l'action vise à améliorer les soins d'urgence au Canada pour les collectivités méritant l'équité, grâce à une représentation équitable parmi les médecins d'urgence à l'échelle nationale. Plus précisément, ce travail décrit les processus actuels de sélection des médecins résidents et formule des recommandations pour améliorer l'équité, la diversité et l'inclusion (EDI) de la sélection des médecins résidents dans les programmes de résidence en médecine d'urgence (SE) du Canada. MéTHODES: Un groupe diversifié de directeurs du programme de résidence en GU, de médecins résidents, d'étudiants en médecine et de représentants communautaires se sont réunis mensuellement de septembre 2021 à mai 2022 par vidéoconférence pour coordonner une analyse documentaire, deux sondages et des entrevues structurées. Ces travaux ont orienté l'élaboration de recommandations pour l'intégration de l'IDE dans la sélection des médecins résidents en SE au Canada. À l'occasion du Symposium universitaire 2022 de l'Association canadienne des médecins d'urgence (ACMU), ces recommandations ont été présentées aux participants au symposium composé de dirigeants, de membres et d'apprenants de la communauté nationale de la GU. Les participants ont été divisés en petits groupes de travail pour discuter des recommandations et aborder trois questions facilitant la conversation. RéSULTATS: Les commentaires recueillis lors du symposium ont servi à formuler une dernière série de huit recommandations visant à promouvoir les pratiques de l'IDE au cours du processus de sélection des résidents qui traitent du recrutement, du maintien en poste, de l'atténuation des inégalités et des préjugés, et de l'éducation. Chaque recommandation est accompagnée de sous-éléments précis et réalisables pour orienter les programmes vers un processus de sélection plus équitable. Les petits groupes de travail ont également décrit les obstacles perçus à la mise en œuvre de ces recommandations et décrit les stratégies de réussite qui sont intégrées aux recommandations. CONCLUSION: Nous demandons aux programmes canadiens de formation en GU de mettre en œuvre ces huit recommandations afin de renforcer les pratiques d'IDE dans la sélection des médecins résidents en GU et, ce faisant, d'aider à améliorer les soins que les patients des groupes méritant l'équité reçoivent dans les services d'urgence du Canada.

Simulation in the Continuing Professional Development of Academic Emergency Physicians: A Canadian National Survey.

INTRODUCTION: Simulation is becoming a popular educational modality for physician continuing professional development (CPD). This study sought to characterize how simulation-based CPD (SBCPD) is being used in Canada and what academic emergency physicians (AEPs) desire in an SBCPD program. METHODS: Two national surveys were conducted from March to June 2018. First, the SBCPD Needs Assessment Survey was administered online to all full-time AEPs across 9 Canadian academic emergency medicine (EM) sites. Second, the SBCPD Status Survey was administered by telephone to the department representatives (DRs)-simulation directors or equivalent-at 20 Canadian academic EM sites. RESULTS: Response rates for the SBCPD Needs Assessment and the SBCPD Status Survey were 40% (252/635) and 100% (20/20) respectively. Sixty percent of Canadian academic EM sites reported using SBCPD, although only 30% reported dedicated funding support. Academic emergency physician responses demonstrated a median annual SBCPD of 3 hours. Reported incentivization for SBCPD participation varied with AEPs reporting less incentivization than DRs. Academic emergency physicians identified time commitments outside of shift, lack of opportunities, and lack of departmental funding as their top barriers to participation, whereas DRs thought AEPs fear of peer judgment and inexperience with simulation were substantial barriers. Content areas of interest for SBCPD were as follows: rare procedures, pediatric resuscitation, and neonatal resuscitation. Lastly, interprofessional involvement in SBCPD was valued by both DRs and AEPs. CONCLUSIONS: Simulation-based CPD programs are becoming common in Canadian academic EM sites. Our findings will guide program coordinators in addressing barriers to participation, selecting content, and determining the frequency of SBCPD events.

Just the Facts: Protecting frontline clinicians during the COVID-19 pandemic.

There is no patient emergency more important than protecting health care workers during a pandemic.

Emergency Medicine Oral Case Presentations: Evaluation of a Novel Curriculum.

OBJECTIVES: Oral case presentation (OCP) is recognized as a central educational and patient care activity, yet has not been well studied in the emergency medicine (EM) setting. The purpose of this study was to evaluate the effect of a novel curriculum on medical students' EM-OCP skills. METHODS: An EM-OCP assessment tool and novel blended curriculum were developed based on results from a Canadian survey of emergency physicians and focus groups with key stakeholders. We conducted a randomized controlled trial of 96 clerkship students between 2017 and 2018. Students were randomly assigned into an intervention group where they completed a novel EM-OCP curriculum or a control group without the curriculum. A pretest baseline assessment of students' OCP skills was performed using a standardized patient case at the beginning of their EM rotation. Similarly, all students completed a posttest assessment with a different standardized patient case at the end of their 6-week EM rotation. Audio recordings of pre- and posttests were assessed using the EM-OCP assessment tool by two blinded assessors. RESULTS: Using the Kruskal-Wallis test, all students demonstrated improvement in EM-OCP skills between their pretest and posttest; however, those who received the curriculum (intervention group) showed significantly greater improvement in "synthesis of information," "management," and "overall entrustment decision" scores. CONCLUSIONS: Implementation of a novel EM-OCP curriculum resulted in improved clinical reasoning and higher entrustment scores. This curriculum could improve OCP performance not only in EM settings but also across specialties where medical students and residents manage critically ill patients.

Harnessing the power of simulation for assessment: Consensus recommendations for the use of simulation-based assessment in emergency medicine.

OBJECTIVES: To address the increasing demand for the use of simulation for assessment, our objective was to review the literature pertaining to simulation-based assessment and develop a set of consensus-based expert-informed recommendations on the use of simulation-based assessment as presented at the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. METHODS: A panel of Emergency Medicine (EM) physicians from across Canada, with leadership roles in simulation and/or assessment, was formed to develop the recommendations. An initial scoping literature review was conducted to extract principles of simulation-based assessment. These principles were refined via thematic analysis, and then used to derive a set of recommendations for the use of simulation-based assessment, organized by the Consensus Framework for Good Assessment. This was reviewed and revised via a national stakeholder survey, and then the recommendations were presented and revised at the consensus conference to generate a final set of recommendations on the use of simulation-based assessment in EM. CONCLUSION: We developed a set of recommendations for simulation-based assessment, using consensus-based expert-informed methods, across the domains of validity, reproducibility, feasibility, educational and catalytic effects, acceptability, and programmatic assessment. While the precise role of simulation-based assessment will be a subject of continued debate, we propose that these recommendations be used to assist educators and program leaders as they incorporate simulation-based assessment into their programs of assessment.

A case for feedback and monitoring assessment in competency-based medical education.

PURPOSE: Within competency-based medical education, self-regulated learning (SRL) requires residents to leverage self-assessment and faculty feedback. We sought to investigate the potential for competency-based assessments to foster SRL by quantifying the relationship between faculty feedback and entrustment ratings as well as the congruence between faculty assessment and resident self-assessment. MATERIALS AND METHODS: We collected comments in (a) an emergency medicine objective structured clinical examination group (objective structured clinical examinations [OSCE] and emergency medicine OSCE group [EMOG]) and (b) a first-year resident multidisciplinary resuscitation "Nightmares" course assessment group (NCAG) and OSCE group (NOG). We assessed comments across five domains including Initial Assessment (IA), Diagnostic Action (DA), Therapeutic Action (TA), Communication (COM), and entrustment. Analyses included structured qualitative coding and (non)parametric and descriptive analyses. RESULTS: In the EMOG, faculty's positive comments in the entrustment domain corresponded to lower entrustment score Mean Ranks (MRs) for IA (<11.1), DA (<11.2), and entrustment (<11.6). In NOG, faculty's negative comments resulted in lower entrustment score MRs for TA (<11.8 and <10) and DA (<12.4), and positive comments resulted in higher entrustment score MRs for IA (>15.4) and COM (>17.6). In the NCAG, faculty's positive IA comments were negatively correlated with entrustment scores (ρ = -.27, P = .04). Across programs, faculty and residents made similar domain-specific comments 13% of the time. CONCLUSIONS: Minimal and inconsistent associations were found between narrative and numerical feedback. Performance monitoring accuracy and feedback should be included in assessment validation.

CAEP 2019 Academic Symposium: Got competence? Best practices in trainee progress decisions.

BACKGROUND: Competence committees play a key role in a competency-based system of assessment. These committees are tasked with reviewing and synthesizing clinical performance data to make judgments regarding residents' competence. Canadian emergency medicine (EM) postgraduate training programs recently implemented competence committees; however, a paucity of literature guides their work. OBJECTIVE: The objective of this study was to develop consensus-based recommendations to optimize the function and decisions of competence committees in Canadian EM training programs. METHODS: Semi-structured interviews of EM competence committee chairs were conducted and analyzed. The interview guide was informed by a literature review of competence committee structure, processes, and best practices. Inductive thematic analysis of interview transcripts was conducted to identify emerging themes. Preliminary recommendations, based on themes, were drafted and presented at the 2019 CAEP Academic Symposium on Education. Through a live presentation and survey poll, symposium attendees representing the national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback and identified consensus among symposium attendees on a final set of nine high-yield recommendations. CONCLUSION: The Canadian EM community used a structured process to develop nine best practice recommendations for competence committees addressing: committee membership, meeting processes, decision outcomes, use of high-quality performance data, and ongoing quality improvement. These recommendations can inform the structure and processes of competence committees in Canadian EM training programs.

Simulation-based research in emergency medicine in Canada: Priorities and perspectives.

OBJECTIVE: Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM). METHODS: Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators. RESULTS: Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. CONCLUSION: This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

The Implementation of a Multi-institutional Multidisciplinary Simulation-based Resuscitation Skills Training Curriculum.

Competency-based curricula require the development of novel simulation-based programs focused on the assessment of entrustable professional activities. The design and delivery of simulation-based programs are labor-intensive and expensive. Furthermore, they are often developed by individual programs and are rarely shared between institutions, resulting in duplicate efforts and the inefficient use of resources. The purpose of this study is to demonstrate the feasibility of implementing a previously developed simulation-based curriculum at a second institution. We sought to demonstrate comparable program-level outcomes between our two study sites. A multi-disciplinary, simulation-based, resuscitation skills training curriculum developed at Queen's University was implemented at the University of Saskatchewan. Standardized simulation cases, assessment tools, and program evaluation instruments were used at both institutions. Across both sites, 87 first-year postgraduate medical trainees from 14 different residency programs participated in the course and the related research. A total of 226 simulated cases were completed in over 80 sessions. Program evaluation data demonstrated that the instructor experience and learner experience were consistent between sites. The average confidence score (on a 5-point scale) across sites for resuscitating acutely ill patients was 3.14 before the course and 4.23 (p < 0.001) after the course. We have described the successful implementation of a previously developed simulation-based resuscitation curriculum at a second institution. With the growing need for competency-based instructional methods and assessment tools, we believe that programs will benefit from standardizing and sharing simulation resources rather than developing curricula de novo.

Implementation of an Emergency Department Sepsis Bundle and System Redesign: A Process Improvement Initiative.

BACKGROUND: In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. METHODS: This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. RESULTS: We included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.