"The Cost in the Individual": Longitudinal Burnout Prevalence Among Pediatric Emergency Physicians Through 9 Months of the COVID-19 Pandemic.

OBJECTIVES: Emergency medicine (EM) confers a high risk of burnout that may be exacerbated by the COVID-19 pandemic. We aimed to determine the longitudinal prevalence of burnout in pediatric EM (PEM) physicians/fellows working in tertiary PEM departments across Canada and its fluctuation during the pandemic. METHODS: A national mixed-methods survey using a validated 2-question proxy for burnout was distributed monthly through 9 months. The primary outcome was the trajectory in probability of burnout, which was examined as both emotional exhaustion (EE) and depersonalization (DP), EE alone, and DP alone. Secondary outcomes investigated burnout and its association with demographic variables. Quantitative data were analyzed using logistic regression for primary outcomes and subanalyses for secondary outcomes. Conventional content analysis was used to analyze qualitative data and generate themes. RESULTS: From February to October 2021, 92 of 98 respondents completed at least 1 survey, 78% completed at least 3 consecutive surveys, and 48% completed at least 6 consecutive surveys. Predicted probability of EE was bimodal with peaks in May (25%) and October (22%) 2021. Rates of DP alone or having both EE and DP were approximately 1% and stable over the study period. Mid-career physicians were at lower risk of EE (odds ratio, 0.02; 95% confidence interval, 0-0.22) compared with early-career physicians. Underlying drivers of burnout were multifaceted. CONCLUSIONS: Our study suggests that increased COVID-19 case burden was correlated with EE levels during the third and fourth waves of the pandemic. Emotional exhaustion was worsened by systemic factors, and interventions must target common themes of unsustainable workloads and overwhelming lack of control.

Comparing methods to classify admitted patients with SARS-CoV-2 as admitted for COVID-19 versus with incidental SARS-CoV-2: A cohort study.

INTRODUCTION: Not all patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection develop symptomatic coronavirus disease 2019 (COVID-19), making it challenging to assess the burden of COVID-19-related hospitalizations and mortality. We aimed to determine the proportion, resource utilization, and outcomes of SARS-CoV-2 positive patients admitted for COVID-19, and assess the impact of using the Center for Disease Control's (CDC) discharge diagnosis-based algorithm and the Massachusetts state department's drug administration-based classification system on identifying admissions for COVID-19. METHODS: In this retrospective cohort study, we enrolled consecutive SARS-CoV-2 positive patients admitted to one of five hospitals in British Columbia between December 19, 2021 and May 31,2022. We completed medical record reviews, and classified hospitalizations as being primarily for COVID-19 or with incidental SARS-CoV-2 infection. We applied the CDC algorithm and the Massachusetts classification to estimate the difference in hospital days, intensive care unit (ICU) days and in-hospital mortality and calculated sensitivity and specificity. RESULTS: Of 42,505 Emergency Department patients, 1,651 were admitted and tested positive for SARS-CoV-2, with 858 (52.0%, 95% CI 49.6-54.4) admitted for COVID-19. Patients hospitalized for COVID-19 required ICU admission (14.0% versus 8.2%, p<0.001) and died (12.6% versus 6.4%, p<0.001) more frequently compared with patients with incidental SARS-CoV-2. Compared to case classification by clinicians, the CDC algorithm had a sensitivity of 82.9% (711/858, 95% CI 80.3%, 85.4%) and specificity of 98.1% (778/793, 95% CI 97.2%, 99.1%) for COVID-19-related admissions and underestimated COVID-19 attributable hospital days. The Massachusetts classification had a sensitivity of 60.5% (519/858, 95% CI 57.2%, 63.8%) and specificity of 78.6% (623/793, 95% CI 75.7%, 81.4%) for COVID-19-related admissions, underestimating total number of hospital and ICU bed days while overestimating COVID-19-related intubations, ICU admissions, and deaths. CONCLUSION: Half of SARS-CoV-2 hospitalizations were for COVID-19 during the Omicron wave. The CDC algorithm was more specific and sensitive than the Massachusetts classification, but underestimated the burden of COVID-19 admissions. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

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.

Guidelines: The Do's, Don'ts and Don't Knows of Creating Open Educational Resources.

Background: In medical education, there is a growing global demand for Open Educational Resources (OERs). However, OER creators are challenged by a lack of uniform standards. In this guideline, the authors curated the literature on how to produce OERs for medical education with practical guidance on the Do's, Don'ts and Don't Knows for OER creation in order to improve the impact and quality of OERs in medical education. Methods: We conducted a rapid literature review by searching OVID MEDLINE, EMBASE, and Cochrane Central database using keywords "open educational resources" and "OER". The search was supplemented by hand searching the identified articles' references. We organized included articles by theme and extracted relevant content. Lastly, we developed recommendations via an iterative process of peer review and discussion: evidence-based best practices were designated Do's and Don'ts while gaps were designated Don't Knows. We used a consensus process to quantify evidentiary strength. Results: The authors performed full text analysis of 81 eligible studies. A total of 15 Do's, Don't, and Don't Knows guidelines were compiled and presented alongside relevant evidence about OERs. Discussion: OERs can add value for medical educators and their learners, both as tools for expanding teaching opportunities and for promoting medical education scholarship. This summary should guide OER creators in producing high-quality resources and pursuing future research where best practices are lacking.

Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

BACKGROUND: Treatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves. METHODS: This observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes. RESULTS: We enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2-8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4-0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6-0.8) and critical care admission (OR 0.7; 95% CI 0.6-0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5-1.1). INTERPRETATION: In patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

RéSUMé: CONTEXTE: Le traitement de la maladie à coronavirus 2019 (COVID-19) a évolué entre les vagues pandémiques. Notre objectif était de comparer les traitements, l'utilisation des soins aigus et les résultats des patients atteints de la maladie COVID-19 se présentant aux urgences à travers les vagues de pandémie. MéTHODES: Cette étude observationnelle a recruté des patients COVID-19 éligibles consécutifs se présentant à 46 services d'urgence participant au Réseau canadien de réponse rapide aux services d'urgence COVID-19 (CCEDRRN) entre le 1er mars et le 31 décembre 2020. Nous avons recueilli des données au moyen d'un examen rétrospectif des dossiers. Notre principal résultat a été la mortalité à l'hôpital. Les résultats secondaires incluaient les traitements, les admissions à l'hôpital et aux soins intensifs, les revisites aux urgences et les réadmissions. La modélisation par régression logistique a évalué l'impact de la vague de pandémie sur les résultats. RéSULTATS: Nous avons recruté 9 967 patients dans 8 provinces, 3 336 de la première vague et 6 631 de la deuxième vague. Les patients de la deuxième vague étaient plus jeunes, moins nombreux à répondre aux critères de gravité de la COVID-19 et plus nombreux à quitter les urgences. Après ajustement en fonction des caractéristiques des patients et de la gravité de la maladie, le recours aux stéroïdes a augmenté (rapport de cotes [RC] 7.4 ; intervalle de confiance à 95 % [IC] 6.2­8.9) et la ventilation mécanique invasive a diminué (RC 0.5 ; IC à 95 % 0.4­0.7) lors de la deuxième vague par rapport à la première. Après ajustement pour tenir compte des différences dans les caractéristiques des patients et la gravité de la maladie, les probabilités d'hospitalisation (RC 0.7 ; IC à 95 % 0.6­0.8) et d'admission en soins intensifs (RC 0.7 ; IC à 95 % 0.6­0.9) ont diminué, tandis que la mortalité est restée inchangée (RC 0.7 ; IC à 95 % 0.5­1.1). INTERPRéTATION: Chez les patients se présentant dans les établissements de soins de santé, nous avons observé une adoption rapide des thérapies fondées sur des données probantes et un moindre recours aux thérapies expérimentales lors de la deuxième vague. Nous avons observé une augmentation des taux de sortie des services d'urgence et une diminution de l'utilisation des ressources hospitalières et des soins intensifs au fil du temps. Les réductions substantielles de la ventilation mécanique n'étaient pas associées à une augmentation de la mortalité. Les progrès réalisés dans les stratégies de traitement ont permis d'améliorer l'efficacité des systèmes de santé sans compromettre les résultats pour les patients.

The Journal Club 3.0: A qualitative, multisite study examining a new educational paradigm in the era of open educational resources.

BACKGROUND: The journal club is a ubiquitous and time-honored tradition within medical education. However, in recent years, open educational resources (OERs) have become increasingly influential in how physicians interact with the medical literature across multiple specialties. The authors sought to explore how emergency medicine (EM) resident physicians reconcile different perspectives across OERs into their educational experience at the journal club. METHODS: From January 2018 to September 2019, the authors enrolled 25 EM residents from four teaching sites associated with the University of British Columbia, Canada, to participate in either a focus group (seven residents) or individual interviews (18 residents). The authors used a snowball sampling technique. Using a constructivist grounded theory analysis, two investigators independently reviewed transcripts, meeting regularly to discuss themes until sufficiency was achieved. RESULTS: The study data expand the theoretical understanding of the resident journal club experience. Residents used multiple sources including OERs to learn about new evidence in the specialty. The rise of OERs helped residents to focus on developing critical appraisal skills and social bonds during the journal club. The local journal club gained a new relevancy in acting as a quality control mechanism against the premature adoption of research findings discussed in OERs. DISCUSSION: To date, most educators assume that residents prepare for a journal club by reading the selected articles and applying knowledge from their previous education. Instead, our findings suggest a more dynamic experience that integrates OERs. OERs enhance the journal club experience by allowing junior residents to more easily participate in discussions and to broaden the discussion to multiple clinical settings. Understanding these processes could inform future educational strategies around the journal club.

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study.

BACKGROUND: Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS: This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION: Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT04702945.

Quality Appraisal and Assurance Techniques for Free Open Access Medical Education (FOAM) Resources: A Rapid Review.

Free open access medical education (FOAM) has disrupted traditional modes of knowledge translation and dissemination. These are popular resources with a wide educational reach. Nephrology has been a leader in FOAM, but many skeptics still question the accuracy and reliability of this content. Recently, quality-assurance techniques have been developed to address these concerns. These techniques may be helpful for readers to appraise the online literature and for institutions to reward the production of high-quality open educational resources. We performed a rapid review of the literature. A medical librarian conducted a systematic search of the Medline and Cumulative Index of Nursing and Allied Health Literature databases. Two independent assessors screened and selected articles, performed a hand-search of reference lists, and scored articles on their quality using the Medical Education Research Study Quality Instrument. Thirteen reports were included for the final descriptive analysis. We identified 10 quality-assessment techniques, and 4 of them having been validated. The quality of the reports was fairly high, with an average Medical Education Research Study Quality Instrument score of 11.5 of 18 (SD, 2.3; range, 7.25-14.25). The calculated Cronbach α was 0.85. There is burgeoning literature on the topic of critical appraisal of open educational resources, and, more specifically, FOAM resources. Many of the techniques used are of varying quality and developed with different intended uses and audiences. By continuing to refine these tools, we can continue not only to support and legitimize the FOAM movement, but also foster individual critical appraisal skills that increasingly are necessary in this age of information.

Palliative and end-of-life care education in Canadian emergency medicine residency programs: A national cross-sectional survey.

OBJECTIVES: Emergency physicians play an important role in providing care at the end-of-life as well as identifying patients who may benefit from a palliative approach. Several studies have shown that emergency medicine (EM) residents desire further training in palliative care. We performed a national cross-sectional survey of EM program directors. Our primary objective was to describe the number of Canadian postgraduate EM training programs with palliative and end-of-life care curricula. METHODS: A 15-question survey in English and French was sent by email to all program directors of both the Canadian College of Family Physicians emergency medicine (CCFP(EM)) and the Royal College of Physicians and Surgeons of Canada emergency medicine (RCPSC-EM) postgraduate training programs countrywide using FluidSurveys™ with a modified Dillman approach. RESULTS: We received a total of 26 responses from the 36 (response rate = 72.2%) EM postgraduate programs in Canada. Ten out of 26 (38.5%) programs had a structured educational program pertaining to palliative and end-of-life care. Lectures or seminars were the exclusive choice to teach content. Clinical palliative medicine rotations were mandatory in one out of 26 (3.8%) programs. The top two barriers to implementation of palliative and end-of-life care curricula were lack of time (84.6%) and curriculum development concerns (80.8%). CONCLUSIONS: Palliative and end-of-life care training within EM has been identified as an area of need. This cross-sectional survey demonstrates that a minority of Canadian EM programs have palliative and end-of-life care curricula. It will be important for all EM training programs, RCPSC-EM and CCFP(EM), in Canada, to develop an agreed upon set of competencies and to structure their curricula around them.

CanadiEM: Accessing a Virtual Community of Practice to Create a Canadian National Medical Education Institution.

BACKGROUND: The rise of free open-access medical education (FOAM) has led to a wide range of online resources in emergency medicine. Canadian physicians have been active contributors to FOAM. OBJECTIVES: We aimed to create a virtual community of practice that would serve as a national platform for collaboration, learning, and knowledge dissemination. METHODS: CanadiEM was formed in 2016 from the merger of two Canadian websites and a podcast. Using a community-of-practice model, we introduced two training programs to support junior community members in becoming core editorial team members and employed asynchronous Web technologies to facilitate collaboration. We also introduced a coached peer review process and formed strategic alliances that aim to ensure a high quality of publication. RESULTS: CanadiEM has become a portal for readers to access a broad range of FOAM content. The website has published 782 articles. Of these, 71 have undergone a coached peer review process. The website has received over 2.5 million page views from 217 countries, and the associated CRACKCast podcast has been downloaded over 750,000 times. CONCLUSIONS: CanadiEM has succeeded in building a national multi-interface dissemination network that fosters collaboration and knowledge sharing in emergency medicine while fostering junior digital scholars. The construction of a community of practice has been facilitated by quality assurance, training programs, and the use of asynchronous Web technologies. Ongoing challenges in sustainability include a volunteer workforce with high turnover.

Medical Students Learn Professionalism in Near-Peer Led, Discussion-Based Small Groups.

Problem: Medical educators recognize that professionalism is difficult to teach to students in lecture-based or faculty-led settings. An underused but potentially valuable alternative is to enroll near-peers to teach professionalism. Intervention: We describe a novel near-peer curriculum on professionalism developed at Queen's University School of Medicine. Senior medical students considered role models by their classmates were nominated to facilitate small-group seminars with junior students on topics in professionalism. Each session was preceded by brief pre-readings or prompts and engaged students in semistructured, open-ended discussion. Three 2-hour sessions have occurred annually. Context: The near-peer sessions are a required component (6 hours; 20%) of the 1st-year professionalism course at Queen's University (30 hours), which otherwise includes faculty-led seminars, lectures, and online modules. Senior facilitators are selected through a peer nomination process during their 3rd year of medical school. This format was chosen to create a highly regarded position to which students could aspire by demonstrating positive professionalism. Outcome: We performed a qualitative descriptive evaluation of the near-peer curriculum. Fifty-six medical students participated in 11 focus group interviews, which were coded and analyzed for themes inductively and deductively. Quantitative reviews of student feedback forms and a third-party thematic analysis were performed to triangulate results. Medical students preferred the near-peer-led discussion-based curriculum to faculty-led seminars and didactic or online formats. Junior students could describe specific examples of how the curriculum had influenced their behavior in academic, clinical, and personal settings. They cited senior near-peer facilitators as the strongest aspect of the curriculum for their social and cognitive congruence. Senior students who had facilitated sessions regarded the peer teaching experience as formative to their own understanding of professionalism. Lessons Learned: Formal medical curricula on professionalism should emphasize near-peer-led small-group discussion as it fosters a nuanced understanding of professionalism for both early level students and senior students acting as teachers.

Apneic oxygenation provides incremental benefit during intubation of patients in the emergency medicine and critical care settings.

Clinical questionShould I use apneic oxygenation when intubating patients in the emergency department to increase peri-intubation oxygen saturation and first-pass success?Article chosenOliveira JE, Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Ann Emerg Med 2017;70(4):483-94. OBJECTIVE: The purpose of this study was to synthesize and appraise the apneic oxygenation literature for its effect on peri-intubation outcomes.

A writer's guide to education scholarship: Qualitative education scholarship (part 2).

OBJECTIVE: Education scholarship can be conducted using a variety of methods, from quantitative experiments to qualitative studies. Qualitative methods are less commonly used in emergency medicine (EM) education research but are well-suited to explore complex educational problems and generate hypotheses. We aimed to review the literature to provide resources to guide educators who wish to conduct qualitative research in EM education. METHODS: We conducted a scoping review to outline: 1) a list of journals that regularly publish qualitative educational papers; 2) an aggregate set of quality markers for qualitative educational research and scholarship; and 3) a list of quality checklists for qualitative educational research and scholarship. RESULTS: We found nine journals that have published more than one qualitative educational research paper in EM. From the literature, we identified 39 quality markers that were grouped into 10 themes: Initial Grounding Work (preparation, background); Goals, Problem Statement, or Question; Methods (general considerations); Sampling Techniques; Data Collection Techniques; Data Interpretation and Theory Generation; Measures to Optimize Rigour and Trustworthiness; Relevance to the Field; Evidence of Reflective Practice; Dissemination and Reporting. Lastly, five quality checklists were found for guiding educators in reporting their qualitative work. CONCLUSION: Many problems that EM educators face are well-suited to exploration using qualitative methods. The results of our scoping review provide publication venues, quality indicators, and checklists that may be useful to EM educators embarking on qualitative projects.

CAEP 2016 Academic Symposium: A Writer's Guide to Key Steps in Producing Quality Medical Education Scholarship.

A key skill for successful clinician educators is the effective dissemination of scholarly innovations and research. Although there are many ways to disseminate scholarship, the most accepted and rewarded form of educational scholarship is publication in peer-reviewed journals. This paper provides direction for emergency medicine (EM) educators interested in publishing their scholarship via traditional peer-reviewed avenues. It builds upon four literature reviews that aggregated recommendations for writing and publishing high-quality quantitative and qualitative research, innovations, and reviews. Based on the findings from these literature reviews, the recommendations were prioritized for importance and relevance to novice clinician educators by a broad community of medical educators. The top items from the expert vetting process were presented to the 2016 Canadian Association of Emergency Physicians (CAEP) Academic Symposium Consensus Conference on Education Scholarship. This community of EM educators identified the highest yield recommendations for junior medical education scholars. This manuscript elaborates upon the top recommendations identified through this consensus-building process.