Considering Burnout and Well-Being: Emergency Medicine Resident Shift Scheduling Platform and Satisfaction Insights from a Quality Improvement Project.

Few studies explore emergency medicine (EM) residency shift scheduling software as a mechanism to reduce administrative demands and broader resident burnout. A local needs assessment demonstrated a learning curve for chief resident schedulers and several areas for improvement. In an institutional quality improvement project, we utilized an external online cross-sectional convenience sampling pilot survey of United States EM residency programs to collect information on manual versus software-based resident shift scheduling practices and associated scheduler and scheduler-perceived resident satisfaction. Our external survey response rate was 19/253 (8%), with all United States regions (i.e., northeast, southeast, midwest, west, and southwest) represented. Two programs (11%) reported manual scheduling without any software. ShiftAdmin was the most popularly reported scheduling software (53%). Although not statistically significant, manual scheduling had the lowest satisfaction score and programs with ≤30 residents reported the highest levels of satisfaction. Our data suggest that improvements in existing software-based technologies are needed. Artificial intelligence technologies may prove useful for reducing administrative scheduling demands and optimizing resident scheduling satisfaction.

From inequity to access: Evidence-based institutional practices to enhance care for individuals with disabilities.

People with disabilities experience barriers to care in all facets of health care, from engaging with the provider in a clinical setting (attitudinal and communication barriers) to navigating a large institution in a complex health care environment (organizational and environmental barriers), culminating in significant health care disparities. Institutional policy, culture, and physical layout may be inadvertently fostering ableism, which can perpetuate health care inaccessibility and health disparities in the disability community. Here, we present evidence-based interventions at the provider and institutional levels to accommodate patients with hearing, vision, and intellectual disabilities. Institutional barriers can be met with strategies of universal design (i.e., accessible exam rooms and emergency alerts), maximizing electronic medical record accessibility/visibility, and institutional policy development to recognize and reduce discrimination. Barriers at the provider level can be met with dedicated training on care of patients with disabilities and implicit bias training specific to the surrounding patient demographics. Such efforts are crucial to ensuring equitable access to quality care for these patients.

Direct Observation Tools in Emergency Medicine: A Systematic Review of the Literature.

OBJECTIVES: Direct observation is important for assessing the competency of medical learners. Multiple tools have been described in other fields, although the degree of emergency medicine-specific literature is unclear. This review sought to summarize the current literature on direct observation tools in the emergency department (ED) setting. METHODS: We searched PubMed, Scopus, CINAHL, the Cochrane Central Register of Clinical Trials, the Cochrane Database of Systematic Reviews, ERIC, PsycINFO, and Google Scholar from 2012 to 2020 for publications on direct observation tools in the ED setting. Data were dual extracted into a predefined worksheet, and quality analysis was performed using the Medical Education Research Study Quality Instrument. RESULTS: We identified 38 publications, comprising 2,977 learners. Fifteen different tools were described. The most commonly assessed tools included the Milestones (nine studies), Observed Structured Clinical Exercises (seven studies), the McMaster Modular Assessment Program (six studies), Queen's Simulation Assessment Test (five studies), and the mini-Clinical Evaluation Exercise (four studies). Most of the studies were performed in a single institution, and there were limited validity or reliability assessments reported. CONCLUSIONS: The number of publications on direct observation tools for the ED setting has markedly increased. However, there remains a need for stronger internal and external validity data.

Individualized Interactive Instruction: A Guide to Best Practices from the Council of Emergency Medicine Residency Directors.

Over the last several years, there has been increasing interest in transitioning a portion of residency education from traditional, lecture-based format to more learner-centered asynchronous opportunities. These asynchronous learning activities were renamed in 2012 by the Accreditation Council for Graduate Medical Education (ACGME) as individualized interactive instruction (III). The effectiveness and applicability of III in residency education has been proven by multiple studies, and its routine use has been made officially acceptable as per the ACGME. This article provides a review of the current literature on the implementation and utilization of III in emergency medicine residency education. It provides examples of currently implemented and studied III curricula, identifies those III learning modalities that can be considered best practice, and provides suggestions for program directors to consider when choosing how to incorporate III into their residency teaching.

A Novel Simulation to Assess Residents' Utilization of a Medical Interpreter.

Introduction: Physicians must be facile in working with a medical interpreter (MI) given the large population of patients with limited English proficiency. Methods: To facilitate residents' assessment of their ability to interact with non-English-speaking patients, we developed a simulation case involving one such patient. The case involved a 31-year-old Spanish-speaking postpartum female who presented with eclamptic seizures. The learner needed to request an MI to assist with obtaining the patient's medical history once her concerned family member (also Spanish speaking) arrived. The major critical actions included appropriate use of MI services, recognition of the risk for eclamptic seizures, proper evaluation and treatment, and appropriate disposition to an obstetrician. The case required a high-fidelity mannequin and simulation operator, nurse simulated participant, Spanish-speaking actor (to play the husband or family member), certified Spanish MI, and faculty evaluator. Results: We implemented this case with 60 emergency medicine residents, ranging from PGY 1 to 3. The learner was assessed by both the faculty observer and MI. Checklists for assessment and debriefing materials were provided. Two of 60 residents did not request an MI. When compared to a prior version of this case that did not include the language barrier, median scores dropped from 12 to 10 out of 24, suggesting that the language barrier created a more challenging case. Discussion: The use of MIs is an integral part of health care practice in the United States, and we present a simulation case that can assess learners' use of MIs.

Gender Bias in Simulation-Based Assessments of Emergency Medicine Residents.

BACKGROUND: Gender-related disparities persist in medicine and medical education. Prior work has found differences in medical education assessments based on gender. OBJECTIVE: We hypothesized that gender bias would be mitigated in a simulation-based assessment. METHODS: We conducted a retrospective cohort study of emergency medicine residents at a single, urban residency program. Beginning in spring 2013, residents participated in mandatory individual simulation assessments. Twelve simulated cases were included in this study. Rating forms mapped milestone language to specific observable behaviors. A Bayesian regression was used to evaluate the effect of resident and rater gender on assessment scores. Both 95% credible intervals (CrIs) and a Region of Practical Equivalence approach were used to evaluate the results. RESULTS: Participants included 48 faculty raters (25 men [52%]) and 102 residents (47 men [46%]). The difference in scores between male and female residents (M = -0.58, 95% CrI -3.31-2.11), and male and female raters (M = 2.87, 95% CrI -0.43-6.30) was small and 95% CrIs overlapped with 0. The 95% CrI for the interaction between resident and rater gender also overlapped with 0 (M = 0.41, 95% CrI -3.71-4.23). CONCLUSIONS: In a scripted and controlled system of assessments, there were no differences in scores due to resident or rater gender.

Simulation for Assessment of Milestones in Emergency Medicine Residents.

OBJECTIVES: All residency programs in the United States are required to report their residents' progress on the milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency-based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed three simulation scenarios with scenario-specific milestone-based assessment tools. We aimed to gather validity evidence for this tool. METHODS: We conducted a prospective observational study to investigate the validity evidence for three mannequin-based simulation scenarios for assessing individual residents on emergency medicine (EM) milestones. The subcompetencies (i.e., patient care [PC]1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario-specific checklist (CL) items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The inter-rater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the CL items as well as the global rating scales (GRSs) for each scenario. Comparing GRS and CL scores between various postgraduate year (PGY) levels was performed with analysis of variance. RESULTS: Eight subcompetencies were chosen to assess with three simulation cases, using 118 subjects. Evidence of test content, internal structure, response process, and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were >0.8 for all cases, with one exception (clinical management GRS = 0.74 in sepsis case). The sum of CL items and GRSs (p < 0.05) discriminated between PGY levels on all cases. However, when the specific CL items were mapped back to milestones in various proficiency levels, the milestones in the higher proficiency levels (level 3 [L3] and 4 [L4]) did not often discriminate between various PGY levels. L3 milestone items discriminated between PGY levels on five of 12 occasions they were assessed, and L4 items discriminated only two of 12 times they were assessed. CONCLUSION: Three simulation cases with scenario-specific assessment tools allowed evaluation of EM residents on proficiency L1 to L4 within eight of the EM milestone subcompetencies. Evidence of test content, internal structure, response process, and relations with other variables were found. Good to excellent IRR and the ability to discriminate between various PGY levels was found for both the sum of CL items and the GRSs. However, there was a lack of a positive relationship between advancing PGY level and the completion of higher-level milestone items (L3 and L4).

Isoniazid Poisoning: A Pediatric Simulation Case for Emergency Medicine Residents.

INTRODUCTION: Seizures in the setting of isoniazid (abbreviated INH, from isonocotinylhydrazide) toxicity can be intractable and persistent despite treatment with the usual status epilepticus (SE) medications. If not recognized in a timely fashion, SE can lead to significant morbidity and mortality. This simulation scenario instructs emergency medicine and pediatric residents and fellows in any year of training on the principles and management strategies of approaching a pediatric patient with SE due to INH toxicity. METHODS: This scenario presents a 5-year-old pediatric patient brought into the emergency department after a witnessed seizure at home, another en route to the emergency department, and a third event in front of the medical provider. This scenario was designed to include one 15- to 20-minute group simulation session, followed by a 10- to 15-minute debriefing of the case. The simulation can be run with a minimum of two participants-one to play the role of physician and the other to play the case director or simulation operator. Also included are visual stimuli consisting of relevant lab results, imaging, and other diagnostic studies. Finally, an educational handout created for all simulation participants reviews important teaching points related to the case. RESULTS: To date, 30 residents have participated in this simulation during one of the weekly conference days. In the postactivity survey reviews, residents have reaffirmed their appreciation for their simulation time and have requested more exposure. DISCUSSION: Simulation scenarios are an ideal teaching tool for rare and life-threatening diseases, as medical trainees will have little to no prior applied experience with such conditions.

Tachydysrhythmia treatment and adverse events in patients with wolff-Parkinson-white syndrome.

BACKGROUND: Current guidelines recommend avoiding atrioventricular-nodal blocking agents (AVNB) when treating tachydysrhythmias in Wolff-Parkinson-White syndrome (WPW) patients. STUDY OBJECTIVES: We investigated medications selected and resulting outcomes for patients with tachydysrhythmias and WPW. METHODS: In this single-center retrospective cohort study, we searched a hospital-wide database for the following inclusion criteria: WPW, tachycardia, and intravenous antidysrhythmics. The composite outcome of adverse events was acceleration of tachycardia, new hypotension, new malignant dysrhythmia, and cardioversion. The difference in binomial proportions of patients meeting the composite outcome after AVNB or non-AVNB (NAVNB) treatment was calculated after dividing the groups by QRS duration. A random-effects mixed linear analysis was performed to analyze the vital sign response. RESULTS: The initial database search yielded 1158 patient visits, with 60 meeting inclusion criteria. Patients' median age was 52.5 years; 53% were male, 43% presented in wide complex tachycardia (WCT), with 75% in atrial fibrillation (AF) or flutter. AVNBs were administered in 42 (70%) patient visits. For those patients with WCT in AF, the difference in proportions of patients meeting the composite outcome after AVNBs vs. NAVNBs treatment was an increase of 3% (95% confidence interval [CI] -39%-49%), and for those with narrow complex AF it was a decrease of 13% (95% CI -37%-81%). No instances of malignant dysrhythmia occurred. Mixed linear analysis showed no statistically significant effects on heart rate, though suggested a trend toward increasing heart rate after AVNB in wide complex AF. CONCLUSION: In this sample of WPW-associated tachydysrhythmia patients, many were treated with AVNBs. The composite outcome was similarly met after use of either AVNB or NAVNB, and no malignant dysrhythmias were observed.