Simulation-based assessment for the emergency medicine milestones: a national survey of simulation experts and program directors

The focus of outcome-based education has shifted from the process of training to the end“product”of education.This has necessitated a reframing of the teaching,learning,and assessment.Therefore,in 2013,the Accreditation Council for Graduate Medical Education(ACGME)implemented the educational milestones for all accredited residencies and fellowship programs.[1]The milestones have been described as“developmentally based,specialty-specific achievements that residents are expected to demonstrate at established intervals as they progress through training.”[1]Milestones are based on the six core competencies established by the ACGME and American Board of Medical Specialties(ABMS),which consist of medical knowledge(MK),patient care(PC),interpersonal and communication skills(ICS),practice-based learning and improvement(PBLI),professionalism(PROF),and systems-based practice(SBP).[2,3]ACGME,in conjunction with the American Board of Emergency Medicine(ABEM),drafted 23 detailed subcompetencies relevant to emergency medicine(EM).[4]

Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts： A randomized trial

BACKGROUND: Sleep deprivation resulting from night shifts, is a major cause of burnout among physicians. Exogenous melatonin may improve sleep quality in night-shift workers. The study aims to compare the effectiveness of melatonin versus placebo on sleep effi ciency in emergency medicine(EM) residents. METHODS: A randomized, double-blind, replicated crossover trial was performed on EM residents. This study consisted of 4 phases within a month with intervention periods of 2 nights and washouts of 6 days. In our study, EM residents had nine-hour shifts on 6 consecutive days, 2 mornings, 2 evenings and 2 nights and then 2 days off. At the end of shifts' cycle, 24 EM residents were given 3 mg melatonin or placebo(12 in each arm of the study) for 2 consecutive nights after the second night shift with crossover to the other arm after a six-day off drug. This crossover intervention was repeated for two more another time. Finally, we created 48 cases and comparisons in each arm. Different items related to sleep quality were assessed and compared both within the same group and between the two groups. RESULTS: In the melatonin group, daytime sleepiness(calculated by Karolinska Sleep Scale) had a signifi cant reduction after taking the second dose of drug(P=0.003) but the same result was not observed when comparing the 2 groups. Mood status(calculated by Profile of Mood States) showed no remarkable difference between the 2 groups. CONCLUSION: Melatonin might have a limited benefi t on sleep quality in EM residents working night shifts.

German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005–2015

BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classifi cation resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.CONCLUSION: Communication defi cits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.

Emergency medicine as a growing career in Iran： an Internet-based survey

BACKGROUND: In Iran, few studies have evaluated emergency medicine as a career option. In the present study, we aimed to find out how Iranian emergency-medicine specialists view their specialty as a career.METHODS: Following a qualitative study, a Likert-scale questionnaire was developed. Iranian emergency physician specialists who had at least two years' job experience were contacted via email. A uniform link to a Web-based survey and a cover letter that explained the survey were sent to the recipients. We used the Kruskal-Wallis test and post hoc analysis to determine the differences between demographic subgroups.RESULTS: A total of 109 eligible responses were received, a response rate of 72.63%. Of the responders, 57.8% were 30–40 years of age, 86.2% were male, 86.2% were single, 84.4% were faculty members and 90.8% had fewer than 10 years' job experience. The main problems occurring during the career of Iranian emergency physicians were: insuffi cient income, inadequate recognition of the specialty by the community, inadequate union support, insecurity in the emergency wards, overcrowding, job stresses and night shifts. Despite insufficiency of income, Iranian emergency physicians(EPs) did not care about the financial benefits of patient care. Academic activity had positive effects on the perspectives of Iranian emergency physicians regarding their careers.CONCLUSION: Iranian emergency physicians and leaders in emergency medicine should struggle to improve the present situation, aiming at an ideal state.

Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia

BACKGROUND: We compare educational environments(i.e. physical, emotional and intellectual experiences) of emergency medicine(EM) residents training in the United States of America(USA) and Saudi Arabia(SA).METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure(PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales(autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance.RESULTS: A total of 219 surveys were returned for 260 residents across six programs(3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%–100%. All six residencies were qualitatively rated as "more positive than negative but room for improvement". Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries(P=0.243); however, role autonomy(P<0.001) and teaching(P=0.005) were better in USA programs. There were no significant differences by post-graduate training year.CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.

Emergency department operations and management education in emergency medicine training

BACKGROUND:This study was undertaken to examine the current level of operations and management education within US-based Emergency Medicine Residency programs.METHODS:Residency program directors at all US-based Emergency Medicine Residency programs were anonymously surveyed via a web-based instrument.Participants indicated their levels of residency education dedicated to documentation,billing/coding,core measure/quality indicator compliance,and operations management.Data were analyzed using descriptive statistics for the ordinal data/Likert scales.RESULTS:One hundred and six(106)program directors completed the study instrument of one hundred and fifty-six(156)programs(70%).Of these,82.6%indicated emergency department(ED)operations and management education within the training curriculum.Dedicated documentation training was noted in all but 1 program(99%).Program educational offerings also included billing/coding(83%),core measure/quality indicators(78%)and operations management training(71%).In all areas,the most common means of educating came through didactic sessions and direct attending feedback or 69%-94%and 72%-98%respectively.Residency leadership was most confident with resident understanding of quality documentation(80%)and less so with core measures(72%),billing/coding/RVUs(58%),and operations management tools(23%).CONCLUSIONS:While most EM residency programs integrate basic operational education related to documentation and billing/coding,a smaller number provide focused education on the dayto-day management and operations of the ED.Residency leadership perceives graduating resident understanding of operational management tools to be limited.All respondents value further resident curriculum development of ED operations and management.

Expert consensus on emergency medicine procedure optimization guided by routine prevention and control strategy for COVID-19

The outbreak of coronavirus disease 2019(COVID-19)was declared a global public health emergency on 31 January 2020.Emergency medicine procedures in Emergency Department should be optimized to cope with the current COVID-19 pandemic by providing subspecialty services,reducing the spread of nosocomial infections,and promoting its capabilities to handle emerging diseases.Thus,the Chinese Society of Emergency Medicine and Wuhan Society of Emergency Medicine drafted this consensus together to address concerns of medical staffs who work in Emergency Department.Based on in-depth review of COVID-19 diagnosis and treatment plans,literatures,as well as management approval,this consensus proposes recommendations for improving the rationalization and efficiency of emergency processes,reducing the risk of nosocomial infections,preventing hospital viral transmission,and ensuring patient safety.

The use of outcome feedback by emergency medicine physicians: Results of a physician survey

BACKGROUND: Feedback on patient outcomes is invaluable to the practice of emergency medicine but examples of effective forms of feedback have not been well characterized in the literature. We describe one system of emergency department(ED) outcome feedback called the return visit report(RVR) and present the results of a survey assessing physicians' perceptions of this novel form of feedback. METHODS: An Opinio web-based survey was conducted in 81 emergency physicians(EPs) at three EDs.RESULTS: Of the 81 physicians surveyed, 40(49%) responded. Most participants indicated that they frequently review their RVRs(83%), that RVRs are valuable to their practice of medicine(80%), and that RVRs alter their practice in future encounters(57%). Respondents reported seeking other forms of outcome feedback including speaking with other EPs(83%) and reviewing discharge summaries of admitted patients(87%). There was no correlation between demographic data and use of RVRs.CONCLUSION: EPs value RVRs as a form of feedback. RVRs could be improved by reducing the observational interval and optimizing report relevance and differential weighting.

Emergency medicine providers＇ opioid prescribing practices stratified by gender, age, and years in practice

BACKGROUND: Emergency medicine providers(EMPs) prescribe about 25% of opioids, but the effect of EMP risk perception on decisions to prescribe opioids is unknown. This study was undertaken to identify factors that infl uence EMP risk and opioid prescribing practices.METHODS: We distributed an anonymous questionnaire to EMPs at a military trauma and referral center. Response frequencies and distributions were assessed for independence using the Chi-square test.RESULTS: Eighty-nine EMPs completed the questionnaire(100% response). Respondents were primarily younger male physicians(80%) in practice under fi ve years(55%). Male EMPs were more likely to prescribe more opioid tablets than female ones both when and when not concerned for opioid misuse(P<0.001, P<0.007, respectively). Of the providers, 70% stated that patient age would inf luence their prescribing decisions. Hydrocodone and oxycodone were the opioids prescribed most frequently. About 60% of the providers reported changing their prescribing behavior would not prevent opioid misuse. Additionally, 40% of the providers believed at least 10% of patients seen at this military ED misused opioids.CONCLUSION: Female EM providers reported prescribing fewer opioid tablets. Patient age infl uenced prescribing behavior, but the effect is unknown. Finally, EM providers reported that altering their prescribing behavior would not prevent prescription opioid misuse.

Community emergency medicine:Benefits and challenges of screening for elder abuse in the emergency department of a developing country

As people live longer and fewer babies are born, the elderly became the fastest and largest growing population of the world, expected to increase further from 86 million in 2005 to 394 million in 2050 worldwide. Older patients represent a large bulk of the population arriving in emergency departments （EDs） all over the world.[1] They use hospitals more frequently than younger patients, have more hospital admissions from the ED and more prolonged hospital stays.[2] Elder abuse is defined as a single, or repeated, act which causes harm or distress to an older person and it can occur within any relationship where there is an expectation of trust from the elder person＇s perspective.[3,4] The ED setting is a particularly important environment being the first point of contact with formal services for the abused elderly population.[5] Careful consideration is demanded when older people attend the ED, with particular attention paid to assessment of subjective and objective data in terms of manifestations and potential indicators of abuse.

The state and future of emergency medicine in Macedonia

BACKGROUND:Macedonia has universal public health care coverage.Acute and emergency patient care is provided in different care environments based on the medical complaint and resource proximity.While emergency medicine and well organized emergency departments(EDs) are an essential component of any developed health care system,emergency medicine as a specialty is relatively non-existent in Macedonia.DATA RESOURCES:A system assessment regarding presence,availability and capacity of EDs was completed from 2013-2015,based upon assessments of 21 institutions providing emergency care and information provided by the Ministry of Health.This assessment establishes a benchmark from which to strategically identify,plan and implement the future of emergency medicine in Macedonia.RESULTS:In general,emergency departments- defined by offering acute care 24 hours per day,7 days per week- were available at all general and university hospitals.However,care resources,emergency and acute care training,and patient care capacity vary greatly within the country.There is limited uniformity in acute care approach and methodology.Hospital EDs are not organized as separate divisions run by a head medical doctor,nor are they staffed by specialists trained in emergency medicine.The diagnostic and treatment capacities are insufficient or outdated by current international emergency medicine standards and frequently require patient transfer or admission prior to initiation.CONCLUSION:Most of the surveyed hospitals are capable of providing essential diagnostic tests,but very few are able to do so at the point or time of presentation.While emergency medical services(EMS) have improved system-wide,emergent care interventions by EMS and within all hospitals remain limited.Further system-wide acute and emergency care improvements are forthcoming.

Emergency medicine in China： present and future

BACKGROUND： Emergency medicine was inaugurated, as an official specialty in China, only25 years ago, and its growth in clinical practice and academic development since that time have beenremarkable.METHODS： This paper is a critical and descriptive review on current situations in emergencymedicine in China, based on the literature review, personal observations, interviews with manyChinese emergency medicine doctors and experts, and personal experience in both China and USA.RESULTS： The current practice of emergency medicine in China encompasses three areas： prehospitalmedicine, emergency medicine, and critical care medicine. Most tertiary emergency departments（EDs） are structurally and functionally divided into several clinical areas, allowing the ED itself to functionas a small independent hospital. While Chinese emergency physicians receive specialty training througha number of pathways, national standards in training and certifi cation have not yet been developed. As aresult, the scope of practice for emergency physicians and the quality of clinical care vary greatly betweenindividual hospitals. Physician recruitment, diffi cult working conditions, and academic promotion remain asmajor challenges in the development of emergency medicine in China.CONCLUSION： To further strengthen the specialty advancement, more government leadershipis needed to standardize regional training curriculums, elucidate practice guidelines, provide fundingopportunities for academic development in emergency medicine, and promote the development of asystem approach to emergency care in China.

Images in emergency medicine:giant ascending aortic aneurysm dissection with hemopericardium

Acute chest pain represents a common presentation at emergency department. Aortic dissection in young patients, however, is fortunately rare. We report a case of giant ascending aortic aneurysm with Stanford type A aortic dissection in an otherwise well 22-year-old male patient. Operative aortic valve and root replacement was undertaken with favourable outcome. Histopathologic examination of the resected aorta revealed acute on chronic inflammatory change with Langerhans type giant cells consistent with a diagnosis of giant cell aortitis. While uncommon, emergencies of the aorta may present in young patients. Predisposing conditions are discussed.

Evaluation of factors affecting psychological morbidity in emergency medicine practitioners

BACKGROUND: Assessing and evaluating mental health status can provide educational planners valuable information to predict the quality of physicians' performance at work. These data can help physicians to practice in the most desired way. The study aimed to evaluate factors affecting psychological morbidity in Iranian emergency medicine practitioners at educational hospitals of Tehran.METHODS: In this cross sectional study 204 participants(emergency medicine residents and specialists) from educational hospitals of Tehran were recruited and their psychological morbidity was assessed by using a 28-question Goldberg General Health Questionnaire(GHQ-28). Somatization, anxiety and sleep disorders, social dysfunction and depression were evaluated among practitioners and compared to demographic and job related variables.RESULTS: Two hundreds and four participants consisting of 146(71.6%) males and 58(28.4%) females were evaluated. Of all participants, 55(27%) were single and 149(73%) were married. Most of our participants(40.2%) were between 30–35 years old. By using GHQ-28, 129(63.2%) were recognized as normal and 75(36.8%) suffered some mental health disorders. There was a signifi cant gender difference between normal practitioners and practitioners with disorder(P=0.02) while marital status had no significant difference(P=0.2). Only 19(9.3%) declared having some major mental health issue in the previous month.CONCLUSION: Females encountered more mental health disorders than male(P=0.02) and the most common disorder observed was somatization(P=0.006).

Emergency medicine residencies structure of trainees'administrative experience:A cross-sectional survey

BACKGROUND:While the Accreditation Council for Graduate Medical Education(ACGME)mandates that emergency medicine residencies provide an educational curriculum that includes administrative seminars and morbidity and mortality conference,there is significant variation as to how administrative topics are implemented into training programs.We seek to determine the prevalence of dedicated administrative rotations and details about the components of the curriculum.METHODS:In this descriptive study,a 12-question survey was distributed via the CORD listserv;each member program was asked questions concerning the presence of an administrative rotation and details about its components.These responses were then analyzed with simple descriptive statistics.RESULTS:A total of 114 of the 168 programs responded,leading to a 68%response rate.Of responders,73%have a dedicated administrative rotation(95%CI 64.0 to 80.4).The content areas covered by the majority of programs with a dedicated program include performance improvement(n=68),patient safety(n=64),ED operations(n=58),patient satisfaction(n=54),billing and coding(n=47),and inter-professional collaboration(n=43).Experiential learning activities include review of patient safety reports(n=66)and addressing patient complaints(n=45).Most of the teaching on the rotation is either in-person(n=65)and/or self-directed reading assignments(n=48).The most commonly attended meetings during the rotation include performance improvement(n=60),ED operations(n=59),and ED faculty(n=44).CONCLUSION:This paper provides an overview of the most commonly covered resident administrative experiences that can be a guide as we work to develop an ideal administrative curriculum for EM residents.

Retrospective Cohort Study on Acute Care in Obstetrics and Gynecology: Analogies and Differences When Compared to Emergency Medicine

Introduction: the demand for urgent obstetric and gynecology care has progressively increased: in the United States approximately 1.4 million gynecologic visits are made to the emergency department (ED) annually, while almost 75% of women make at least 1 unscheduled visit during pregnancy. Moreover, research has recently focused on setting standards in unscheduled care, and developing quality indicators to improve patients’ health. Therefore, we investigated the characteristics of women with acute gynecological or pregnancy complaints using quality indicators developed for emergency medicine, to better define the needs of this population and improve care. Methods: Retrospective cohort study on ED, and Obstetrics and Gynecology (ObGyn) triage visits, at a tertiary care hospital in Italy, during 2012. Data were analyzed with population-averaged logistic regression and Poisson regression. Results: When compared to the 33,557 ED visits, the 9245 ObGyntriage referrals were more frequently associated with pregnancy (≤12 weeks’ gestation, OR: 30.7, 95%CI;24.5 - 38.4;>12 weeks’ gestation, OR 81.2, 95%CI;64.8 - 101.4), vaginal bleeding (OR 156.6, 95%CI;82.7 - 294.4), diurnal (night access OR 0.87, 95% CI;0.78 - 0.96) and weekday access (holiday access OR 0.87, 95%CI;0.78 - 0.95), frequent users (recurrent ED visits IRR 0.87, 95%CI;0.83 - 0.9) and lower hospital admissions (ED admission OR 1.6, 95%CI;1.4 - 1.8). Conclusion: ObGyn triage patients differed from ED users, and were at higher risk of “crowding”. Such diversities should be considered to improve female healthcare services and allocate resources more efficiently.

COVID-19 and cardiovascular complications:updates of emergency medicine

Coronavirus disease 2019(COVID-19),caused by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)and SARS-CoV-2 variants,has become a global pandemic resulting in significant morbidity and mortality.Severe cases of COVID-19 are characterized by hypoxemia,hyperinflammation,cytokine storm in lung.Clinical studies have reported an association between COVID-19 and cardiovascular disease(CVD).Patients with CVD tend to develop severe symptoms and mortality if contracted COVID-19 with further elevations of cardiac injury biomarkers.Furthermore,COVID-19 itself can induce and promoted CVD development,including myocarditis,arrhythmia,acute coronary syndrome,cardiogenic shock,and venous thromboembolism.Although the direct etiology of SARS-CoV-2–induced cardiac injury remains unknown and underinvestigated,it is suspected that it is related to myocarditis,cytokine-mediated injury,microvascular injury,and stress-related cardiomyopathy.Despite vaccinations having provided the most effective approach to reducing mortality overall,an adapted treatment paradigm and regular monitoring of cardiac injury biomarkers is critical for improving outcomes in vulnerable populations at risk for severe COVID-19.In this review,we focus on the latest progress in clinic and research on the cardiovascular complications of COVID-19 and provide a perspective of treating cardiac complications deriving from COVID-19 in emergency medicine.

Epidemiology of Hand Injuries That Presented to the Emergency Department of a Tertiary Care Facility in Suburban Mumbai, India: A Study Including 489 Patients

Background: Hand injuries are very common and responsible for a significant number of emergency department (ED) visits, most of which are not to hand specialists [1]. The functionality and outcome of hand injuries can vary significantly depending on the mechanism and pattern of injuries, which is why it is imperative for emergency physicians to recognize the complexities, and the potential repercussion of missed injuries in such cases. Objective: The aim of this study is to provide epidemiological information on hand injuries and their patterns. The objective is 1) to assess whether most hand injuries are superficial (simple), or involve underlying deeper structures (complex) and 2) to assess whether most hand injuries presented to the emergency department were managed by the emergency physician or plastic/orthopaedic surgeon. Methods: This retrospective single-centre observational study conducted at an emergency department in a tertiary care hospital in Mumbai, India collected data from hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, and disposition plans were analysed. Results: A total of 489 cases sustained hand injuries over a period of one year. The patients were predominantly males in the 20 - 30 year age group and injuries were mainly sustained over the right hand. Most of the injuries were sustained at home (42%). The most common mechanism (34%) was sharp object injury (including needle-stick and other sharps in hospital), followed by blunt injury (30%). Among grievous hand injuries, door jamb was a mechanism noted in 11% of patients, accounting for 50% of all crush injuries. Lacerations were the most common pattern (24.7%) noticed, followed closely by fractures (23.3%). Digits II - IV were injured most commonly (54%), followed by carpals (14%) and the thumb (10%). Nearly 80% of the hand injuries were managed by emergency physicians alone, with 61% of cases involving superficial structures. Though 14% of the cases required plastic surgery intervention, the initial evaluation of all these patients was performed by the emergency physician. Conclusions: Our study highlights the burden of hand injuries on the emergency physician, as well as the odds of missed injuries, directly indicating the necessity of a thorough anatomical knowledge of the structures of the hand, and in turn, a proper physical examination. A dedicated registry for hand trauma would help quantify the mechanism and pattern of injuries, and formulate preventive strategies.

Quantitative assessment of the impact of a triage physician on the Accreditation Council for Graduate Medical Education resident milestones in the emergency department

The “door-to-doctor” time for patients to be seen by a physician is an increasingly studied metric.Hospitals may shorten this time by implementing a triage physician (TP).The exact role of a TP may vary across departments.TPs put in preliminary orders for lab work,imaging,and treatment,and decide treatment location for further evaluation.As the prevalence of TPs grows,its effect on resident education in academic emergency departments (EDs) remains unclear.We implemented a TP in the spring of 2016 and assessed resident physicians before and after implementation.

Evaluation of hand infections in the emergency department using point-of-care ultrasound

BACKGROUND:We aimed to evaluate the utility of point-of-care ultrasound(POCUS)in the assessment of hand infections that present to the emergency department(ED)and its impact on medical decision making and patient management.METHODS:We conducted a retrospective review of patients who presented to two urban academic EDs with clinical presentations concerning for skin and soft tissue infections(SSTI)of the hand between December 2015 and December 2021.Two trained POCUS fellowship physicians reviewed an ED POCUS database for POCUS examinations of the hand.We then reviewed patients’electronic health records(EHR)for demographic characteristics,history,physical examination findings,ED course,additional imaging studies,consultations,impact of POCUS on patient care and final disposition.RESULTS:We included a total of 50 cases(28 male,22 female)in the final analysis.The most common presenting symptoms and exam findings were pain(100%),swelling(90%),and erythema(74%).The most common sonographic findings were edema(76%),soft tissue swelling(78%),and fluid surrounding the tendon(57%).POCUS was used in medical decision making 68%of the time(n=34),with the use of POCUS leading to changes in management 38%of the time(n=19).POCUS use led to early antibiotic use(11/19),early consultation(10/19),and led to the performance of a required procedure(8/19).The POCUS diagnosis was consistent with the discharge diagnosis of flexor tenosynovitis 8/12 times,abscess 12/16 times,and cellulitis 14/20 times.CONCLUSION:POCUS is beneficial for evaluating of hand infections that present to the ED and can be used as an important part of medical decision making to expedite patient care.