"Going through the motions": A qualitative exploration of the impact of emergency medicine resident burnout on patient care.

Objectives: Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care. Methods: Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes. Results: Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making. Conclusions: According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

"Pulling the Parachute": A Qualitative Study of Burnout's Influence on Emergency Medicine Resident Career Choices.

OBJECTIVES: About half of all resident physicians report symptoms of burnout. Burnout negatively influences multiple aspects of their education and training. How burnout may impact residents' career choices remains unclear. The authors explored the role burnout played in residents' career decisions. METHODS: This was a qualitative study among a sample of 29 emergency medicine residents from four institutions. Qualitative data were generated through four semistructured focus groups. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major themes. RESULTS: Five major themes connecting burnout with residents' career choices emerged: 1) residents' current burnout and the prevention of future burnout figured prominently in their career considerations, 2) residents aimed to mitigate sources of burnout through their career choices, 3) residents' view of clinical work as a burden and a burnout contributor spurred the pursuit of other interests, 4) faculty advice and role modeling in relation to burnout shaped residents' career perspectives, and 5) residents weighed long-term burnout concerns with short-term financial needs. CONCLUSION: Burnout played an important role in multiple aspects of residents' career considerations. Educators, program directors, and organization leaders can focus on identified target areas to address burnout's influence on residents' career decisions.

"Necessary Compromises": A Qualitative Exploration of the Influence of Burnout on Resident Education.

OBJECTIVE: Burnout is prevalent among resident physicians and has a negative impact on their well-being and effectiveness at work. How burnout shapes residents' educational experiences, attitudes, habits, and practices is not well understood. There is also a lack of research regarding self-identified mitigation strategies for residents. The authors qualitatively explored burnout's role in the educational experiences of resident physicians. METHODS: Qualitative data were generated from a sample of 29 emergency medicine residents through four semistructured focus groups across four institutions in January and February 2019. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major and minor themes. RESULTS: Residents reported that a misalignment of their individual versus institutional priorities and a lack of agency were significant contributors to their burnout. Residents described how burnout affected multiple aspects of their education, including their motivation and curiosity to learn, engagement in scholarly activity, and teaching of others. Residents identified several ways of building a sense of community that they explained was most useful in mitigating their experiences with burnout. CONCLUSION: Burnout had a negative influence on many facets of residents' educational experiences during training. Program directors and educators can take resident-identified steps to moderate its detrimental role on trainee education.

Intern as Patient: A Patient Experience Simulation to Cultivate Empathy in Emergency Medicine Residents.

INTRODUCTION: Prior work links empathy and positive physician-patient relationships to improved healthcare outcomes. The objective of this study was to analyze a patient experience simulation for emergency medicine (EM) interns as a way to teach empathy and conscientious patient care. METHODS: We conducted a qualitative descriptive study on an in situ, patient experience simulation held during EM residency orientation. Half the interns were patients brought into the emergency department (ED) by ambulance and half were family members. Interns then took part in focus groups that discussed the experience. Data collected during these focus groups were coded by two investigators using a grounded theory approach and constant comparative methodology. RESULTS: We identified 10 major themes and 28 subthemes in the resulting qualitative data. Themes were in three broad categories: the experience as a patient or family member in the ED; application to current clinical practice; and evaluation of the exercise itself. Interns experienced firsthand the physical discomfort, emotional stress and confusion patients and families endure during the ED care process. They reflected on lessons learned, including the importance of good communication skills, frequent updates on care and timing, and being responsive to the needs and concerns of patients and families. All interns felt this was a valuable orientation experience. CONCLUSION: Conducting a patient experience simulation may be a practical and effective way to develop empathy in EM resident physicians. Additional research evaluating the effect of participation in the simulation over a longer time period and assessing the effects on residents' actual clinical care is warranted.

What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda.

OBJECTIVES: To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients. SETTING: A single emergency department (ED) of a district-level hospital in rural Uganda. PARTICIPANTS: 26 710 patient visits. RESULTS: Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound. CONCLUSION: This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.

Mortality related to acute illness and injury in rural Uganda: task shifting to improve outcomes.

BACKGROUND: Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients. METHODS: Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department's quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit. FINDINGS: Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives. INTERPRETATION: This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.

Point-of-care ultrasound education for non-physician clinicians in a resource-limited emergency department.

OBJECTIVE: To describe the outcomes and curriculum components of an educational programme to train non-physician clinicians working in a rural, Ugandan emergency department in the use of POC ultrasound. METHODS: The use of point-of-care ultrasound was taught to emergency care providers through lectures, bedsides teaching and hands-on practical sessions. Lectures were tailored to care providers' knowledge base and available therapeutic means. Every ultrasound examination performed by these providers was recorded over 4.5 years. Findings of these examinations were categorised as positive, negative, indeterminate or procedural. Other radiologic studies ordered over this same time period were also recorded. RESULTS: A total of 22,639 patients were evaluated in the emergency department by emergency care providers, and 2185 point-of-care ultrasound examinations were performed on 1886 patients. Most commonly used were the focused assessment with sonography in trauma examination (53.3%) and echocardiography (16.4%). Point-of-care ultrasound studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all examinations. CONCLUSIONS: We describe a novel curriculum for point-of-care ultrasound education of non-physician emergency practitioners in a resource-limited setting. These non-physician clinicians integrated ultrasound into clinical practice and utilised this imaging modality more frequently than traditional radiology department imaging with a large proportion of positive findings.

Nurse-administered ketamine sedation in an emergency department in rural Uganda.

STUDY OBJECTIVE: We determine whether, after a brief training program in procedural sedation, nurses can safely independently administer ketamine sedation in a resource-limited environment. METHODS: This is an observational case series of consecutive sedations performed in an emergency department in rural Uganda at approximately 5,000 feet above sea level. The data were collected prospectively in a quality assurance database. As part of a larger training program in emergency care at Karoli Lwanga Hospital in rural Uganda, nurses with no sedation experience were trained in procedural sedation with ketamine. All sedations were monitored by a nonphysician research assistant, who recorded ketamine dosing, duration of each procedure, adverse events, and nurse interventions for each adverse event. In accordance with standard definitions in the emergency medicine sedation literature, adverse events were defined a priori and classified as major (death, need for bag-valve-mask ventilation, or unanticipated admission to the hospital) or minor (hypoxia, vomiting, emergence reactions, hypersalivation). The primary statistical analysis was descriptive, with reporting of adverse event rates with 95% confidence intervals (CIs), using the nurse as the unit of analysis. RESULTS: There were a total of 191 administrations by 6 nurses during the study period (December 2009 through March 2010). Overall, there was an 18% adverse event rate (95% CI 7% to 30%), which is similar to the rate reported in resource-rich countries. These events included hypoxia (22 cases; 12%), vomiting (9 cases; 5%), and emergence reaction (7 cases; 4%). All adverse events met our a priori defined criteria for minor events, with a 0% incidence of major events (1-sided 97.5% CI with the nurse as unit of analysis 0% to 46%). The procedural success rate was 99%. Sedation was practitioner rated as "excellent" in 91% of cases (95% CI 86% to 94%) and "good" in 9% (95% CI 6% to 14%). Patients reported they would want ketamine for a future procedure in 98% of cases (95% CI 95% to 100%). CONCLUSION: In resource-limited settings, nurse-administered ketamine sedation appears to be safe and effective. A brief procedural sedation training program, coupled with a comprehensive training program in emergency care, can increase access to appropriate and safe sedation for patients in resource-limited settings.

Alcohol-related hypoglycemia in rural Uganda: socioeconomic and physiologic contrasts.

Hypoglycemia is a rare but important complication seen in patients who present with alcohol intoxication. In a study by Marks and Teale, less than one percent of people with alcohol intoxication who presented to an American emergency department were hypoglycemic [1]. It is even more rare to see an intoxicated patient, who had been eating appropriately prior to or during the intoxication, present in a hypoglycemic coma. However, our analysis of the first 500 patients seen in a newly opened five-bed Emergency Department (ED) at Nyakibale Karoli Lwanga Hospital in rural southwestern Uganda, revealed multiple intoxicated patients who presented in hypoglycemic coma within hours of eating a full meal. Three of these cases are summarized and discussed below.

Comparison of a radial artery compression device with invasive radial artery blood pressure monitoring.

OBJECTIVE: The goal of this study was to validate the accuracy of the Primo radial artery compression device (RACD) according to the guidelines recommended by the American National Standards Institute/Association for the Advancement of Medical Instrumentation (AAMI) SP10-2002 Standards for Electronic or Automated Sphygmomanometers. METHODS: A prospective, nonblind, convenience sample trial at a level 1 trauma center (annual emergency department census 70,000) enrolled 17 adult patients with preexisting radial artery line catheters (RAL). Each patient had 10 blood pressure measurements giving an n=170. This number is consistent with calculations on the basis of the American National Standards Institute/AAMI guidelines. RESULTS: The mean arterial pressures (MAPs), systolic blood pressures (SBPs), and diastolic blood pressures (DBPs) measured by both the RACD and the RAL were compared. The R for the RAL/RACD were 0.94, 0.96, and 0.85 for MAP, SBP, and DBP, respectively (P<0.05). The mean difference between the RAL MAP and the RACD MAP was +1.0 mmHg (95% confidence interval, -1.69 to -0.33). The mean SBP difference was -2.8 mmHg (SD 6.4 mmHg) and the mean DBP difference was +2.6 mmHg (SD 5.7 mmHg). CONCLUSION: The RACD meets the guidelines for automated blood pressure monitors set by the AAMI SP10-2002 Standards for Electronic or Automated Sphygmomanometers with an accuracy of +/- 5 mmHg and SD of 8 mmHg or less for both SBP and DBP measurements.

Measuring access to emergency obstetric care in rural Zambia.

BACKGROUND: Global health experts identify emergency obstetric care (EmOC) as the most important intervention to improve maternal survival in low- and middle-income countries. In Zambia, 1 in 27 women will die of maternal causes, yet the level of availability of EmOC is not known at the provincial level. AIMS: Our goal was to develop a tool to measure the availability of EmOC in rural Zambia in order to estimate pregnant women's access to this life-saving intervention. METHODS: We created an instrument for determining the availability of EmOC based on the supplies and medicines in stock at health facilities as well as the skill level of health workers. We then surveyed a random sample of 35 health centres in the Central Province of Zambia using our novel instrument. RESULTS: We graded health centres based on their ability to provide the six basic functions of EmOC: administering parenteral antibiotics, administering parenteral oxytocics, administering parenteral anticonvulsants, performing manual removal of the placenta, removing retained products of conception and performing assisted vaginal delivery. Of the 29 health centres providing delivery care, 65% (19) were graded as level 1 or 2, 28% (8) as level 3 or 4 and 7% (2) as level 5. No health centre received a grade of level 6. CONCLUSION: The availability of EmOC in the Central Province of Zambia is extremely limited; the majority of health centres provide only one or two basic functions of EmOC, and no health centres perform all six functions. Our grading system allows for inter- and intra-country comparisons by providing a systematic process for monitoring access to EmOC in rural, low-income countries similar to Zambia.