Experiential Learning in Patient Safety: A Multi-Center Study Examining Emergency Medicine Residents' Situational Awareness of Hazards via Simulation.

Introduction The 2016 Clinical Learning Environment Review established that experiential patient safety curricula for residents are uncommon. Moreover, these curricula do not incorporate non-technical skills linked to safety, such as situational awareness (SA). We developed an in-situ patient safety simulation exercise incorporating core SA concepts and subsequently assessed exercise feasibility and acceptability, and measured residents' safety SA. Methods A simulation scenario and mock chart were designed, incorporating 16 patient safety hazards. Residents at two institutions reviewed the chart and had 10 minutes in an emergency department room with the simulated scenario to document identified hazards, followed by a facilitated debriefing. Pre- and post-exercise surveys were completed. We used regression analyses to compare exercise performance and survey responses by training year, and measures of proportional difference and association for survey responses. Results This study included 76 of 104 eligible residents (73.1%). Around 56.5% initially reported being comfortable identifying hazards. During the exercise, hazards requiring higher SA were identified less frequently. Senior residents identified more hazards (OR 2.26; 95%CI 1.56-3.28) (mean 8.28, SD1.45); 93.4% expressed satisfaction with the session, and residents reporting comfort increased significantly (89.5%, p<0.001). Conclusion In-situ simulation incorporating SA concepts feasibly provides experiential safety education and enhances resident comfort with safety issues. Visible hazards were often identified; those requiring information synthesis were usually missed, suggesting a need for developing more robust resident SA. While interns demonstrated the poorest performance, senior residents only identified 50% of errors, indicating that patient safety education enhancing SA should begin early and continue longitudinally.

Application of the World Health Organization's Basic Emergency Care course in Zambia.

BACKGROUND: In 2013, the Zambian Ministry of Health identified action priorities for strengthening their emergency care system; one of these priorities was emergency care training for healthcare providers. To rapidly train the existing cadre of frontline providers, trainings were implemented in multiple provinces using the World Health Organization's Basic Emergency Care (BEC) course. The BEC course is open-access and emphasizes a practical syndrome-based approach to critical emergency conditions. This paper describes the first reported larger scale educational intervention of the BEC course in 7 provinces of Zambia. METHODS: Course delivery occurred at seven Zambian hospitals selected by the Ministry of Health over a 1 year period. Participant emergency care knowledge was assessed pre- and post-course with a 25-question multiple choice exam. Participant confidence levels related to emergency care provision and emergency care skills were assessed pre- and post-course using a Likert scale survey. RESULTS: Overall, 210 participants were trained at 7 sites. Participants demonstrated significant improvements in their multiple-choice exam scores; the overall pre-course mean was 61.47, and the post-course mean was 79.87 (p < 0.0001). Self-reported confidence in the care of ill and injured adults and children increased after taking the course, and participants generally agreed that the BEC course was highly valuable and applicable to local needs. CONCLUSION: Implementation of the WHO's BEC course at seven hospitals throughout Zambia led to improvement in the participants' emergency care knowledge and confidence levels at all sites. The BEC course has the potential to be implemented in a nationwide initiative but would require allocation of significant human and physical resources. Additional work evaluating patient outcomes and long-term participant educational outcomes is needed.

San Antonio refugees: Their demographics, healthcare profiles, and how to better serve them.

OBJECTIVE: The recent refugee crisis has resulted in the largest burden of displacement in history, with the US being the top resettlement country since 1975. Texas welcomed the second most US-bound refugees in 2016, with a large percentage arriving in San Antonio. Yet, the composition of the San Antonio refugees has not been described and their healthcare needs remain ill-defined. Through this study, we aim at elucidating their demographics and healthcare profiles, with the goal of devising recommendations to help guide refugee program development and guide other refugee resettlement programs. METHODS: Data from 731 charts belonging to 448 patients at the San Antonio Refugee Health Clinic (SARHC) were extracted and analyzed. Data included age, gender, country of origin, first language, interpretation need, health insurance status, medical history, vital signs, diagnoses, and prescribed medications. RESULTS: Women constituted the majority of patients (n = 267; 56.4%), and the median age of all patients was 39 (Q1:26, Q3:52). Nepali-speaking Bhutanese patients were the most represented group (n = 107, 43.1%), followed by Iraqi (n = 35, 14.1%), Burmese (n = 30, 12.1%), and Iranian (n = 19, 7.7%) refugees. Of those who responded, 200 (86.6%) did not have any form of health insurance. Additionally, 262 (50.9%) had a body-mass index (BMI) in the overweight or obese range. Further, 61.4% (n = 337) had blood pressures in the hypertensive range, while 9.3% (n = 51) had an elevated blood pressure. On average, each patient had 1.9 complaints, with abdominal pain, headaches, and cough being the predominant complaints. Allergic rhinitis, viral upper respiratory infections, and elevated blood pressure were the most common diagnoses. However, the list of common diagnoses differed per country of origin. CONCLUSION: The SARHC demographics were different from those of other Texas refugees. The rate of the uninsured and the burden of non-communicable diseases were high. Furthermore, each refugee subgroup had a different set of common problems. These findings reveal important considerations for refugee healthcare providers and the unique approach that may be required for different communities.

Emergency Physicians at War.

Operation Enduring Freedom (OEF-A) in Afghanistan and Operation Iraqi Freedom (OIF) represent the first major, sustained wars in which emergency physicians (EPs) fully participated as an integrated part of the military's health system. EPs proved invaluable in the deployments, and they frequently used the full spectrum of trauma and medical care skills. The roles EPs served expanded over the years of the conflicts and demonstrated the unique skill set of emergency medicine (EM) training. EPs supported elite special operations units, served in medical command positions, and developed and staffed flying intensive care units. EPs have brought their combat experience home to civilian practice. This narrative review summarizes the history, contributions, and lessons learned by EPs during OEF-A/OIF and describes changes to daily clinical practice of EM derived from the combat environment.

Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.

A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.

Six years of epinephrine digital injections: absence of significant local or systemic effects.

STUDY OBJECTIVE: Epinephrine autoinjectors are known to result in accidental digital injections. Treatment recommendations and adverse outcomes are based on case reports. The objective of our study is to determine the frequency of digit ischemia after epinephrine autoinjector digital injections. In addition, we describe the frequency of epinephrine digital injections, treatments used, adverse local effects, and systemic effects. METHODS: We performed a retrospective cohort study on cases reported to 6 poison centers during 6 years, using a search of the Texas Poison Center Network database. Patients who had an epinephrine injection of the hand were reviewed, and digital injections were included. Variables collected included demographics, local and systemic effects, symptom duration, treatments used, comorbidities, and whether admission, surgery, or hand surgery consultation was used. One trained abstractor used a standard electronic data collection form. RESULTS: There were 365 epinephrine injections to the hand identified for the 6-year period. Of these, 213 were digital injections, and 127 had follow-up. All patients had complete resolution of symptoms. None of the patients were hospitalized or received hand surgery consultation or surgical care. Significant systemic effects were not reported. Pharmacologic vasodilatory treatment was used in 23% (29/127) of patients. Ischemic effects were documented for 4 patients, and 2 of these had symptom resolution within 2 hours. All 4 patients received vasodilatory therapy and were discharged home, with complete resolution of symptoms. CONCLUSION: In our series of patients using poison center calls about digital epinephrine autoinjections, there were no cases in which clinically apparent systemic effects were recorded and few patients had ischemia. No patient was admitted or had surgery. Most clinicians did not use vasodilation medications or techniques.