Faculty Bibliography

OBJECTIVES/OBJECTIVE:The objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians. METHODS:We conducted in-depth, one-on-one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content-relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. RESULTS:Three recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of "misses," in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence. CONCLUSIONS:Caring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and resources to improve the ability of residents to care for this vulnerable population. Future research is needed to determine if such interventions improve EM resident education and, ultimately, result in improved care for ED patients who are homeless.

Background: Bedside emergency procedures are often performed on high-acuity patients and frequently under time-sensitive conditions. Interns do not get many opportunities to learn about, observe, or perform procedures in medical school or during their first year of residency. Self-reported confidence is a poor predictor of performance, but studies have shown that low confidence and stress can inhibit or decrease performance, especially under time pressure or when stakes are high. Lack of familiarity with procedure or equipment can contribute to stress and performance anxiety. Objectives: We investigate the need, feasibility, and outcomes of a standardized, systematic, simulation-based emergency procedure curriculum for interns in an emergency medicine residency program. Methods: Common bedside procedures relevant to first year residents were identified using ACGME guidelines. Nine sessions were held over the intern year. Participants were surveyed at the end of their PGY-1 year (June) for curriculum and quality purposes to help inform the next iteration of the curriculum. Descriptive statistics were calculated and means were compared with one-tailed, paired t-tests. Results: 73% (11/15) of interns responded to the survey request. They had the opportunity to perform each of the procedures before, during, and after the workshop. Using a five-point Likert scale, the basic and advanced airway, central venous catheter, and chest tube sessions were most useful. Models used were deemed not very realistic (2.8-3.86). Self-reported comfort with the procedure improved significantly in all except incision and drainage and laceration repair. Conclusion: A monthly curriculum in bedside procedures is well received by interns and improves confidence. Rarer, more-invasive procedures might have a greater effect. (Table presented)

Objectives. We sought to understand interpersonal and systems-level factors relevant to delivering health care to emergency department (ED) patients who are homeless. Methods. We conducted semistructured interviews with emergency medicine residents from 2 residency programs, 1 in New York City and 1 in a medium-sized northeastern city, from February to September 2012. A team of researchers reviewed transcripts independently and coded text segments using a grounded theory approach. They reconciled differences in code interpretations and generated themes inductively. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. Results. From 23 interviews, 3 key themes emerged: (1) use of pattern recognition in identifying and treating patients who are homeless, (2) variations from standard ED care for patients who are homeless, and (3) tensions in navigating the boundaries of ED social care. Conclusions. Our study revealed practical and philosophical tensions in providing social care to patients in the ED who are homeless. Screening for homelessness in the ED and admission practices for patients who are homeless are important areas for future research and intervention with implications for health care costs and patient outcomes.

OBJECTIVES: The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). METHODS: This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. RESULTS: The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of "high-risk" handoffs, and the opportunity for questions and clarification from the handoff recipient. The developed handoff algorithm consisted of five steps: 1) setting the stage, 2) assembling the team, 3) identification of high-risk patients, 4) shift sign-out, and 5) closing the loop. CONCLUSIONS: The authors present specific guidelines for an algorithm-based approach to transitioning care within the ED. This algorithm is based on surveys of perceived deficiencies and emphasizes informational and logistical parameters within a ToC. Standardizing the process of the ToC may allow for future research on the link between effective ToC and patient outcomes.

Background: Team training initiatives have been implemented in hospitals nationwide in response to patient safety reports citing teamwork and communication failures as the most frequent contributors of errors. TeamSTEPPSTM is an evidence-based teamwork training system designed to improve patient outcomes by enhancing communication and skills of health care professionals. We developed a novel ED team training course based on TeamSTEPPSTM principles as a pilot curriculum for the Bellevue Hospital ED. Objectives: This study's purpose was to address the gap in current health care education at the Bellevue ED, by creating an interprofessional curriculum for nursing and residents focused on teamwork and communication utilizing simulation based education. We hypothesized that there would be a significant improvement in the staff's attitudes toward teamwork after the intervention. Methods: The team T\training course was conducted via a simulation center based training session over three hours consisting of an introductory didactic session, two simulation scenarios, video and self-observed evaluation utilizing the TeamSTEPPSTM Team Performance Observation Tool. Subjects consisted of EM nurses and residents organized into teams of six participants. We used the previously validated TeamSTEPPSTM Teamwork Attitudes Questionnaire with a five-point Likert scale model, designed to measure individual attitudes related to core components of teamwork, and distributed them in person pre- and post-session. Data analysis was performed using the Student's t-test to compare scores. Results: Over seven sessions from July to September 2012, a total of 76 nurses and residents participated in the course with 100% survey response. Seven of the pre-session and ten of the post-session surveys were disqualified as dictated in the protocol. Four of the five teamwork construct question groups had significant improvements in scores: 6.4%, 2.8%, 4.0%, and 4.0% for Team Structure, Leadership, Situation Monitoring, and Mutual Suppo!

Background: Homeless patients visit the ED at rates up to 12 times higher than comparable housed patients, yet there is a paucity of research on how this influences emergency medicine residents, who are the primary physician caregivers in many EDs. Objectives: To characterize the experiences of EM residents in caring for homeless patients and explore how these experiences influence resident personal and professional development. Methods: We conducted in-depth interviews with residents of two northeast urban EM residency programs. A random purposeful sample diverse in training year was selected, with sample size determined by theoretical saturation. Interviews were digitally recorded and professionally transcribed. A core team of three researchers with diverse content-relevant expertise independently coded transcripts and met regularly to reconcile coding differences. The constant comparison method was used to identify new codes and refine existing ones iteratively. The final code structure was applied to all data using Atlas.ti (GmbH). Results: Four core themes pertaining to the resident experience emerged from 23 interviews. First, residents learn how to care for homeless patients through modeling more senior physicians, storytelling, and experience, rather than formal curricular training. Second, residents learn unique aspects of EM by caring for homeless patients. For example, residents learn to integrate social and systems-level factors into medical decision making (i.e., considering homelessness in disposition decisions). Third, residents struggle with role boundaries as emergency physicians when caring for homeless patients. Though the ED regularly fills gaps in the social service system by providing shelter, food, and other non-medical resources, residents vary in how much of this care they embrace as their job. Finally, caring for homeless patients affects residents emotionally. While residents feel pride in EM's mission to serve all patients, they feel frustrated by what they perceive !

Background: Myeloneuropathy from chronic exposure to nitrous oxide has been described. Nitrous oxide irreversibly alters B(12) activation, causing signs and symptoms of B(12) deficiency. Objectives: We describe a case of myeloneuropathy secondary to acute use of high-dose nitrous oxide. Case Report: A 24-year-old man presented to the Emergency Department complaining of numbness and tingling of his hands and feet, as well as worsening clumsiness and gait disturbances after escalating use of nitrous oxide in the prior 2 weeks. He was found to have dysmetria, poor proprioception, decreased sensation to vibration and light touch over his extremities, and a mildly positive Romberg sign. Laboratory test values revealed a normal B(12) level but increased methylmalonic acid and homocysteine levels. The patient was admitted to the hospital and started on a course of B(12) injections. He was discharged after 3 days with daily B(12) supplementation. Conclusions: This case demonstrates myeloneuropathic changes secondary to acute high-dose nitrous oxide exposure

Medical control of prehospital emergency services, triage in the emergency department, and the dual duties within the Emergency Medical Treatment and Active Labor Act challenge emergency medicine physicians with both statutory obligations and liabilities. Each independently may seem to present a definable boundary of liability for the practitioner. Under the Emergency Medical Treatment and Active Labor Act, the sequential duties of the medical screening examination and subsequent stabilization or transfer are confounded by the potential for tremendous sanction for a mechanistic violation. Nevertheless, the true obligation is to provide appropriate care to all who present to the emergency department and not simply weigh the totality of risk to the emergency medicine physician