Faculty Bibliography

OBJECTIVES: The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population in order to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. METHODS: We conducted uniprofessional focus groups and individual interviews using a phenomenological approach with emergency medicine resident physicians, ED staff nurses, patient care technicians and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. RESULTS: We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: (1) ED healthcare workers provide high quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; (2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; (3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. CONCLUSION: The experience of ED staff members while caring for agitated patients is complex and multi-dimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment and system levels. Future research is needed to determine applicability of our findings across institutions in order to build a comprehensive framework for ED agitated patient care

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.

Background: Transvenous pacemaker (TVP) insertion is a potentially lifesaving procedure that is performed in the Emergency Department (ED). There are no published data on incidence however one single center study of complications reported over 90 ED TVP insertions in one year. Rates of complications range from 10-60% depending on provider experience and in rare cases include death. These data reinforce the high stakes and high risk nature of TVP placement in the ED. We aimed to simplify a previously described Hi-Fi TVP model and develop a program that allows for troubleshooting and simulation of adverse events. Design: As previously described we used materials obtained from online sources as well as from the ED. The total cost was $54.35 not including shipping or the TVP kit. We glued five sensors to a cardboard base beginning at 15cm from a pre-placed right internal jugular access and spaced 5cm apart. Each sensor was connected to an Arduino device using the attached breadboard as a ground, which allowed us to avoid soldering. IV tubing was glued in the sensors as a guide for the TVP wire, simulating venous access. The program was written in Processing development tool that allows for either still images or repeating video clips of EKG waveforms to be displayed as the TVP wire is inserted into IV tubing. We developed a troubleshooting program that displays EKG images indicating improper placement at appropriate times. The learner must recognize the error, pull the TVP out at least 5cm and re-advance in order to continue to progress through the training. Impact: This is a low cost, hi-fidelity, easy to assemble TVP training model that also allows for practice trouble shooting and simulating potential complications. In the future we plan to use this device as part of a simulation based mastery learning curriculum and assess its impact on learning and retention of TVP placement skills. (Figure Presented)

INTRODUCTION: Health care providers must effectively function in highly skilled teams in a collaborative manner, but there are few interprofessional training strategies in place. Interprofessional education (IPE) using simulation technology has gained popularity to address this need because of its inherent ability to impact learners' cognitive frames and promote peer-to-peer dialog. Provider attitudes toward teamwork have been directly linked to the quality of patient care. Investigators implemented a simulation-enhanced IPE intervention to improve staff attitudes toward teamwork and interprofessional communication in the emergency department setting. METHODS: The 3-hour course consisted of a didactic session highlighting teamwork and communication strategies, 2 simulation scenarios on septic shock and cardiac arrest, and structured debriefing directed at impacting participant attitudes to teamwork and communication. This was a survey-based observational study. We used the TeamSTEPPS Teamwork Attitudes Questionnaire immediately before and after the session as a measurement of attitude change as well as the Hospital Survey on Patient Safety Culture before the session and 1 year after the intervention for program impact at the behavior level. RESULTS: Seventy-two emergency department nurses and resident physicians participated in the course from July to September 2012. Of the 5 constructs in TeamSTEPPS Teamwork Attitudes Questionnaire, 4 had a significant improvement in scores-6.4%, 2.8%, 4.0%, and 4.0% for team structure, leadership, situation monitoring, and mutual support, respectively (P < 0.0001, P = 0.029, P = 0.014, and P = 0.003, respectively). For Hospital Survey on Patient Safety Culture, 3 of 6 composites directly related to teamwork and communication showed a significant improvement-20.6%, 20.5%, and 23.9%, for frequency of event reporting, teamwork within hospital units, and hospital handoffs and transitions, respectively (P = 0.028, P = 0.035, and P = 0.024, respectively). CONCLUSIONS: A simulation-enhanced IPE curriculum was successful in improving participant attitudes toward teamwork and components of patient safety culture related to teamwork and communication.

INTRODUCTION: While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design. METHODS: Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs. RESULTS: One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training. CONCLUSION: A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

Introduction: The opening of a new emergency department creates numerous unknowns that can become latent safety threats (LSTs) to patient welfare. Healthcare providers can also experience increased stress working in a novel environment, which has been shown to negatively affect decision making, teamwork, and ultimately patient safety. Methods: In order to identify LSTs and orient staff, multidisciplinary teams participated in 15 in-situ simulations followed by focused debriefing sessions that stressed uncovering LSTs prior to the ED's opening. Participants also received an electronic, de-identified survey requesting feedback and recollection of any additional LSTs not mentioned during the debriefing. Staff members were then sent the NASA-Task Load Index questionnaire during the first week of opening, which focused on the staff members stress level. Results: Over 100 healthcare workers of various disciplines participated in 15 in-situ simulations over the course of one day. Thirty-five LSTs were identified and modified before the opening of the new emergency department. The majority (93%) of participants felt that simulations helped them orient to the new space. While the absolute level of stress was the same between cohorts, irritation and discouragement were 16% less in the group completing the simulation. Discussion: In-situ simulations performed prior to the opening of a new emergency department identified 35 modifiable latent safety threats. Simulations were an effective way to orient staff to the new space and seemed to decrease the level of discouragement and irritation of healthcare workers during the first few weeks of the emergency department's opening. (C) 2015 Elsevier Ltd. All rights reserved.

Background: Airway management skills are an essential part of EM resident training. They are recognized as a key ACGME competency milestone. All EM trainees must achieve mastery in performing basic support of oxygenation and ventilation until a definitive airway can be secured. Junior residents frequently overlook these important fundamental skills. In our residency, no formalized program was in place to assess first year residents' airway skill retention or identify potential skill improvement and remediation. Objectives: The goal of our study is to demonstrate improvements in PGY1 residents' comfort with basic airway management skills using an immersive simulation-based curriculum. Methods: Residents participated in three high fidelity simulations. The scenarios required identification of risk factors for a difficult airway, demonstration of effective BVM skills, patient repositioning, and use of nasal trumpets, oral airways and PEEP valve if necessary. The cases included a patient with methadone overdose where naloxone was not yet available, a patient with pulmonary edema requiring ventilatory support, and a MVC patient requiring maintenance of C-spine immobilization during airway management. We utilized a survey-based design with pre- and post-session distribution assessing trainees' comfort with basic airway skills. The survey consisted of 5-point Likertscale questions, and we employed the paired Student t-test for data analysis. Results: A total of 13 PGY1 residents completed the one-on-one didactic session. All residents universally chose "strongly agree" when asked if the simulations were helpful. Instructors responded that the residents' airway techniques improved at the completion of the scenarios. The trainees reported significantly higher confidence in basic airway skills after training (mean score +1.13, p<0.005). During subsequent feedback, residents identified how cognitive stress impaired information retrieval, decision-making, and in some, fine motor skills. Adherence to an airway checklist mitigated these potential safety threats. Conclusion: An immersive simulation-based curriculum significantly improved PGY1 residents in their comfort level toward basic airway skills. As a secondary objective, program leadership was also able to assess and complete the level 1 ACGME milestones for airway skills for all PGY1 session attendees

Background: The prevalence of completed Advance Directives (ADs) by adults range between 18-36%. With 75% of Americans 65 or older being seen in the ED in the last six months of life, knowledge of patient goals for care and ADs are essential to provide medical management specific for each patient. Objectives: The purpose of this study is to: 1) assess the knowledge of ADs in patients presenting to the ED; 2) explore correlation between the presence of ADs and demographic data; and 3) assess whether patients are willing to speak to ED staff about their end of life care. Methods: An IRB-exempt, voluntary, paper-based survey was distributed to a convenience sample of patients over the age of 25 presenting to the EDs of an academic urban public hospital and private hospital between June 25, 2013 and July 28, 2013. Results: During the study period, 329 participants completed the survey, 189 from the public hospital and 140 from the private hospital. The majority of participants 88.1% (290/329) failed to identify the components of an AD. Of our patients, 54.7% (180/329) have never had a conversation with anyone about ADs, and 89.1% (283/329) have not spoken to their primary care doctors about ADs. Of patients over the age of 65, 31.6% (18/57), have never had a conversation about ADs. At the same time 75.4% (248/329) of patients feel comfortable speaking with an ED physician about ADs, and 62.9% (207/329) of patients think that the ED should ask their patients about end of life care. Patients in the public hospital were less likely to have ADs, with only 12.7% (24/ 189) having spoken to primary care doctors about ADs, compared to patients in the private hospital, where 45% (63/140) have spoken to their primary care doctors about ADs. Conclusion: Many patients are unaware of the components of an AD. A majority of patients presenting to the ED feel comfortable about discussing ADs with an ED physician. The ED visit offers an opportunity to educate patients about ADs

Background: While treating potentially violent patients in the ED, both patients and staff may be subject to unintentional injury. Preliminary studies have shown that a team-based approach with targeted staff training have significant positive outcomes in mitigating violence in health care settings. Objectives: The goal for our study was to show that a simulationbased interdisciplinary curriculum would improve attitudes and staff safety toward management of patient aggression in the ED. Methods: Formal roles and responsibilities for each member of the care team including positioning during restraint placement were predefined in conjunction with ED leadership. EM residents, nurses and hospital police officers were assigned to interdisciplinary teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement. Next, we conducted two simulation scenarios using standardized participants and structured debriefing. The study consisted of a survey-based design comparing pre- and postintervention responses to assess changes in staff attitudes. We utilized the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs and performed analysis with the Student paired t-test. Results: 162 ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/ interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively, Figure 479). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented including the creation of an ED-based interprofessional crisis management alert and response protocol. Conclusion: A structured interdisciplinary simulation-based intervention was successful in improving ED staff attitudes toward caring for agitated patients. Attitudes towards managing them remained conflicted. Ongoing work includes a follow-up qualitative study utilizing staff focus groups and tracking patient outcomes. (Figure Presented)

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.