Faculty Bibliography

BACKGROUND:Approximately 90% of pediatric emergency care is provided in community emergency departments (CEDs) that care for both adults and children. Paradoxically, the majority of pediatric emergency medicine knowledge generation, quality improvement work, and clinical training occurs in children's hospitals. There is a paucity of information of perceptions on pediatric care from CED providers. This information is needed to guide the development of strategies to improve CED pediatric readiness. OBJECTIVE:The objective was to explore interprofessional CED providers' perceptions of caring for pediatric patients. METHODS:A preparticipation survey collected data on demographics, experience, and comfort in caring for children. Emergency pediatric simulations were then utilized to prime interprofessional teams for debriefings. These discussions underwent qualitative analysis by three blinded authors who coded transcripts into themes through an inductive method derived from grounded theory. The other authors participated in confirmability and dependability checks. RESULTS:A total of 171 community hospital providers from six CEDs completed surveys (49% nurses, 22% physicians, 23% technicians). The majority were PALS trained (70%) and experienced fewer than five pediatric resuscitations in their careers (61%). Most self-reported comfort in caring for acutely ill and injured children. From the debriefings, three major challenge themes emerged: 1) knowledge and skill limitations attributed to infrequency of training and actual clinical events, 2) the emotional toll of caring for a sick child, and 3) acknowledgment of pediatric specific quality and safety deficits. Subthemes focused on causes and potential mitigating factors contributing to these challenges. A solution theme highlighted novel partnering opportunities with local children's hospitals. CONCLUSION:Interprofessional CED providers perceive that caring for pediatric patients is challenging due to case infrequency, the emotional toll of caring for sick children, and pediatric quality and safety deficits in their systems. These areas of focus can be used to generate specific strategies for improving CED pediatric readiness.

PURPOSE/OBJECTIVE:The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED). DESIGN/METHODOLOGY/APPROACH/METHODS:A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications. FINDINGS/RESULTS:This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries. ORIGINALITY/VALUE/CONCLUSIONS:Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

Interprofessional education (IPE) using simulations provides a rich environment for mastery learning and deliberate practice. The debriefing phase is identified as the most valuable by learners, yet investigation into the most effective format for debriefing interprofessional (IP) groups has largely gone unexplored. To determine the best practices in IP simulation debriefing, we compared perceived effectiveness of in-person versus teledebriefing, and single versus IP co-debriefer models according to 404 Debriefing Assessment for Simulation in Healthcare Student-Version (DASH-SV) scores from students in medicine, nursing, and respiratory therapy (n = 135) following three critical care simulations. All calculated total mean scores were in the acceptable range (above 4.0), indicating a positive experience for all methods. We found statistically significantly higher scores for in-person (M = 5.79) compared to teledebriefing (M = 4.96, p < .001). Single debriefer (M = 6.09) compared to IP co-debriefer DASH scores (M = 5.93) for all scenarios were not significantly different (p = .059). Our results suggest that teledebriefing may provide a solution for simulation programs with off-site or rural learners, and that a single in-person debriefing can be equally effective as co-debriefing for IP students.

INTRODUCTION/BACKGROUND:Emergency departments (EDs) have seen harm rise for both patients and health workers from an increasing rate of agitation events. Team effectiveness during care of this population is particularly challenging because fear of physical harm leads to competing interests. Simulation is frequently employed to improve teamwork in medical resuscitations but has not yet been reported to address team-based behavioral emergency care. As part of a larger investigation of agitated patient care, we designed this secondary study to examine the impact of an interprofessional standardized patient simulation for ED agitation management. METHODS:We used a mixed-methods approach with emergency medicine resident and attending physicians, Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs), ED nurses, technicians, and security officers at two hospital sites. After a simulated agitated patient encounter, we conducted uniprofessional and interprofessional focus groups. We undertook structured thematic analysis using a grounded theory approach. Quantitative data consisted of responses to the KidSIM Questionnaire addressing teamwork and simulation-based learning attitudes before and after each session. RESULTS:We reached data saturation with 57 participants. KidSIM scores revealed significant improvements in attitudes toward relevance of simulation, opportunities for interprofessional education, and situation awareness, as well as four of six questions for roles/responsibilities. Two broad themes emerged from the focus groups: (1) a team-based agitated patient simulation addressed dual safety of staff and patients simultaneously and (2) the experience fostered interprofessional discovery and cooperation in agitation management. CONCLUSIONS:A team-based simulated agitated patient encounter highlighted the need to consider the dual safety of staff and patients while facilitating interprofessional dialog and learning. Our findings suggest that simulation may be effective to enhance teamwork in behavioral emergency care.

BACKGROUND:The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation. METHODS:A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management. RESULTS:Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes. CONCLUSION/CONCLUSIONS:Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.

INTRODUCTION/BACKGROUND:Although error disclosure is critical in promoting safety and patient-centered care, physicians are inconsistently trained in its practice, and few objective methods to assess competence exist. We used an immersive simulation scenario to determine whether providers with varying levels of clinical experience adhere to the disclosure safe practice guidelines when exposed to a serious adverse event simulation scenario. METHODS:This was a prospective cohort study with medical students, junior emergency medicine (EM) residents (PGY 1-2), senior EM residents (PGY 3-4), and attending EM physicians participating in a simulated case in which a scripted medication overdose resulted in an adverse event. Each scenario was videotaped and scored by two expert raters based on a 6-component, 21-point disclosure assessment instrument. RESULTS:There were 12 participants in each study group (N = 48). There was good interrater reliability (κ = 0.70). Total scores improved significantly as the level of training increased: medical student = 10.3 (2.7), PGY 1-2 = 12.3 (6.2), PGY 3-4 = 13.7 (3.2), and attending physicians = 12.8 (3.7) (P = 0.03). Seventy-five percent of participants did not address preventing recurrence of the error. Fifty-six percent offered no apology or only offered it with prompting from the patient; only 23% offered an apology with the initial disclosure. CONCLUSIONS:We demonstrated suboptimal adherence to best practices guidelines for error disclosure when providers are assessed in an immersive simulation setting. Despite a correlation in performance of medical error disclosure with increased physician experience, this study suggests that healthcare providers may need additional training to comply with safe practice guidelines for disclosure of unanticipated adverse events.

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Teams are the building blocks of the healthcare system, with growing evidence linking the quality of healthcare to team effectiveness, and team effectiveness to team training. Simulation has been identified as an effective modality for team training and assessment. Despite this, there are gaps in methodology, measurement, and implementation that prevent maximizing the impact of simulation modalities on team performance. As part of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes," we explored the impact of simulation on various aspects of team effectiveness. The consensus process included an extensive literature review, group discussions, and the conference "workshop" involving emergency medicine physicians, medical educators, and team science experts. The objectives of this work were to: 1) explore the antecedents and processes that support team effectiveness, 2) summarize the current role of simulation in developing and understanding team effectiveness, and 3) identify research targets to further improve team-based training and assessment, with the ultimate goal of improving healthcare systems.

Introduction/UNASSIGNED:High-fidelity mannequin-based simulation is frequently used to compliment medical student education during clinical clerkships. However, psychiatric educators have not broadly adopted this modality, focusing rather on standardized patient actors. We developed and delivered a simulation case involving a patient with alcohol withdrawal and lithium toxicity followed by a debriefing session to medical students at the end of their psychiatric clerkship. Methods/UNASSIGNED:The case involves a 40-year-old male truck driver with a history of bipolar disorder who presents to the emergency room after a truck accident. The patient is in alcohol withdrawal, which responds to benzodiazepines. A workup reveals that the patient also has lithium toxicity related to the co-ingestion of lithium and naproxen for pain. Participants learn to evaluate and treat alcohol withdrawal, consider medical comorbidities and legal consequences, and complete a brief intervention for substance use. This case requires a simulation mannequin. Results/UNASSIGNED:) on a question about enjoyment, and 3.93 on a question about confidence with evaluation and treatment of patients in alcohol withdrawal. Discussion/UNASSIGNED:Psychiatric education currently underutilizes mannequin-based simulation compared to other medical disciplines. Mannequin simulation is feasible and effective in psychiatric education, especially in cases involving medical complexity, as shown in this novel case involving a patient with alcohol withdrawal and lithium toxicity.

In situ simulation (ISS), a point of care training strategy that occurs within the patient care environment involving actual healthcare team members, provides additional benefits to centre-based simulation. ISS can serve several roles within emergency medicine (EM): improves provider/team performance, identifies and mitigates threats to patient safety and improves systems and infrastructure. The effective use of ISS fosters inter-professional team training and a culture of safety essential for high performance EM teams and resilient systems. Using a case example, this article addresses the uses of ISS in EM, strategies for implementation and mitigation strategies for ED-specific challenges.