Navigating the Healthcare Conundrum: Leadership Perspective from a Premier Healthcare Organization in Loma Linda's Blue Zone.

Navigating the healthcare conundrum in the Blue Zone of Loma Linda, California, requires understanding the unique factors that make this region stand out in terms of health and longevity. But more important is understanding the healthcare system sustaining the Blue Zone in Loma Linda, California. In an era marked by soaring healthcare costs and diminishing reimbursement rates, hospitals and physicians face an unprecedented challenge: providing excellent patient care while maintaining financial sustainability. This leadership perspective publication paper delves into the multifaceted struggles encountered by healthcare and hospital leaders, exploring the root causes, implications, and potential solutions for this complex issue. As we examine the evolving healthcare landscape, we aim to shed light on the critical need for innovative approaches to sustain the future of healthcare excellence in one of the five original Blue Zones.

Healthcare students interprofessional critical event/disaster response course.

OBJECTIVE: Numerous disasters confirm the need for critical event training in healthcare professions. However, no single discipline works in isolation and interprofessional learning is recognized as a necessary component. An interprofessional faculty group designed a learning curriculum crossing professional schools. DESIGN: Faculty members from four healthcare schools within the university (nursing, pharmacy, allied health, and medicine) developed an interdisciplinary course merging both published cross-cutting competencies for critical event response and interprofessional education competencies. SETTING: Students completed a discipline-specific online didactic course. Interdisciplinary groups then participated in a 4-hour synchronous experience. This live course featured high-fidelity medical simulations focused on resuscitation, as well as hands-on modules on decontamination and a mass casualty triage incorporating moulaged standardized patients in an active shooter scenario. PARTICIPANTS: Participants were senior students from allied health, medicine, nursing, and pharmacy. MAIN OUTCOME MEASURES: Precourse and postcourse assessments were conducted online to assess course impact on learning performance, leadership and team development, and course satisfaction. RESULTS: Students participated were 402. Precourse and postcourse evaluations showed improvement in team participation values, critical event knowledge, and 94 percent of participants reported learning useful skills. Qualitative responses evidenced positive response; most frequent recurring comments concerned value of interprofessional experiences in team communication and desire to incorporate this kind of education earlier in their curriculum. Students demonstrated improvement in both knowledge and attitudes in a critical event response course that includes interprofessional instruction and collaboration. Further study is required to demonstrate sustained improvement as well as benefit to clinical outcomes.

Effect of Educational Debt on Emergency Medicine Residents: A Qualitative Study Using Individual Interviews.

STUDY OBJECTIVE: In 2001, less than 20% of emergency medicine residents had more than $150,000 of educational debt. Our emergency medicine residents anecdotally reported much larger debt loads. Surveys have reported that debt affects career and life choices. Qualitative approaches are well suited to explore how and why such complex phenomena occur. We aim to gain a better understanding of how our emergency medicine residents experience debt. METHODS: We conducted individual semistructured interviews with emergency medicine residents. We collected self-reported data related to educational debt and asked open-ended questions about debt influence on career choices, personal life, future plans, and financial decisions. We undertook a structured thematic analysis using a qualitative approach based in the grounded theory method. RESULTS: Median educational debt was $212,000. Six themes emerged from our analysis: (1) debt influenced career and life decisions by altering priorities; (2) residents experienced debt as a persistent source of background stress and felt powerless to change it; (3) residents made use of various techniques to negotiate debt in order to focus on day-to-day work; (4) personal debt philosophy, based on individual values and obtained from family, shaped how debt affected each individual; (5) debt had a normative effect and was acculturated in residency; and (6) residents reported a wide range of financial knowledge, but recognized its importance to career success. CONCLUSION: Our emergency medicine residents' debt experience is complex and involves multiple dimensions. Given our current understanding, simple solutions are unlikely to be effective in adequately addressing this issue.

The Development of a Physician Vitality Program: A Brief Report.

We describe the development of an innovative program to support physician vitality. We provide the context and process of program delivery which includes a number of experimental support programs. We discuss a model for intervention and methods used to enhance physician resilience, support work-life balance, and change the culture to one that explicitly addresses the physician's biopsychosocial-spiritual needs. Recommendations are given for marriage and family therapists (MFTs) who wish to develop similar support programs for healthcare providers. Video Abstract.

The flipped classroom: a modality for mixed asynchronous and synchronous learning in a residency program.

INTRODUCTION: A "flipped classroom" educational model exchanges the traditional format of a classroom lecture and homework problem set. We piloted two flipped classroom sessions in our emergency medicine (EM) residency didactic schedule. We aimed to learn about resident and faculty impressions of the sessions, in order to develop them as a regular component of our residency curriculum. METHODS: We evaluated residents' impression of the asynchronous video component and synchronous classroom component using four Likert items. We used open-ended questions to inquire about resident and faculty impressions of the advantages and disadvantages of the format. RESULTS: For the Likert items evaluating the video lectures, 33/35 residents (94%, 95% CI 80%-99%) responded that the video lecture added to their knowledge about the topic, and 33/35 residents felt that watching the video was a valuable use of their time. For items evaluating the flipped classroom format, 36/38 residents (95%, 95% CI 82%-99%) preferred the format to a traditional lecture on the topic, and 38/38 residents (100%, 95% CI 89%-100%) felt that the small group session was effective in helping them learn about the topic. Most residents preferred to see the format monthly in our curriculum and chose an ideal group size of 5.5 (first session) and 7 (second session). Residents cited the interactivity of the sessions and access to experts as advantages of the format. Faculty felt the ability to assess residents' understanding of concepts and provide feedback were advantages. CONCLUSION: Our flipped classroom model was positively received by EM residents. Residents preferred a small group size and favored frequent use of the format in our curriculum. The flipped classroom represents one modality that programs may use to incorporate a mixture of asynchronous and interactive synchronous learning and provide additional opportunities to evaluate residents.

Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.

This clinical policy from the American College of Emergency Physicians is an update of a 2002 clinical policy on the evaluation and management of adult patients presenting to the emergency department (ED) with acute, nontraumatic headache. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following 5 critical questions: (1) Does a response to therapy predict the etiology of an acute headache? (2) Which patients with headache require neuroimaging in the ED? (3) Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal? (4) In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? (5) Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.

Mass-casualty triage: time for an evidence-based approach.

Mass-casualty triage has developed from a wartime necessity to a civilian tool to ensure that constrained medical resources are directed at achieving the greatest good for the most number of people. Several primary and secondary triage tools have been developed, including Simple Treatment and Rapid Transport (START), JumpSTART, Care Flight Triage, Triage Sieve, Sacco Triage Method, Secondary Assessment of Victim Endpoint (SAVE), and Pediatric Triage Tape. Evidence to support the use of one triage algorithm over another is limited, and the development of effective triage protocols is an important research priority. The most widely recognized mass-casualty triage algorithms in use today are not evidence-based, and no studies directly address these issues in the mass-casualty setting. Furthermore, no studies have evaluated existing mass-casualty triage algorithms regarding ease of use, reliability, and validity when biological, chemical, or radiological agents are introduced. Currently, the lack of a standardized mass-casualty triage system that is well validated, reliable, and uniformly accepted, remains an important gap. Future research directed at triage is recognized as a necessity, and the development of a practical, universal, triage algorithm that incorporates requirements for decontamination or special precautions for infectious agents would facilitate a more organized mass-casualty medical response.

Healthcare worker competencies for disaster training.

BACKGROUND: Although training and education have long been accepted as integral to disaster preparedness, many currently taught practices are neither evidence-based nor standardized. The need for effective evidence-based disaster training of healthcare staff at all levels, including the development of standards and guidelines for training in the multi-disciplinary health response to major events, has been designated by the disaster response community as a high priority. We describe the application of systematic evidence-based consensus building methods to derive educational competencies and objectives in criteria-based preparedness and response relevant to all hospital healthcare workers. METHODS: The conceptual development of cross-cutting competencies incorporated current evidence through a systematic consensus building process with the following steps: (1) review of peer-reviewed literature on relevant content areas and educational theory; (2) structured review of existing competencies, national level courses and published training objectives; (3) synthesis of new cross-cutting competencies; (4) expert panel review; (5) refinement of new competencies and; (6) development of testable terminal objectives for each competency using similar processes covering requisite knowledge, attitudes, and skills. RESULTS: Seven cross-cutting competencies were developed: (1) Recognize a potential critical event and implement initial actions; (2) Apply the principles of critical event management; (3) Demonstrate critical event safety principles; (4) Understand the institutional emergency operations plan; (5) Demonstrate effective critical event communications; (6) Understand the incident command system and your role in it; (7) Demonstrate the knowledge and skills needed to fulfill your role during a critical event. For each of the cross-cutting competencies, comprehensive terminal objectives are described. CONCLUSION: Cross-cutting competencies and objectives developed through a systematic evidence-based consensus building approach may serve as a foundation for future hospital healthcare worker training and education in disaster preparedness and response.

The incident command system in disasters: evaluation methods for a hospital-based exercise.

OBJECTIVES: No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted. METHODS: A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant- and observer-based instruments. Two different post-exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed. RESULTS: A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0-4.0), 4.1 (3.0-5.0) and 5.2 (3.0-9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified. CONCLUSIONS: A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.

Developing and implementing emergency medicine programs globally.

International EM development requires a comprehensive assessment of the current system and careful planning to ensure that the most important needs are addressed. Modeling a country's EM system after an existing foreign system underestimates the complex needs for instituting appropriate system interventions. Planning must include all stakeholders. With appropriate planning, international interventions can contribute to health system advancement.

Pediatric considerations in chemical exposures: are we prepared?

Manmade disasters have risen over the past decaFde. Specifically, chemical weapons used in acts of aggression pose an increasing threat to our society. These potential disaster situations raise concerns regarding preparedness for both adults and children. This article's purpose is to review general principles of chemical exposure and treatment of specific chemical agents, and to identify specific pediatric considerations involved.

Generic evaluation methods for disaster drills in developing countries.

Disaster simulations (drills) are widely used throughout the world and are considered a fundamental tool for evaluation and improvement of local disaster response capacity. Despite this, no generally accepted methodology exists for quantitative evaluation of the medical response to a disaster drill. We therefore set out to develop and prospectively test a comprehensive method to assess both medical provider and organizational performance during a disaster simulation. Because disasters disproportionately affect the populations of developing countries, we designed these methods to be sufficiently flexible to be applicable in both the developed and the developing world. Objective outcome measures were identified for each component of disaster medical response and were incorporated into 3 data collection instruments. The derived methods were applied to a multiagency disaster simulation in Guatemala City, Guatemala. On the basis of this pilot study, suggested modifications and recommendations were made. The ability to objectively identify the specific strengths and weaknesses of an emergency medical services systems' medical response to a disaster is an important step toward optimizing system performance. On the basis of our experience, we recommend the incorporation of objective evaluation methods such as these into every disaster simulation.