Utility of 360-degree assessment of residents in a Turkish academic emergency medicine residency program.

OBJECTIVES: This study was designed to test a 360-degree assessment tool for four of the emergency medicine resident competencies as outlined by the Council of Residency Directors in Emergency Medicine on patient care, communication skills, professionalism and system based practice in an academic Emergency Department. MATERIAL AND METHODS: Using the competency framework of the American Accreditation Council for Graduate Medical Education, a 57 item-containing assessment tool was created. Based on the different exposure aspects of the involved evaluator groups, the items were integrated into seven different evaluation forms. All sixteen of 16 residents and members from each evaluator group voluntarily participated in the study. Internal consistency scores, multilayer and multilevel Kappa values were measured. Evaluator group scores and resident ranks in competency areas were compared. All evaluators were asked to comment on the applicability and usefulness of the assessment tool in emergency medicine. RESULTS: Seven groups completed a total of 1088 forms to evaluate 16 residents. The reliability coefficient for the faculty members was 0.99 while it was 0.60 for the ancillary staff. The interrater Kappa values for faculty members, nurses and peer assessment were relevant with a value of greater than 70%. DISCUSSION AND CONCLUSION: Our results showed that the 360-degree assessment did meet expectations by the evaluator group and residents, and that this method was readily accepted in the setting of a Akdeniz University Emergency Medicine residency training program. However, only evaluations by faculty, nurses, self and peers were reliable to have any value. Doing a 360° evaluation is time and effort consuming and thus may not be an ideal tool for larger programs.

Characteristics of Real-Time, Non-Critical Incident Debriefing Practices in the Emergency Department.

INTRODUCTION: Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM). METHODS: We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel. RESULTS: The data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted. CONCLUSION: This survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, real-time debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use.

A structured approach to transforming a large public hospital emergency department via lean methodologies.

Emergency Departments (EDs) face significant challenges in providing efficient, quality, safe, cost-effective care. Lean methodologies are a proposed framework to redesign ED practices and processes to meet these challenges. We outline a systematic way that lean principles can be applied across the entire ED patient experience to transform a high volume ED in a safety net hospital. We review the change in ED performance metrics prior to and after lean implementation. We discuss critical insights and key lessons learned from our lean transformation to date. The steps to implementing lean principles across the patient's ED experience are described with specific attention to executive planning of rapid improvement experiments and the subsequent roll-out of lean transformation over an 18-month time frame. Basic ED performance data were compared to the year prior. Results of the exploratory analysis (using median and interquartile ranges and nonparametric tests for group comparisons) have shown improvement in several performance metrics after initiating lean transformation. The approach, lessons learned, and early data of our transformation can provide critical insights for EDs seeking to incorporate continuous improvement strategies. Key lessons and unique challenges encountered in safety net hospitals are discussed.

ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients.

OBJECTIVES: The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO2) measurement and bicarbonate (HCO3) level reflecting the patient's metabolic status. METHOD: This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospital's emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO2 measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS: Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO2 and HCO3 levels (r = 0.506). The mean ET(CO)2 level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)2 measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO2 less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO2 greater than or equal to 36 was 0.05. CONCLUSION: ETCO2 values correlate moderately with HCO3 levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.

The value of ETCO2 measurement for COPD patients in the emergency department.

We aimed to determine the value of sidestream end-tidal carbon dioxide (SS-ETCO2) measurement in patients with chronic obstructive pulmonary disease (COPD) in the emergency department. Cross-sectional associations between ETCO2 and PaCO2 were examined in the study. This prospective cross-sectional study has been carried out over a 3-month period in a tertiary care university hospital emergency department with an annual census of 75 000 visits. During the study period, simultaneous SS-ETCO2 measurement using a Medlab Cap 10 sidestream capnograph was performed on every COPD patient requiring arterial blood gas analysis. The demographics, diagnosis, vital signs, laboratory test results and clinical outcomes of the patients were recorded. SS-ETCO2 measurement and arterial blood gas analysis were carried out on 118 patients. Mean arterial PCO2 levels were 43.24±14.73 and mean ETCO2 levels were 34.23±10.86 mmHg. Agreement between PCO2 and ETCO2 measurements was 8.4 mmHg and a precision of 11.1 mmHg.As there is only a moderate correlation between PCO2 and ETCO2 levels in COPD patients, ETCO2 measurement should not be considered as a part of the decision-making process to predict PaCO2 level in COPD patients.

Reliability of a core competency checklist assessment in the emergency department: the Standardized Direct Observation Assessment Tool.

OBJECTIVES: A Council of Emergency Medicine Residency Directors task force developed the Standardized Direct Observation Assessment Tool (SDOT), a 26-item checklist assessment tool to evaluate Accreditation Council for Graduate Medical Education resident core competencies by direct observation. Each of the checklist items is assigned to one or more of five core competencies. The objective of this study was to test the interrater measurement properties of the SDOT instrument. METHODS: Two videos of simulated patient-resident-attending physician encounters were produced. Academic emergency medicine faculty members not involved in the development of the form viewed the two encounters and completed the SDOT for each. Faculty demographic data were collected. Data were collected from 82 faculty members at 16 emergency medicine residency programs. The checklist items were used to generate a composite score for each core competency of patient care, medical knowledge, interpersonal and communication skills, professionalism, and systems-based practice. RESULTS: Univariate analysis demonstrated a high degree of agreement between evaluators in evaluating residents for both videos. Multivariate analysis found no differences in rating by faculty when examined by experience, academic title, site, or previous use of the SDOT. CONCLUSIONS: Faculty from 16 emergency medicine residency programs had a high interrater agreement when using the SDOT to evaluate resident core competency performance. This study did not test the validity of the tool. This data analysis is mainly descriptive, and scripted video scenarios may not approximate direct observation in the emergency department.

Serum ionized magnesium levels and ionized calcium-to-magnesium ratios in adult patients with sickle cell anemia.

Low levels of total magnesium in sickle cell erythrocytes have been linked to increased sickling due to cell dehydration. We tested the null hypothesis that adult sickle cell anemia (SCA) patients have the same serum level of ionized Mg (Mg(2+)) and Ca(2+)/Mg(2+) ratio as healthy African Americans (AA) and healthy Caucasians (CAUC). We measured serum Mg(2+) and ionized calcium (Ca(2+)) with ion-selective electrodes and calculated the serum Ca(2+)/Mg(2+) ratios in patients with SCA and control groups (AA and CAUC). Seventy-four SCA patients and 61 controls were compared. SCA patients had significantly (P < 0.001) lower levels of serum Mg(2+) (0.52 +/- 0.05) compared to healthy AA (0.57 +/- 0.04) and CAUC (0.62 +/- 0.03). Eighty-six percent of the adult SCA patients had serum Mg(2+) levels below the mean for the AA group, and 96% of SCA patients were above the AA group's mean serum Ca(2+)/Mg(2+). Of the SCA patients studied, 25.6% (95% CI, 16.2-37.2%) had serum Mg(2+) levels below the racially adjusted lower limit of normal and 50% (95% CI, 38.1-61.9%) were above the upper limit of serum Ca(2+)/Mg(2+) for AA controls. By measuring serum Mg(2+) and Ca(2+), we were able to define a subset of SCA patients with hypomagnesemia and elevated Ca(2+)/Mg(2+) ratios, who may benefit from magnesium supplementation.

Systems-based practice: the sixth core competency.

Systems-Based Practice (SBP) is the sixth competency defined by the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. Specifically, SBP requires "Residents [to] demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value." This competency can be divided into four subcompetencies, all of which are integral to training emergency medicine (EM) physicians: resources, providers, and systems; cost-appropriate care; delivery systems; and patient advocacy. In March 2002, the Council of Emergency Medicine Residency Directors (CORD-EM) convened a consensus conference to assist residency directors in modifying the SBP competency specific for EM. The Consensus Group modified the broad ACGME definition for SBP into EM-specific goals and objectives for residency training in SBP. The primary assessment methods from the Toolbox of Assessment Methods were also identified for SBP. They are direct observation, global ratings, 360-degree evaluations, portfolio assessment, and testing by both oral and written exams. The physician tasks from the Model of the Clinical Practice of Emergency Medicine that are most relevant to SBP are out-of-hospital care, modifying factors, legal/professional issues, diagnostic studies, consultation and disposition, prevention and education, multitasking, and team management. Suggested EM residency curriculum components for SBP are already in place in most residency programs, so no additional resources would be required for their implementation. These include: emergency medical services and administrative rotations, directed reading, various interdisciplinary and hospital committee participation, continuous quality improvement project participation, evidence-based medicine instruction, and various didactic experiences, including follow-up, interdisciplinary, and case conferences. With appropriate integration and evaluation of this competency into training programs, it is likely that future generations of physicians and patients will reap the benefits of an educational system that is based on well-defined outcomes and a more systemic view of health care.