Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis.

BACKGROUND: Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD: The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS: In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS: Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Characterizing malpractice cases involving emergency department advanced practice providers, physicians in training, and attending physicians.

OBJECTIVE: The objective was to evaluate available characteristics and financial costs of malpractice cases among advanced practice providers (APPs; nurse practitioners [NPs] and physician assistants [PAs]), trainees (medical students, residents, fellows), and attending physicians. METHODS: This study was a retrospective analysis of claims occurring in the emergency department (ED) from January 1, 2010, to December 31, 2019, contained in the Candello database. Cases were classified according to the provider type(s) involved: NP, PA, trainee, or cases that did not identify an extender as being substantially involved in the adverse event that resulted in the case ("no extender"). RESULTS: There were 5854 cases identified with a total gross indemnity paid of $1,007,879,346. Of these cases, 193 (3.3%) involved an NP, 513 (8.8%) involved a PA, 535 (9.1%) involved a trainee, and 4568 (78.0%) were no extender. Cases where a trainee was involved account for the highest average gross indemnity paid whereas no-extender cases are the lowest. NP and PA cases differed by contributing factors compared to no-extender cases: clinical judgment (NP 89.1% vs. no extender 76.8%, p < 0.0001; PA 84.6% vs. no extender, p < 0.0001), documentation (NP 23.3% vs. no extender 17.8%, p = 0.0489; PA 25.9% vs. no extender, p < 0.0001), and supervision (NP 22.3% vs. no extender 1.8%, p < 0.0001; PA 25.7% vs. no extender p < 0.0001). Cases involving NPs and PAs had a lower percentage of high-severity cases such as loss of limb or death (NP 45.6% vs. no extender 50.2%, p = 0.0004; PA 48.3% vs. no extender, p < 0.0001). CONCLUSIONS: APPs and trainees comprise approximately 21% of malpractice cases and 33% of total gross indemnity paid in this large national ED data set. Understanding differences in characteristics of malpractice claims that occur in emergency care settings can be used to help to mitigate provider risk.

Assessing resident and attending error and adverse events in the emergency department.

BACKGROUND: There is a paucity of data looking at resident error or contrasting errors and adverse events among residents and attendings. This type of data could be vital in developing and enhancing educational curricula OBJECTIVES: Using an integrated, readily accessible electronic error reporting system the objective of this study is to compare the frequency and types of error and adverse events attributed to emergency medicine residents with those attributed to emergency medicine attendings. METHODS: Individual events were classified into errors and/or adverse events, and were attributed to one of three groups-residents only, attendings only, or both (if the event had both resident and attending involvement). Error and adverse events were also classified into five different categories of events-systems, documentation, diagnostic, procedural and treatment. The proportion of error events were compared between the residents only and the attendings only group using a one-sample test of proportions. Categorical variables were compared using Fisher's exact test. RESULTS: Of a total of 115 observed events over the 11-month data collection period, 96 (83.4%) were errors. A majority of these errors, 40 (41.7%), were attributed to both residents and attendings, 20 (20.8%) were attributed to residents only, and 36 (37.5%) were attributed to attendings only. Of the 19 adverse events, 14 (73.7%) were attributed to both residents and attendings, and 5 (26.3%) adverse events were attributed to attendings only. No adverse events were attributed solely to residents (Table 1). Excluding events attributed to both residents and attendings, there was a significant difference between the proportion of errors attributed to attendings only (64.3%, CI: 50.6, 76.0), and residents only (35.7%, CI: 24.0, 49.0), p = 0.03. (Table 2). There was no significant difference between the residents only and the attendings only group in the distribution of errors and adverse events (Fisher's exact, p = 0.162). (Table 2). There was no statistically significant difference between the two groups in errors that did not result in adverse events and the rate of errors proceeding to adverse events (Fisher's exact, p = 0.15). (Table 3). There was no statistically significant difference between the two groups in the distribution of the types of errors and adverse events (Fisher's exact, p = 0.09). Treatment related errors were the most common error types, for both the attending and the resident groups. CONCLUSIONS: Resident error, somewhat expectedly, is most commonly related to treatment interventions, and rarely is due to an individual resident mistake. Resident error instead seems to reflect concomitant error on the part of the attending. Error, in general as well as adverse events, are more likely to be attributed to an attending alone rather than to a resident.

Correlation of attending and patient assessment of resident communication skills in the emergency department.

BACKGROUND: Communication and interpersonal skills are one of the Accreditation Council for Graduate Medical Education's six core competencies. Validated methods for assessing these among trainees are lacking. Educators have developed various communication assessment tools from both the supervising attending and the patient perspectives. How these different assessment methods and tools compare with each other remains unknown. The goal of this study was to determine the degree of agreement between attending and patient assessment of resident communication skills. METHODS: This was a retrospective study of emergency medicine (EM) residents at an academic medical center. From July 2017 to June 2018, residents were assessed on communication skills during their emergency department shifts by both their supervising attending physicians and their patients. The attendings rated residents' communication skills with patients, colleagues, and nursing/ancillary staff using a 1 to 5 Likert scale. Patients completed the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1 to 5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each resident. Means were divided into tertiles due to nonparametric distribution of scores. Agreement between attending and patient ratings of residents were measured using Cohen's kappa for each attending evaluation question. Scores were weighted to assign adjacent tertiles partial agreement. RESULTS: During the study period, 1,097 attending evaluations and 952 patient evaluations were completed for 26 residents. Attending scores and CAT scores of the residents showed slight to fair agreement in the following three domains: patient communication (κ = 0.21), communication with colleagues (κ = 0.21), and communication with nursing/ancillary staff (κ = 0.26). CONCLUSIONS: Attending and patient ratings of EM residents' communication skills show slight to fair agreement. The use of different types of raters may be beneficial in fully assessing trainees' communication skills.

Procedural training models among emergency medicine residency programs.

OBJECTIVE: Optimal training methods remain controversial for rarely performed emergency procedures. Previous research has failed to demonstrate the superiority or inferiority of live anesthetized animal models (LAA) as compared to other modalities. Most of the data on LAA use comes from military contexts; less information is available for civilian emergency medicine (EM) training. We sought to characterize the prevalence of LAA use among civilian EM residency programs and reasons for its use or discontinuation. METHODS: Survey study of program directors of EM residency programs accredited by the Accreditation Council for Graduate Medical Education. A 16-item questionnaire was electronically delivered to program directors, including program region, current and historical use of LAA, and attitudes regarding the optimal procedural training modalities. RESULTS: Of 179 survey recipients, 83 completed the survey (46.4%). Twelve programs (14.3%) currently use LAA, and 17 programs (20.5%) report previous LAA use. Reasons for discontinuing LAA use included ethical concerns, financial and logistical limitations, political pressures, and feeling that there were superior or equivalent alternative models available. Programs that currently use LAA were more likely to rank LAA as being the most preferable training modality while programs that do not currently use LAA were more likely to rank human cadavers as the most preferable modality. CONCLUSION: Despite a lack of data showing educational outcomes-driven differences between LAA and alternative training models, LAA use is declining among civilian EM residencies. Despite this, disagreement exists among programs that do and do not use LAA regarding the most optimal procedural training.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes.

BACKGROUND: Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population. OBJECTIVE: To report our experience with protocol implications and patient outcome. METHODS: Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed. RESULTS: Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations. CONCLUSION: Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage.

BACKGROUND: Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI). METHODS: Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018. INCLUSION CRITERIA: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm). EXCLUSION CRITERIA: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion. OUTCOMES: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits. RESULTS: 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring. CONCLUSIONS: ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events.

OBJECTIVE: Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. METHODS: We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. RESULTS: EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%-7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%-2.9%). CONCLUSION: A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Year-to-year trends in emergency medicine morbidity and mortality cases.

BACKGROUND: Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings. METHODS: All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed. RESULTS: 350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001). CONCLUSIONS: There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.

Diagnostic error, quality assurance, and medical malpractice/risk management education in emergency medicine residency training programs.

Background Diagnostic errors in emergency medicine (EM) can lead to patient harm as well as potential malpractice claims and quality assurance (QA) reviews. It is therefore essential that these topics are part of the core education of trainees. The methods training programs use to educate residents on these topics are unknown. The goal of this study was to identify the current methods used to teach EM residents about diagnostic errors, QA, and malpractice/risk management and determine the amount of educational teaching time EM programs dedicate to these topics. Methods An 11-item questionnaire pertaining to resident education on diagnostic errors, QA, and malpractice was sent through the Council of Emergency Medicine Residency Directors (CORD) listserv. Differences in the proportions of responses by duration of training program were analyzed using chi-squared or Fisher's exact tests. Results Fifty-four percent (91/168) of the EM programs responded. There was no difference in prevalence of formal education on these topics among 3- and 4-year programs. The majority of programs (59.5%) offer fewer than 4 h per year of additional QA education beyond morbidity and mortality rounds; a minority of the programs (18.8%) offer more than 4 h per year of medical malpractice/risk management education. Conclusions This needs assessment demonstrated that there is a lack of dedicated educational time devoted to these topics. A more formalized and standard curricular approach with increased time allotment may enhance EM resident education about diagnostic errors, QA, and malpractice/risk management.

Chest computed tomography imaging utility for radiographically occult rib fractures in elderly fall-injured patients.

BACKGROUND: Previous studies demonstrate an association between rib fractures and morbidity and mortality in trauma. This relationship in low-mechanism injuries, such as ground-level fall, is less clearly defined. Furthermore, computed tomography (CT) has increased sensitivity for rib fractures compared with chest x-ray (CXR); its utility in elderly fall patients is unknown. We sought to determine whether CT-diagnosed rib fractures in elderly fall patients with a normal CXR were associated with increased in-hospital resource utilization or mortality. METHODS: Retrospective analysis of emergency department patients presenting over a 3-year period. INCLUSION CRITERIA: age, 65 years or older; chief complaint, including mechanical fall; and both CXR and CT obtained. We quantified rib fractures on CXR and CT and reported operating characteristics for both. Outcomes of interest included hospital admission/length of stay (LOS), intensive care unit (ICU) admission/LOS, endotracheal intubation, tube thoracostomy, locoregional anesthesia, pneumonia, in-hospital mortality. RESULTS: We identified 330 patients, mean age was 84 years (±SD, 9.4 years); 269 (82%) of 330 were admitted. There were 96 (29%) patients with CT-diagnosed rib fracture, 56 (17%) by CT only. Compared with CT, CXR had a sensitivity of 40% (95% confidence interval, 30-50%) and specificity of 99% (95% confidence interval, 97-100%) for rib fracture. A median of two additional radiographically occult rib fractures were identified on CT. Despite an increased hospital admission rate (91% vs. 78%) p = 0.02, there was no difference between patients with and without radiographically occult (CT+ CXR-) rib fracture(s) for: median LOS (4; interquartile range (IQR) 2-7 vs 4, IQR 2-8); p = 0.92), ICU admission (28% vs. 27%) p = 0.62, median ICU LOS (2, IQR 1-8 vs 3, IQR 1-5) p = 0.54, or in-hospital mortality (10.3% vs. 7.3%) p = 0.45. CONCLUSION: Among elderly fall patients, CT-identified rib fractures were associated with increased hospital admissions. However, there was no difference in procedural interventions, ICU admission, hospital/ICU LOS or mortality for patients with and without radiographically occult fractures. LEVEL OF EVIDENCE: Diagnostic, level III.

The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department.

BACKGROUND: Acute appendicitis is common in the adult emergency department (ED). Computed tomography (CT) scan is frequently used to diagnose this condition, but ultrasound (US)-commonly used in pediatric diagnosis-may also have a role. OBJECTIVES: Review the clinical utility and define the frequency and diagnostic accuracy of US to diagnose appendicitis in an adult population in the ED setting. METHODS: Retrospective cohort study of patients who underwent appendiceal US in an academic, tertiary ED from July 2013-October 2015. RESULTS: There were 174 patients included, of which 39 (22%) had pathology-confirmed appendicitis. There were 25 patients who had an US scan that was positive for appendicitis, 146 (84%) were indeterminate, and 3 (1.7%) were negative. Among patients with a positive US, 25/25 (100%, 95% confidence interval [CI] 84-100%) had appendicitis, 32/146 (22%, 95% CI 16-29%) with an indeterminate US had appendicitis, and 0/3 (0%, 95% CI 0-6.2%) with a negative US had appendicitis. In the 28 definitive cases, US had a sensitivity of 64%, specificity of 2%, positive predictive value of 100%, and negative predictive value of 100%. The likelihood ratio positive and negative were 173 and 0, respectively. CONCLUSION: Our initial data suggest that an US that shows appendicitis seems to be reliable; however, a high prevalence of indeterminate studies limits the diagnostic utility as a universal approach in adult patients in the ED setting. Larger studies are needed to identify which patient populations would benefit from US as the initial imaging modality, what factors contribute to the large numbers of indeterminate results, and if any interventions may reduce the number of indeterminate results.

Standardized Video Interview Scores Correlate Poorly with Faculty and Patient Ratings.

The Standardized Video Interview (SVI) was developed by the Association of American Medical Colleges to assess professionalism, communication, and interpersonal skills of residency applicants. How SVI scores compare with other measures of these competencies is unknown. The goal of this study was to determine whether there is a correlation between the SVI score and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants. This was a retrospective analysis of a prospectively collected dataset of medical students. Students enrolled in the fourth-year EM clerkship at our institution and who applied to the EM residency Match were included. We collected faculty ratings of the students' professionalism and patient care/communication abilities as well as patient ratings using the Communication Assessment Tool (CAT) from the clerkship evaluation forms. Following completion of the clerkship, students applying to EM were asked to voluntarily provide their SVI score to the study authors for research purposes. We compared SVI scores with the students' faculty and patient scores using Spearman's rank correlation. Of the 43 students from the EM clerkship who applied in EM during the 2017-2018 and 2018-2019 application cycles, 36 provided their SVI scores. All 36 had faculty evaluations and 32 had CAT scores available. We found that SVI scores did not correlate with faculty ratings of professionalism (rho = 0.09, p = 0.13), faculty assessment of patient care/communication (rho = 0.12, p = 0.04), or CAT scores (rho = 0.11, p = 0.06). Further studies are needed to validate the SVI and determine whether it is indeed a predictor of these competencies in residency.

Comparison of Emergency Medicine Malpractice Cases Involving Residents to Nonresident Cases.

BACKGROUND: Data are lacking on how emergency medicine (EM) malpractice cases with resident involvement differs from cases that do not name a resident. OBJECTIVES: The objective was to compare malpractice case characteristics in cases where a resident is involved (resident case) to cases that do not involve a resident (nonresident case) and to determine factors that contribute to malpractice cases utilizing EM as a model for malpractice claims across other medical specialties. METHODS: We used data from the Controlled Risk Insurance Company (CRICO) Strategies' division Comparative Benchmarking System (CBS) to analyze open and closed EM cases asserted from 2009 to 2013. The CBS database is a national repository that contains professional liability data on > 400 hospitals and > 165,000 physicians, representing over 30% of all malpractice cases in the United States (>350,000 claims). We compared cases naming residents (either alone or in combination with an attending) to those that did not involve a resident (nonresident cohort). We reported the case statistics, allegation categories, severity scores, procedural data, final diagnoses, and contributing factors. Fisher's exact test or t-test was used for comparisons (alpha set at 0.05). RESULTS: A total of 845 EM cases were identified of which 732 (87%) did not name a resident (nonresident cases), while 113 (13%) included a resident (resident cases). There were higher total incurred losses for nonresident cases. The most frequent allegation categories in both cohorts were "failure or delay in diagnosis/misdiagnosis" and "medical treatment" (nonsurgical procedures or treatment regimens, i.e., central line placement). Allegation categories of safety and security, patient monitoring, hospital policy and procedure, and breach of confidentiality were found in the nonresident cases. Resident cases incurred lower payments on average ($51,163 vs. $156,212 per case). Sixty-six percent (75) of resident versus 57% (415) of nonresident cases were high-severity claims (permanent, grave disability or death; p = 0.05). Procedures involved were identified in 32% (36) of resident and 26% (188) of nonresident cases (p = 0.17). The final diagnoses in resident cases were more often cardiac related (19% [21] vs. 10% [71], p < 0.005) whereas nonresident cases had more orthopedic-related final diagnoses (10% [72] vs. 3% [3], p < 0.01). The most common contributing factors in resident and nonresident cases were clinical judgment (71% vs. 76% [p = 0.24]), communication (27% vs. 30% [p = 0.46]), and documentation (20% vs. 21% [p = 0.95]). Technical skills contributed to 20% (22) of resident cases versus 13% (96) of nonresident cases (p = 0.07) but those procedures involving vascular access (2.7% [3] vs 0.1% [1]) and spinal procedures (3.5% [4] vs. 1.1% [8]) were more prevalent in resident cases (p < 0.05 for each). CONCLUSIONS: There are higher total incurred losses in nonresident cases. There are higher severity scores in resident cases. The overall case profiles, including allegation categories, final diagnoses, and contributing factors between resident and nonresident cases are similar. Cases involving residents are more likely to involve certain technical skills, specifically vascular access and spinal procedures, which may have important implications regarding supervision. Clinical judgment, communication, and documentation are the most prevalent contributing factors in all cases and should be targets for risk reduction strategies.

Experience Within the Emergency Department and Improved Productivity for First-Year Residents in Emergency Medicine and Other Specialties.

INTRODUCTION: Resident productivity is an important educational and operational measure in emergency medicine (EM). The ability to continue effectively seeing new patients throughout a shift is fundamental to an emergency physician's development, and residents are integral to the workforce of many academic emergency departments (ED). Our previous work has demonstrated that residents make gains in productivity over the course of intern year; however, it is unclear whether this is from experience as a physician in general on all rotations, or specific to experience in the ED. METHODS: This was a retrospective cohort study, conducted in an urban academic hospital ED, with a three-year EM training program in which first-year residents see new patients ad libitum. We evaluated resident shifts for the total number of new patients seen. We constructed a generalized estimating equation to predict productivity, defined as the number of new patients seen per shift, as a function of the week of the academic year, the number of weeks spent in the ED, and their interaction. Off-service residents' productivity in the ED was analyzed in a secondary analysis. RESULTS: We evaluated 7,779 EM intern shifts from 7/1/2010 to 7/1/2016. Interns started at 7.16 (95% confidence interval [CI] [6.87 - 7.45]) patients per nine-hour shift, with an increase of 0.20 (95% CI [0.17 - 0.24]) patients per shift for each week in the ED, over 22 weeks, leading to 11.5 (95% CI [10.6 - 12.7]) patients per shift at the end of their training in the ED. The effects of the week of the academic year and its interaction with weeks in the ED were not significant. We evaluated 2,328 off-service intern shifts, in which off-service residents saw 5.43 (95% CI [5.02 - 5.84]) patients per nine-hour shift initially, with 0.46 additional patients per week in the ED (95% CI [0.25 - 0.68]). The weeks of the academic year were not significant. CONCLUSION: Intern productivity in EM correlates with time spent training in the ED, and not with experience on other rotations. Accordingly, an EM intern's productivity should be evaluated relative to their aggregate time in the ED, rather than the time in the academic year.

Cultural Competency Training in Emergency Medicine.

BACKGROUND: The Emergency Department is widely regarded as the epicenter of medical care for diverse and largely disparate types of patients. Physicians must be aware of the cultural diversity of their patient population to appropriately address their medical needs. A better understanding of residency preparedness in cultural competency can lead to better training opportunities and patient care. OBJECTIVE: The objective of this study was to assess residency and faculty exposure to formal cultural competency programs and assess future needs for diversity education. METHODS: A short survey was sent to all 168 Accreditation Council for Graduate Medical Education program directors through the Council of Emergency Medicine Residency Directors listserv. The survey included drop-down options in addition to open-ended input. Descriptive and bivariate analyses were used to analyze data. RESULTS: The response rate was 43.5% (73/168). Of the 68.5% (50/73) of residency programs that include cultural competency education, 90% (45/50) utilized structured didactics. Of these programs, 86.0% (43/50) included race and ethnicity education, whereas only 40.0% (20/50) included education on patients with limited English proficiency. Resident comfort with cultural competency was unmeasured by most programs (83.6%: 61/73). Of all respondents, 93.2% (68/73) were interested in a universal open-source cultural competency curriculum. CONCLUSIONS: The majority of the programs in our sample have formal resident didactics on cultural competency. Some faculty members also receive cultural competency training. There are gaps, however, in types of cultural competency training, and many programs have expressed interest in a universal open-source tool to improve cultural competency for Emergency Medicine residents.

Interview Day Environment May Influence Applicant Selection of Emergency Medicine Residency Programs.

INTRODUCTION: The structure of the interview day affects applicant interactions with faculty and residents, which can influence the applicant's rank list decision. We aimed to determine if there was a difference in matched residents between those interviewing on a day on which didactics were held and had increased resident and faculty presence (didactic day) versus an interview day with less availability for applicant interactions with residents and faculty (non-didactic day). METHODS: This was a retrospective study reviewing interview dates of matched residents from 2009-2015. RESULTS: Forty-two (61.8%) matched residents interviewed on a didactic day with increased faculty and resident presence versus 26 (38.2%) on a non-didactic interview day with less availability for applicant interactions (p = 0.04). CONCLUSION: There is an association between interviewing on a didactic day with increased faculty and resident presence and matching in our program.

The Integration of Electronic Medical Student Evaluations Into an Emergency Department Tracking System is Associated With Increased Quality and Quantity of Evaluations.

BACKGROUND: Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. OBJECTIVES: To determine whether electronic medical student evaluations (EMSEs) provide more evaluations and content when compared to paper shift card evaluations. METHODS: This before and after cohort study was conducted over a 2.5-year period at an academic hospital affiliated with a medical school and emergency medicine residency program. EMSEs replaced the paper shift evaluations that had previously been used halfway through the study period. A random sample of the free text comments on both paper and EMSEs were blindly judged by medical student clerkship directors for their helpfulness and usefulness. Logistic regression was used to test for any relationship between quality and quantity of words. RESULTS: A total of 135 paper evaluations for 30 students and then 570 EMSEs for 62 students were collected. An average of 4.8 (standard deviation [SD] 3.2) evaluations were completed per student using the paper version compared to 9.0 (SD 3.8) evaluations completed per student electronically (p < 0.001). There was an average of 8.8 (SD 8.5) words of free text evaluation on paper evaluations when compared to 22.5 (SD 28.4) words for EMSEs (p < 0.001). A statistically significant (p < 0.02) association between quality of an evaluation and the word count existed. CONCLUSIONS: EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.