Just the Facts: Hypertension in the emergency department.

A 65-year-old female smoker complains of dizziness and mild headache. While at the local pharmacy buying acetaminophen, she decides to check her blood pressure to see if it could be "causing her symptoms." Her initial measurement is 220/96 mm Hg. In consultation with the on-duty pharmacist she is instructed to immediately attend the emergency department (ED) for management of her hypertension.

A Model Partnership: Mentoring Underrepresented Students in Medicine (URiM) in Emergency Medicine.

INTRODUCTION: Creating a racially and ethnically diverse workforce remains a challenge for medical specialties, including emergency medicine (EM). One area to examine is a partnership between a predominantly white institution (PWI) with a historically black college and university (HBCU) to determine whether this partnership would increase the number of underrepresented in medicine (URiM) in EM who are from a HBCU. METHODS: Twenty years ago Emory Department of Emergency Medicine began its collaboration with Morehouse School of Medicine (MSM) to provide guidance to MSM students who were interested in EM. Since its inception, our engagement and intervention has evolved over time to include mentorship and guidance from the EM clerkship director, program director, and key faculty. RESULTS: Since the beginning of the MSM-Emory EM partnership, 115 MSM students have completed an EM clerkship at Emory. Seventy-two of those students (62.6%) have successfully matched into an EM residency program. Of those who matched into EM, 22 (32%) have joined the Emory EM residency program with the remaining 50 students matching at 40 other EM programs across the nation. CONCLUSION: Based on our experience and outcomes with the Emory-MSM partnership, we are confident that a partnership with an HBCU school without an EM residency should be considered by residency programs to increase the number of URiM students in EM, which could perhaps translate to other specialties.

Predictors of an Initial Academic Position in Emergency Medicine.

INTRODUCTION: Each year, emergency medicine (EM) residency graduates enter a variety of community and academic positions. For some training programs, the potential for an academic career is a consideration during the interview process; however, no studies have looked at factors that might predict an academic career. Our goal was to identify variables present during the EM application cycle that predict an initial academic position. METHODS: We retrospectively reviewed application materials from 211 EM graduates at Emory University from 2003-2013. We analyzed biographical variables, board scores, personal statements, and both undergraduate and medical school research experience and publications. An academic position was defined as working at a site with residents rotating in the emergency department, full or part-time appointment at a medical school, or a position with research required for promotion. We used a logistic regression model to determine the impact of these predictors on obtaining an initial academic position. RESULTS: A total of 79 (37%) graduates initially chose an academic job, and 132 (63%) took a community position. We identified the following statistically significant variables: younger age (odds ratio [OR] [0.79], 95% confidence interval [CI] [0.67-0.93], p=0.01); undergraduate publications (OR [1.41], 95% CI [1.08-1.83], p=0.01); and medical school publications (OR [3.39], 95% CI [1.66-6.94], p<0.001). Of note, mention of an academic career in the personal statement showed no statistical correlation (p = 0.41). CONCLUSION: Younger age, and undergraduate and medical school publications were the variables most associated with an initial academic position. As this is a single-institution study, more studies are needed to validate these findings.

Using the CLER Pathways to Excellence to Evaluate the Learning Environments at a Multi-Site Institution.

BACKGROUND: The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review (CLER) program visits 1 participating site per sponsoring institution. While valuable, feedback on that site does not necessarily generalize to all learning environments where trainees and faculty provide clinical care, and institutions may be missing significant insight and feedback on other clinical learning sites. OBJECTIVE: We explored how the Emory Learning Environment Evaluation process-modeled after CLER-could be used to improve the learning environments at 5 major clinical training sites. METHODS: Participants were recruited via e-mail. Sites hosted separate 60-minute sessions for medical students, residents and fellows, and faculty. We used the CLER Pathways to Excellence to develop a combination of fixed choice and opened-ended questions deployed via an audience response system and verbal queries. Data were analyzed primarily through descriptive statistics and graphs. RESULTS: Across sites, per session, medical student participants ranged from 9-16, residents and fellows ranged 21-30, and faculty ranged 15-29. Learners agreed that sites: (1) provided a supportive culture for requesting supervision (students 100%; residents and fellows 70%-100%), and (2) provided a supportive culture for reporting patient safety events (students 94%-100%; residents and fellows 91%-95%). Only a minority of residents and fellows and faculty agreed that they were educated on how to provide effective supervision (residents and fellows 21%-52%; faculty 45%-64%). CONCLUSIONS: Data from this process have helped standardize improvement efforts across multiple clinical learning environments within our sponsoring institution.

Straight Line Scoring by Clinical Competency Committees Using Emergency Medicine Milestones.

BACKGROUND: In 2013, milestone ratings became a reporting requirement for emergency medicine (EM) residency programs. Programs rate each resident in the fall and spring on 23 milestone subcompetencies. OBJECTIVE: This study examined the incidence of straight line scoring (SLS) for EM Milestone ratings, defined as a resident being assessed the same score across the milestone subcompetencies. METHODS: This descriptive analysis measured the frequencies of SLS for all Accreditation Council for Graduate Medical Education (ACGME)-accredited EM programs during the 2015-2016 academic year. Outcomes were the frequency of SLS in the fall and spring milestone assessments, changes in the number of SLS reports, and reporting trends. Chi-square analysis compared nominal variables. RESULTS: There were 6257 residents in the fall and 6588 in the spring. Milestone scores were reported for 6173 EM residents in the fall (99% of 6257) and spring (94% of 6588). In the fall, 93% (5753 residents) did not receive SLS ratings and 420 (7%) did, with no significant difference compared with the spring (5776 [94%] versus 397 [6%]). Subgroup analysis showed higher SLS results for residents' first ratings (183 of 2136 versus 237 of 4220, P < .0001) and for their final ratings (200 of 2019 versus 197 of 4354, P < .0001). Twenty percent of programs submitted 10% or more SLS ratings, and a small percentage submitted more than 50% of ratings as SLS. CONCLUSIONS: Most programs did not submit SLS ratings. Because of the statistical improbability of SLS, any SLS ratings reduce the validity assertions of the milestone assessments.

Assessing the Influence of a Fitbit Physical Activity Monitor on the Exercise Practices of Emergency Medicine Residents: A Pilot Study.

BACKGROUND: Targeted interventions have improved physical activity and wellness of medical residents. However, no exercise interventions have focused on emergency medicine residents. OBJECTIVE: This study aimed to measure the effectiveness of a wearable device for tracking physical activity on the exercise habits and wellness of this population, while also measuring barriers to adoption and continued use. METHODS: This pre-post cohort study enrolled 30 emergency medicine residents. Study duration was 6 months. Statistical comparisons were conducted for the primary end point and secondary exercise end points with nonparametric tests. Descriptive statistics were provided for subjective responses. RESULTS: The physical activity tracker did not increase the overall self-reported median number of days of physical activity per week within this population: baseline 2.5 days (interquartile range, IQR, 1.9) versus 2.8 days (IQR 1.5) at 1 month (P=.36). There was a significant increase in physical activity from baseline to 1 month among residents with median weekly physical activity level below that recommended by the Centers for Disease Control and Prevention at study start, that is, 1.5 days (IQR 0.9) versus 2.4 days (IQR 1.2; P=.04), to 2.0 days (IQR 2.0; P=.04) at 6 months. More than half (60%, 18/30) of participants reported a benefit to their overall wellness, and 53% (16/30) reported a benefit to their physical activity. Overall continued use of the device was 67% (20/30) at 1 month and 33% (10/30) at 6 months. CONCLUSIONS: The wearable physical activity tracker did not change the overall physical activity levels among this population of emergency medicine residents. However, there was an improvement in physical activity among the residents with the lowest preintervention physical activity. Subjective improvements in overall wellness and physical activity were noted among the entire study population.

A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency.

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.

Critical Appraisal of Emergency Medicine Education Research: The Best Publications of 2014.

OBJECTIVES: The objective was to critically appraise and highlight rigorous education research study articles published in 2014 whose outcomes advance the science of emergency medicine (EM) education. METHODS: A search of the English language literature in 2014 querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 243 EM-related articles using either quantitative (hypothesis-testing or observational investigations of educational interventions) or qualitative (exploring important phenomena in EM education) methods. Two reviewers independently screened all of the publications using previously established exclusion criteria. Six reviewers then independently scored the 25 selected publications using either a qualitative or a quantitative scoring system. Each scoring system consisted of nine criteria. Selected criteria were based on accepted educational review literature and chosen a priori. Both scoring systems use parallel scoring metrics and have been used previously within this annual review. RESULTS: Twenty-five medical education research papers (22 quantitative, three qualitative) met the criteria for inclusion and were reviewed. Five quantitative and two qualitative studies were ranked most highly by the reviewers as exemplary and are summarized in this article. CONCLUSIONS: This annual critical appraisal series highlights seven excellent EM education research studies, meeting a priori criteria and published in 2014. Methodologic strengths in the 2014 papers are noted, and current trends in medical education research in EM are discussed.

The American Board of Emergency Medicine Maintenance of Certification Summit.

BACKGROUND: The American Board of Emergency Medicine (ABEM) convened a summit of stakeholders in Emergency Medicine (EM) to critically review the ABEM Maintenance of Certification (MOC) Program. OBJECTIVE: The newly introduced American Board of Medical Specialties (ABMS) 2015 MOC Standards require that the ABMS Member Boards, including ABEM, "engage in continual quality monitoring and improvement of its Program for MOC …" ABEM sought to have the EM community participate in the quality improvement process. DISCUSSION: A review of the ABMS philosophy of MOC and requirements for MOC were presented, followed by an exposition of the ABEM MOC Program. Roundtable discussions included strengths of the program and opportunities for improvement; defining, teaching, and assessing professionalism; identifying and filling competency gaps; and enhancing relevancy and adding value to the ABEM MOC Program. CONCLUSIONS: Several suggestions to improve the ABEM MOC Program were discussed. ABEM will consider these recommendations when developing its next revision of the ABEM MOC Program.

An Evidence-Based Approach To Managing Asymptomatic Elevated Blood Pressure In The Emergency Department.

Hypertension is a common chronic illness that affects 50 million individuals in the United States and approximately 30% of adults worldwide. United States emergency departments report > 900,000 annual visits for hypertension-related complaints and studies show that approximately one-third of patients with elevated blood pressure lack a formal prior diagnosis. These patients are at risk for long-term morbidity and mortality from cardiovascular, ocular, and neurological consequences. This review examines the most current evidence regarding emergency department treatment of asymptomatic hypertension, including differentiating hypertensive emergency from poorly controlled hypertension, recommendations for choosing appropriate treatment, determining the need for admission, and guidelines for disposition and follow-up.

Critical appraisal of emergency medicine education research: the best publications of 2012.

OBJECTIVES: The objective was to critically appraise and highlight medical education research published in 2012 that was methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM). METHODS: A search of the English language literature in 2012 querying Education Resources Information Center (ERIC), PsychInfo, PubMed, and Scopus identified EM studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. This year, publications limited to a single-site survey design that measured satisfaction or self-assessment on unvalidated instruments were not formally reviewed. Six reviewers then independently ranked all remaining publications using one of two scoring systems depending on whether the study methodology was primarily qualitative or quantitative. Each scoring system had nine criteria, including four related to methodology, that were chosen a priori, to standardize evaluation by reviewers. The quantitative study scoring system was used previously to appraise medical education published annually in 2008 through 2011, while a separate, new qualitative study scoring system was derived and implemented consisting of parallel metrics. RESULTS: Forty-eight medical education research papers met the a priori criteria for inclusion, and 33 (30 quantitative and three qualitative studies) were reviewed. Seven quantitative and two qualitative studies met the criteria for inclusion as exemplary and are summarized in this article. CONCLUSIONS: This critical appraisal series aims to promote superior education research by reviewing and highlighting nine of the 48 major education research studies with relevance to EM published in 2012. Current trends and common methodologic pitfalls in the 2012 papers are noted.

The development of the emergency medicine milestones.

The Accreditation Council for Graduate Medical Education (ACGME) has outlined its "Next Accreditation System" (NAS) that will focus on resident and residency outcome measurements. Emergency medicine (EM) is one of seven specialties that will implement the NAS beginning July 2013. All other specialties will follow in July 2014. A key component of the NAS is the development of assessable milestones, which are explicit accomplishments or behaviors that occur during the process of residency education. Milestones describe competencies more specifically and identify specialty-specific knowledge, skills, attitudes, and behaviors (KSABs) that can be used as outcome measures within the general competencies. The ACGME and the American Board of Emergency Medicine (ABEM) convened an EM milestone working group to develop the EM milestones. This article describes the development, use within the NAS, and challenges of the EM milestones.

Critical appraisal of emergency medicine educational research: the best publications of 2011.

OBJECTIVES: The objective was to critically appraise and highlight medical education research studies published in 2011 that were methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM). METHODS: A search of the English language literature in 2011 querying PubMed, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This method was used previously to appraise medical education published in 2008, 2009, and 2010. RESULTS: Forty-eight educational research papers were identified. Comparing the literature of 2011 to that of 2008 through 2010, the number of published educational research papers meeting the criteria increased over time from 30, to 36, to 41, and now to 48. Five medical education research studies met the a priori criteria for inclusion as exemplary and are reviewed and summarized in this article. The number of funded studies remained fairly stable over the past 3 years, at 13 (2008), 16 (2009), 9 (2010), and 13 (2011). As in past years, research involving the use of technology accounted for almost half (n = 22) of the publications. Observational study designs accounted for 28 of the papers, while nine studies featured an experimental design. CONCLUSIONS: Forty-eight EM educational studies published in 2011 and meeting the criteria were identified. This critical appraisal reviews and highlights five studies that met a priori quality indicators. Current trends and common methodologic pitfalls in the 2011 papers are noted.

Reporter-Interpreter-Manager-Educator (RIME) descriptive ratings as an evaluation tool in an emergency medicine clerkship.

BACKGROUND: Emergency Medicine (EM) clerkships traditionally assess students using numerical ratings of clinical performance. The descriptive ratings of the Reporter, Interpreter, Manager, and Educator (RIME) method have been shown to be valuable in other specialties. OBJECTIVES: We hypothesized that the RIME descriptive ratings would correlate with clinical performance and examination scores in an EM clerkship, indicating that the RIME ratings are a valid measure of performance. METHODS: This was a prospective cohort study of an evaluation instrument for 4(th)-year medical students completing an EM rotation. This study received exempt Institutional Review Board status. EM faculty and residents completed shift evaluation forms including both numerical and RIME ratings. Students completed a final examination. Mean scores for RIME and clinical evaluations were calculated. Linear regression models were used to determine whether RIME ratings predicted clinical evaluation scores or final examination scores. RESULTS: Four hundred thirty-nine students who completed the EM clerkship were enrolled in the study. After excluding items with missing data, there were 2086 evaluation forms (based on 289 students) available for analysis. There was a clear positive relationship between RIME category and clinical evaluation score (r(2)=0.40, p<0.01). RIME ratings correlated most strongly with patient management skills and least strongly with humanistic qualities. A very weak correlation was seen with RIME and final examination. CONCLUSION: We found a positive association between RIME and clinical evaluation scores, suggesting that RIME is a valid clinical evaluation instrument. RIME descriptive ratings can be incorporated into EM evaluation instruments and provides useful data related to patient management skills.

Patient communication during handovers between emergency medicine and internal medicine residents.

BACKGROUND: Communication failures are a key cause of medical errors and are particularly prevalent during handovers of patients between services. OBJECTIVE: To explore current perceptions of effectiveness in communicating critical patient information during admission handovers between emergency medicine (EM) residents and internal medicine (IM) residents. METHODS: Study design was a survey of IM and EM residents at a large urban hospital. Residents were surveyed about whether critical information was communicated during patient handovers. Measurements included comparisons between IM and EM residents about their perceptions of effective communication of key patient information and the quality of handovers. RESULTS: Ninety-three percent of EM residents (50 of 54) and 80% of IM residents (74 of 93) responded to the survey. The EM residents judged their handover performance to be better than how their IM colleagues assessed them on most questions. The IM residents reported that one-half of the time, EM residents provided organized and clear information, whereas EM residents self-reported that they did so most of the time (80%-90%). The IM residents reported that 25% of handovers were suboptimal and resulted in admission to an inappropriate level of care, and 10% led to harm or delay in care. The EM residents reported suboptimal communication was less common (5%). On the global assessment of whether the admission handover provided the information needed for good patient care, IM residents rated the quality of the handover data lower than did responding EM residents. CONCLUSIONS: There are gaps in communicating critical patient information during admission handovers as perceived by EM and IM residents. This information can form the basis for efforts to improve these handovers.