Bereavement scheduling policy for emergency medicine residents: A descriptive pilot study.

Background: The Accreditation Council for Graduate Medical Education has tasked residency programs to prioritize resident wellness, reduce trainee stress, and prevent burnout. Grief and bereavement can significantly impact residents' wellness during difficult clinical training schedules. There are no best practices on how to support residents during this time. Methods: In a split academic county emergency medicine (EM) residency, this pilot study documents a resident-driven change to scheduling practices for bereavement leave. An advisory group of residents, chief residents, and program directors informally polled peer institutions to develop bereavement leave guidelines. Considerations were made to balance resident wellness, education, and patient care in developing a bereavement scheduling policy. Results: The bereavement policy was adopted in January 2023, aiming to "support the resident during a difficult time and reduce concerns around shift coverage" following the death of a family member without impacting sick call. The number of covered days depended on the relationship of the resident to the deceased. Residents covering bereavement days for their peers were financially compensated. During the first 7 months following implementation, five residents utilized the policy. These residents noted this to be the most positive impact on the residency during the past year. Based on resident feedback, the scope was expanded to include grave medical illness of a family member as an implementation criterion. Conclusions: This article outlines the creation, implementation, and benefits of a bereavement scheduling policy within an EM residency. Describing this approach will provide guidance for other residencies to adopt similar wellness-focused strategies.

An investigation into emergency medicine resident cricothyrotomy competency: Is three the magic number?

Objectives: Cricothyrotomy is a high-stakes emergency procedure. Because the procedure is rare, simulation is often used to train residents. The Accreditation Council for Graduate Medical Education (ACGME) requires performance of three cricothyrotomies during residency, but the optimal number of training repetitions is unknown. Additional repetitions beyond three could increase proficiency, though it is unknown whether there is a threshold beyond which there is no benefit to additional repetition. The objective of this study was to establish a minimum number of simulated cricothyrotomy attempts beyond which additional attempts did not increase proficiency. Methods: This was a prospective, observational study conducted over 3 years at the simulation center of an academic emergency medicine residency program. Participants were residents participating in a cricothyrotomy training as part of a longitudinal airway curriculum course. The primary outcome was time to successful completion of the procedure as first-year residents. Secondary outcomes included time to completion as second- and third-year residents. Procedure times were plotted as a function of attempt number. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and correlation analysis. Preprocedure surveys collected further data regarding procedure experience, confidence, and comfort. Results: Sixty-nine first-year residents participated in the study. Steady improvement in time to completion was seen through the first six attempts (from a mean of 75 to 41 sec), after which no further significant improvement was found. Second- and third-year residents initially demonstrated slower performance than first-year residents but rapidly improved to surpass their first-year performance. Resident mean times at five attempts were faster with each year of residency (first-year 48 sec, second-year 30 sec, third-year 24 sec). There was no statistically significant correlation between confidence and time to complete the procedure. Conclusions: Additional repetition beyond the ACGME-endorsed three cricothyrotomy attempts may help increase proficiency. Periodic retraining may be important to maintain skills.

Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS: A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS: A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS: This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.

Frequency of safety net errors in the emergency department: Effect of patient handoffs.

OBJECTIVES: The objective of this study was to determine physician awareness of abnormal vital signs and key clinical interventions (oxygen provision, intravenous access) in the emergency department, and to measure the effect of patient handoffs on this awareness. METHODS: This was a prospective observational study at two large, urban, academic emergency departments. Emergency department physicians were asked the following about each of the physician's patients: 1) the number of IV lines, 2) whether the patient was on supplemental oxygen, and 3) whether the patient had any abnormal vital signs. Physicians were blind to the nature of the study prior to enrollment. Error rates between physician responses and actual patient status were calculated, and logistic regression, adjusted for physician clustering, was used to calculate association of errors with multiple situational factors, including handoff status. RESULTS: We analyzed 463 patient encounters from 74 physicians. Physicians missed abnormal vital signs in 19.4% of encounters. They made errors in oxygen status and number of IV lines in 16.6% and 35.8% of encounters, respectively. Physicians were significantly more likely to make all types of errors on patients who had undergone handoff as opposed to their primary patients. CONCLUSION: Emergency physicians make frequent errors regarding awareness of their patients' vital signs, oxygen and vascular status and patient handoffs are associated with an increased frequency of such errors.

Effect of an Aerosol Box on Intubation in Simulated Emergency Department Airways: A Randomized Crossover Study.

INTRODUCTION: The use of transparent plastic aerosol boxes as protective barriers during endotracheal intubation has been advocated during the severe acute respiratory syndrome coronavirus 2 pandemic. There is evidence of worldwide distribution of such devices, but some experts have warned of possible negative impacts of their use. The objective of this study was to measure the effect of an aerosol box on intubation performance across a variety of simulated difficult airway scenarios in the emergency department. METHODS: This was a randomized, crossover design study. Participants were randomized to intubate one of five airway scenarios with and without an aerosol box in place, with randomization of intubation sequence. The primary outcome was time to intubation. Secondary outcomes included number of intubation attempts, Cormack-Lehane view, percent of glottic opening, and resident physician perception of intubation difficulty. RESULTS: Forty-eight residents performed 96 intubations. Time to intubation was significantly longer with box use than without (mean 17 seconds [range 6-68 seconds] vs mean 10 seconds [range 5-40 seconds], p <0.001). Participants perceived intubation as being significantly more difficult with the aerosol box. There were no significant differences in the number of attempts or quality of view obtained. CONCLUSION: Use of an aerosol box during difficult endotracheal intubation increases the time to intubation and perceived difficulty across a range of simulated ED patients.

Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis.

Importance: Endotracheal intubation of critically ill patients is a high-risk procedure. Checklists have been advocated to improve outcomes. Objective: To assess whether the available evidence supports an association of use of airway checklists with improved clinical outcomes in patients undergoing endotracheal intubation. Data Sources: For this systematic review and meta-analysis, PubMed (OVID), Embase, Cochrane, CINAHL, and SCOPUS were searched without limitations using the Medical Subject Heading terms and keywords airway; management; airway management; intubation, intratracheal; checklist; and quality improvement to identify studies published between January 1, 1960, and June 1, 2019. A supplementary search of the gray literature was performed, including conference abstracts and clinical trial registries. Study Selection: Full-text reviews were performed to determine final eligibility for inclusion. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed 1 of the predefined outcomes. Data Extraction and Synthesis: Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for observational studies and Cochrane risk of bias tool for randomized clinical trials. Study results were meta-analyzed using a random-effects model. Reporting of this study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures: The primary outcome was mortality. Secondary outcomes included first-pass success and known complications of endotracheal intubation, including esophageal intubation, hypoxia, hypotension, and cardiac arrest. Results: The search identified 1649 unique citations of which 11 (3261 patients) met the inclusion criteria. One randomized clinical trial and 3 observational studies had a low risk of bias. Checklist use was not associated with decreased mortality (5 studies [2095 patients]; relative risk, 0.97; 95% CI, 0.80-1.18; I2 = 0%). Checklist use was associated with a decrease in hypoxic events (8 studies [3010 patients]; relative risk, 0.75; 95% CI, 0.59-0.95; I2 = 33%) but no other secondary outcomes. Studies with a low risk of bias did not demonstrate decreased hypoxia associated with checklist use. Conclusions and Relevance: The findings suggest that use of airway checklists is not associated with improved clinical outcomes during and after endotracheal intubation, which may affect practitioners' decision to use checklists in this setting.

Use of Simulation to Improve the Comfort of Pediatric Residents Managing Critically Ill Emergency Department Patients.

OBJECTIVES: The aims of this study were to identify the needs for further critical care experience for pediatric and internal medicine-pediatric residents, to describe a multidisciplinary approach to education, and to assess the impact of high-fidelity simulation on critical care comfort and perceived competence in pediatric residents. In addition, this study assessed pediatric residents' attitudes toward simulation as a means of providing additional education with critically ill patients. METHODS: Residents on their pediatric emergency medicine (PEM) rotation voluntarily participated in a 2-hour simulation session. Each session involved the evaluation and management of 3 critically ill pediatric patients with emergency medicine and pediatric/PEM faculty facilitating and debriefing as a team. All resident participants were asked to complete a presession and postsession survey including questions rating their comfort level with common emergent pediatric disease processes and procedures on a 5-point Likert scale. RESULTS: Overall, the participants reported a significant improvement in comfort level in most categories with P < 0.05. The majority of the resident participants rated the simulation program as a valuable learning tool for managing pediatric emergencies and felt that it would be beneficial to have additional simulation experiences in the PEM curriculum. CONCLUSIONS: This simulation program improved resident comfort in important aspects of the care of critically ill pediatric patients. The use of simulation as an educational tool for pediatric emergencies is considered valuable to residents in our program. In addition, simulation provides an opportunity for educational collaboration between academic departments.

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.

Preparing Emergency Medicine Residents as Teachers: Clinical Teaching Scenarios.

Introduction: Preparing residents for supervision of medical students in the clinical setting is important to provide high-quality education for the next generation of physicians and is mandated by the Liaison Committee on Medical Education as well as the Accreditation Council for Graduate Medical Education. This requirement is met in variable ways depending on the specialty, school, and setting where teaching takes place. This educational intervention was designed to allow residents to practice techniques useful while supervising medical students in simulated encounters in the emergency department and increase their comfort level with providing feedback to students. Methods: The four role-playing scenarios described here were developed for second-year residents in emergency medicine at the Indiana University School of Medicine. Residents participated in the scenarios prior to serving as a supervisor for fourth-year medical students rotating on the emergency medicine clerkship. For each scenario, a faculty member observed the simulated interaction between the resident and the simulated student. The residents were surveyed before and after participating in the scenarios to determine the effectiveness of the instruction. Results: Residents reported that they were more comfortable supervising students, evaluating their performance, and giving feedback after participating in the scenarios. Discussion: Participation in these clinical teaching scenarios was effective at making residents more comfortable with their role as supervisors of fourth-year students taking an emergency medicine clerkship. These scenarios may be useful as part of a resident-as-teacher curriculum for emergency medicine residents.

Feasibility of upright patient positioning and intubation success rates At two academic EDs.

OBJECTIVES: Endotracheal intubation is most commonly taught and performed in the supine position. Recent literature suggests that elevating the patient's head to a more upright position may decrease peri-intubation complications. However, there is little data on the feasibility of upright intubation in the emergency department. The goal of this study was to measure the success rate of emergency medicine residents performing intubation in supine and non-supine, including upright positions. METHODS: This was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed. The number of attempts required for successful intubation was recorded by faculty and espiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0-10° (supine), 11-44° (inclined), and ≥45° (upright); first past success was also analyzed in 5 degree angle increments. RESULTS: A total of 231 intubations performed by 58 residents were analyzed. First pass success was 65.8% for the supine group, 77.9% for the inclined group, and 85.6% for the upright group (p=0.024). For every 5 degree increase in angle, there was increased likelihood of first pass success (AOR=1.11; 95% CI=1.01-1.22, p=0.043). CONCLUSIONS: In our study emergency medicine residents had a high rate of success intubating in the upright position. While this does not demonstrate causation, it correlates with recent literature challenging the traditional supine approach to intubation and indicates that further investigation into optimal positioning during emergency department intubations is warranted.

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position.

There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.

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.

Medical student use of communication elements and association with patient satisfaction: a prospective observational pilot study.

BACKGROUND: Effective communication with patients impacts clinical outcome and patient satisfaction. We measure the rate at which medical students use six targeted communication elements with patients and association of element use with patient satisfaction. METHODS: Participants included fourth year medical students enrolled in an emergency medicine clerkship. A trained observer measured use of six communication elements: acknowledging the patient by name, introducing themselves by name, identifying their role, explaining the care plan, explaining that multiple providers would see the patient, and providing an estimated duration of time in the emergency department. The observer then conducted a survey of patient satisfaction with the medical student encounter. RESULTS: A total of 246 encounters were documented among forty medical student participants. For the six communication elements evaluated, in 61% of encounters medical students acknowledged the patient, in 91% they introduced themselves, in 58 % they identified their role as a student, in 64% they explained the care plan, in 80% they explained that another provider would see the patient, and in only 6% they provided an estimated duration of care. Only 1 encounter (0.4%) contained all six elements. Patients' likelihood to refer a loved one to that ED was increased when students acknowledged the patient and described that other providers would be involved in patient care (P = 0.016 and 0.015 respectively, Chi Square). Likewise, patients' likelihood to return to the ED was increased when students described their role in patient care (P = 0.035, Chi Square). CONCLUSIONS: This pilot study demonstrates that medical students infrequently use all targeted communication elements. When they did use certain elements, patient satisfaction increased. These data imply potential benefit to additional training for students in patient communication.

Introducing Medical Students into the Emergency Department: The Impact upon Patient Satisfaction.

INTRODUCTION: Performance on patient satisfaction surveys is becoming increasingly important for practicing emergency physicians and the introduction of learners into a new clinical environment may impact such scores. This study aimed to quantify the impact of introducing fourth-year medical students on patient satisfaction in two university-affiliated community emergency departments (EDs). METHODS: Two community-based EDs in the Indiana University Health (IUH) system began hosting medical students in March 2011 and October 2013, respectively. We analyzed responses from patient satisfaction surveys at each site for seven months before and after the introduction of students. Two components of the survey, "Would you recommend this ED to your friends and family?" and "How would you rate this facility overall?" were selected for analysis, as they represent the primary questions reviewed by the Center for Medicare Services (CMS) as part of value-based purchasing. We evaluated the percentage of positive responses for adult, pediatric, and all patients combined. RESULTS: Analysis did not reveal a statistically significant difference in the percentage of positive response for the "would you recommend" question at both clinical sites with regards to the adult and pediatric subgroups, as well as the all-patient group. At one of the sites, there was significant improvement in the percentage of positive response to the "overall rating" question following the introduction of medical students when all patients were analyzed (60.3% to 68.2%, p=0.038). However, there was no statistically significant difference in the "overall rating" when the pediatric or adult subgroups were analyzed at this site and no significant difference was observed in any group at the second site. CONCLUSION: The introduction of medical students in two community-based EDs is not associated with a statistically significant difference in overall patient satisfaction, but was associated with a significant positive effect on the overall rating of the ED at one of the two clinical sites studied. Further study is needed to evaluate the effect of medical student learners upon patient satisfaction in settings outside of a single health system.