Original Research Archives - Page 23 of 40 - The Western Journal of Emergency Medicine

Provider Workforce

Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians

Volume 16, Issue 7, December 2015.
Dave W. Lu, MD, MBE

Introduction: Burnout is a syndrome of depersonalization, emotional exhaustion and sense of low
personal accomplishment. Emergency physicians (EPs) experience the highest levels of burnout among
all physicians. Burnout is associated with greater rates of self-reported suboptimal care among surgeons
and internists. The association between burnout and suboptimal care among EPs is unknown. The
objective of the study was to evaluate burnout rates among attending and resident EPs and examine their
relationship with self-reported patient care practices.
Methods: In this cross-sectional study burnout was measured at two university-based emergency
medicine residency programs with the Maslach Burnout Inventory. We also measured depression, quality
of life (QOL) and career satisfaction using validated questionnaires. Six items assessed suboptimal care
and the frequency with which they were performed.
Results: We included 77 out of 155 (49.7%) responses. The EP burnout rate was 57.1%, with no
difference between attending and resident physicians. Residents were more likely to screen positive
for depression (47.8% vs 18.5%, p=0.012) and report lower QOL scores (6.7 vs 7.4 out of 10, p=0.036)
than attendings. Attendings and residents reported similar rates of career satisfaction (85.2% vs 87.0%,
p=0.744). Burnout was associated with a positive screen for depression (38.6% vs 12.1%, p=0.011) and
lower career satisfaction (77.3% vs 97.0%, p=0.02). EPs with high burnout were significantly more likely
to report performing all six acts of suboptimal care.
Conclusion: A majority of EPs demonstrated high burnout. EP burnout was significantly associated
with higher frequencies of self-reported suboptimal care. Future efforts to determine if provider burnout
is associated with negative changes in actual patient care are necessary

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Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke

Volume 16, Issue 7, December 2015.
Bryan Darger, BA, et al.

Introduction: The purpose of this study was to assess safety and efficacy of thrombolysis in the
setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP
control prior to thrombolysis.
Methods: We performed a retrospective review of patients treated with tissue plasminogen activator
(tPA) for acute ischemic stroke (AIS) between 2004-2011. We compared the outcomes of patients
treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring
standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined
by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome
was efficacy, determined by functional status at discharge, and in-hospital deaths.
Results: Of 427 patients included in the analysis, 89 received aggressive BP control prior to
thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis.
Patients requiring BP control had more severe strokes, with median arrival National Institutes of
Health Stroke Scale of 10 (IQR [6-17]) in patients not requiring BP control versus 11 (IQR [5-16]) and
13 (IQR [7-20]) in patients requiring standard and aggressive BP lowering therapies, respectively
(p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no
statistically significant differences in adverse events between the three groups (P>0.10).
Conclusion: We observed no association between BP control and adverse outcomes in ischemic
stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute
the safety of aggressive BP control prior to thrombolysis.

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Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest

Volume 16, Issue 7, December 2015.
David A. Pearson, MD, et al.

Introduction: The utility of troponin as a marker for acute coronary occlusion and patient outcome after
out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin
was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome.
Methods: Single-center retrospective-cohort study of OHCA patients treated in a comprehensive
clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at
presentation, four and eight hours after arrest, and then per physician discretion. Cardiac
catheterization was at the cardiologist’s discretion. Survival and outcome were determined at hospital
discharge, with cerebral performance category score 1-2 defined as a good neurological outcome.
Results: We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good
neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%)
had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI
(0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85
patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in
those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs
1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus nonsurvivors
(0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20,
p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs
1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14).
Conclusion: In our single-center patient cohort, peak troponin, but not initial troponin, was
associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with
survival or neurological outcome in OHCA patients.

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Healthcare Utilization

Written Informed Consent for Computed Tomography of the Abdomen/Pelvis is Associated with Decreased CT Utilization in Low-Risk Emergency Department Patients

Volume 16, Issue 7, December 2015.
Lisa H. Merck, MD, MPH, et al.

Introduction: The increasing rate of patient exposure to radiation from computerized tomography
(CT) raises questions about appropriateness of utilization. There is no current standard to employ
informed consent for CT (ICCT). Our study assessed the relationship between informed consent and
CT utilization in emergency department (ED) patients.
Methods: An observational multiphase before-after cohort study was completed from 4/2010-5/2011.
We assessed CT utilization before and after (Time I/ Time II) the implementation of an informed
consent protocol. Adult patients were included if they presented with symptoms of abdominal/pelvic
pathology or completed ED CT. We excluded patients with pregnancy, trauma, or altered mental
status. Data on history, exam, diagnostics, and disposition were collected via standard abstraction
tool. We generated a multivariate logistic model via stepwise regression, to assess CT utilization
across risk groups. Logistic models, stratified by risk, were generated to include study phase and a
propensity score that controlled for potential confounders of CT utilization.
Results: 7,684 patients met inclusion criteria. In PHASE 2, there was a 24% (95% CI [10-36%])
reduction in CT utilization in the low-risk patient group (p<0.002). ICCT did not affect CT utilization in the
high-risk group (p=0.16). In low-risk patients, the propensity score was significant (p<0.001). There were
no adverse events reported during the study period.
Conclusion: The implementation of ICCT was associated with reduced CT utilization in low-risk ED
patients. ICCT has the potential to increase informed, shared decision making with patients, as well
as to reduce the risks and cost associated with CT.

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Screening for Fall Risks in the Emergency Department: A Novel Nursing-Driven Program

Volume 16, Issue 7, December 2015.
Jill M. Huded, MD, et al.

Introduction: Seniors represent the fasting growing population in the U.S., accounting for 20.3
million visits to emergency departments (EDs) annually. The ED visit can provide an opportunity for
identifying seniors at high risk of falls. We sought to incorporate the Timed Up & Go Test (TUGT),
a commonly used falls screening tool, into the ED encounter to identify seniors at high fall risk and
prompt interventions through a geriatric nurse liaison (GNL) model.
Methods: Patients aged 65 and older presenting to an urban ED were evaluated by a team of
ED nurses trained in care coordination and geriatric assessment skills. They performed fall risk
screening with the TUGT. Patients with abnormal TUGT results could then be referred to physical
therapy (PT), social work or home health as determined by the GNL.
Results: Gait assessment with the TUGT was performed on 443 elderly patients between 4/1/13
and 5/31/14. A prior fall was reported in 37% of patients in the previous six months. Of those
screened with the TUGT, 368 patients experienced a positive result. Interventions for positive
results included ED-based PT (n=63, 17.1%), outpatient PT referrals (n=56, 12.2%) and social work
consultation (n=162, 44%).
Conclusion: The ED visit may provide an opportunity for older adults to be screened for fall risk.
Our results show ED nurses can conduct the TUGT, a validated and time efficient screen, and
place appropriate referrals based on assessment results. Identifying and intervening on high fall
risk patients who visit the ED has the potential to improve the trajectory of functional decline in our
elderly population.

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Direct Versus Video Laryngoscopy for Intubating Adult Patients with Gastrointestinal Bleeding

Volume 16, Issue 7, December 2015.
Jestin N. Carlson, MD, MSc, et al.

Introduction: Video laryngoscopy (VL) has been advocated for several aspects of emergency
airway management; however, there are still concerns over its use in select patient populations
such as those with large volume hematemesis secondary to gastrointestinal (GI) bleeds. Given the
relatively infrequent nature of this disease process, we sought to compare intubation outcomes
between VL and traditional direct laryngoscopy (DL) in patients intubated with GI bleeding, using the
third iteration of the National Emergency Airway Registry (NEARIII).
Methods: We performed a retrospective analysis of a prospectively collected national database
(NEARIII) of intubations performed in United States emergency departments (EDs) from July 1, 2002,
through December 31, 2012. All cases where the indication for intubation was “GI bleed” were analyzed.
We included patient, provider and intubation characteristics. We compared data between intubation
attempts initiated as DL and VL using parametric and non-parametric tests when appropriate.
Results: We identified 325 intubations, 295 DL and 30 VL. DL and VL cases were similar in terms
of age, sex, weight, difficult airway predictors, operator specialty (emergency medicine, anesthesia
or other) and level of operator training (post-graduate year 1, 2, etc). Proportion of successful first
attempts (DL 261/295 (88.5%) vs. VL 28/30 (93.3%) p=0.58) and Cormack-Lehane grade views
(p=0.89) were similar between devices. The need for device change was similar between DL [2/295
(0.7%) and VL 1/30 (3.3%); p=0.15].
Conclusion: In this national registry of intubations performed in the ED for patients with GI bleeds,
both DL and VL had similar rates of success, glottic views and need to change devices.

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Patient Communication

Derivation and Validation of Predictive Factors for Clinical Deterioration after Admission in Emergency Department Patients Presenting with Abnormal Vital Signs Without Shock

Volume 16, Issue 7, December 2015.
Daniel J. Henning, MD, MPH, et al.

Introduction: Strategies to identify high-risk emergency department (ED) patients often use markedly
abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of
shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse
outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.
Methods: We performed a prospective observational study of patients with abnormal vital signs or lactate
level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic
blood pressure <90mm/Hg, or lactate ≥4mmole/L. We excluded patients with isolated atrial tachycardia,
seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary
outcome was deterioration, defined as development of acute renal failure (creatinine 2x baseline), nonelective
intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after
hospitalization were determined using logistic regression.
Results: Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were
excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission.
Independent predictors of in-hospital deterioration were: lactate >4.0mmol/L (OR 5.1, 95% CI [2.1–12.2]),
age ≥80 yrs (OR 1.9, CI [1.0–3.7]), bicarbonate <21mEq/L (OR 2.5, CI [1.3–4.9]), and initial HR≥130 (OR
3.1, CI [1.5–6.1]).
Conclusion: Patients exhibiting abnormal vital signs or elevated lactate levels without shock had
significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered
adverse outcomes with reasonable reliability.

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Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction

Volume 16, Issue 7, December 2015.
Michael J. Ward, MD, MBA, et al.

Introduction: With the majority of U.S. hospitals not having primary percutaneous coronary intervention
(pPCI) capabilities, the time spent at transferring emergency departments (EDs) is predictive of clinical
outcomes for patients with ST-elevation myocardial infarction (STEMI). Compounding the challenges
of delivering timely emergency care are the known delays caused by ED crowding. However, the
association of ED crowding with timeliness for patients with STEMI is unknown. We sought to examine
the relationship between ED crowding and time spent at transferring EDs for patients with STEMI.
Methods: We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The
outcome was time spent at a transferring ED (i.e., door-in-door-out [DIDO]), was CMS measure OP-3b for
hospitals with ≥10 acute myocardial infarction (AMI) cases requiring transfer (i.e., STEMI) annually: Time
to Transfer an AMI Patient for Acute Coronary Intervention. We used four CMS ED timeliness measures
as surrogate measures of ED crowding: admitted length of stay (LOS), discharged LOS, boarding time,
and waiting time. We analyzed bivariate associations between DIDO and ED timeliness measures. We
used a linear multivariable regression to evaluate the contribution of hospital characteristics (academic,
trauma, rural, ED volume) to DIDO.
Results: Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure. These facilities
were primarily non-academic (99.0%), non-trauma centers (65.4%), and in urban locations (68.5%). Median
DIDO was 54.0 minutes (IQR 42.0,68.0). Increased DIDO time was associated with longer admitted
LOS and boarding times. After adjusting for hospital characteristics, a one-minute increase in ED LOS at
transferring facilities was associated with DIDO (coefficient, 0.084 [95% CI [0.049,0.119]]; p<0.001). This
translates into a five-minute increase in DIDO for every one-hour increase in ED LOS for admitted patients.
Conclusion: Among patients with STEMI presenting to U.S. EDs, we found that ED crowding has a
small but operationally insignificant effect on time spent at the transferring ED.

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Voluntary Medical Incident Reporting Tool to Improve Physician Reporting of Medical Errors in an Emergency Department

Volume 16, Issue 7, December 2015.
Nnaemeka G. Okafor, MD, MS, et al.

Introduction: Medical errors are frequently under-reported, yet their appropriate analysis, coupled
with remediation, is essential for continuous quality improvement. The emergency department (ED) is
recognized as a complex and chaotic environment prone to errors. In this paper, we describe the design
and implementation of a web-based ED-specific incident reporting system using an iterative process.
Methods: A web-based, password-protected tool was developed by members of a quality assurance
committee for ED providers to report incidents that they believe could impact patient safety.
Results: The utilization of this system in one residency program with two academic sites resulted
in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents
in 2012. This is an increase in rate of reported events from 0.07% of all ED visits to 0.44% of all
ED visits. In 2012, faculty reported 60% of all incidents, while residents and midlevel providers
reported 24% and 16% respectively. The most commonly reported incidents were delays in care and
management concerns.
Conclusion: Error reporting frequency can be dramatically improved by using a web-based, user friendly,
voluntary, and non-punitive reporting system.

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Societal Impact on Emergency Care

The Changing Use of Intravenous Opioids in an Emergency Department

Volume 16, Issue 7, December 2015.
Mark E. Sutter, MD, et al.

Introduction: Government agencies are increasingly emphasizing opioid safety in hospitals. In
2012, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) started a
sentinel event program, the “Safe Use of Opioids in Hospitals.” We sought to determine if opioid use
patterns in our emergency department (ED) changed from 2011, before the program began, to 2013,
after start of the program.
Methods: This was a retrospective study of all adult ED patients who received an intravenous opioid
and had a serum creatinine measured. We recorded opioids used, dose prescribed, and serum
creatinine. As an index of the safety of opioids, uses of naloxone after administration of an opioid
was recorded.
Results: Morphine is still the most commonly used opioid by doses given, but its percentage of
opioids used decreased from 68.9% in 2011 to 52.8% in 2013. During the same period, use of
hydromorphone increased from 27.5% to 42.9%, while the use of fentanyl changed little (3.6% to
4.3%). Naloxone administration was rare after an opioid had been given. Opioids were not dosed in
an equipotent manner.
Conclusion: The use of hydromorphone in our ED increased by 56% (absolute increase of 15.4%),
while the use of morphine decreased by 30.5% (absolute decrease 16.1%) of total opioid use from
2011 to 2013. The JCAHO program likely was at least indirectly responsible for this change in
relative dosing of the opioids. Based on frequency of naloxone administered after administration of
an opioid, the use of opioids was safe.

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Patient Communication

Inability of Physicians and Nurses to Predict Patient Satisfaction in the Emergency Department

Volume 16, Issue 7, December 2015.
Matthew C. DeLaney, MD, et al.

Introduction: Patient satisfaction is a commonly assessed dimension of emergency department (ED)
care quality. The ability of ED clinicians to estimate patient satisfaction is unknown. We sought to
evaluate the ability of emergency medicine resident physicians and nurses to predict patient-reported
satisfaction with physician and nursing care, pain levels, and understanding of discharge instructions.
Methods: We studied a convenience sample of 100 patients treated at an urban academic ED.
Patients rated satisfaction with nursing care, physician care, pain level at time of disposition and
understanding of discharge instructions. Resident physicians and nurses estimated responses
for each patient. We compared patient, physician and nursing responses using Cohen’s kappa,
weighting the estimates to account for the ordinal responses.
Results: Overall, patients had a high degree of satisfaction with care provided by the nurses and
physicians, although this was underestimated by providers. There was poor agreement between
physician estimation of patient satisfaction (weighted κ=0.23, standard error: 0.078) and nursing
estimates of patient satisfaction (weighted κ=0.11, standard error: 0.043); physician estimation
of patient pain (weighted κ=0.43, standard error: 0.082) and nursing estimates (weighted κ=0.39,
standard error: 0.081); physician estimates of patient comprehension of discharge instruction
(weighted κ=0.19, standard error: 0.082) and nursing estimates (weighted κ=0.13, standard error:
0.078). Providers underestimated pain and patient comprehension of discharge instructions.
Conclusion: ED providers were not able to predict patient satisfaction with nurse or physician
care, pain level, or understanding of discharge instructions.

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Critical Care

Lactate Clearance Predicts Survival Among Patients in the Emergency Department with Severe Sepsis

Volume 16, Issue 7, December 2015.
Sundeep R. Bhat, MD

Introduction: Lactate clearance has been implicated as a predictor of mortality among emergency
department (ED) patients with severe sepsis or septic shock. We aimed to validate prior studies
showing that lactate clearance during the ED stay is associated with decreased mortality.
Methods: Retrospective dual-centered cross-sectional study using patients identified in the YaleNew
Haven Hospital Emergency Medicine sepsis registry with severe sepsis or septic shock who
had initial lactate levels measured in the ED and upon arrival (<24 hours) to the hospital floor.
Lactate clearance was calculated as percent of serum lactate change from ED to floor measurement.
We compared mortality and hospital interventions between patients who cleared lactate and those
who did not.
Results: 207 patients (110 male; 63.17±17.9 years) were included. Two reviewers extracted data
with 95% agreement. One hundred thirty-six patients (65.7%) had severe sepsis and 71 patients
(34.3%) had septic shock. There were 171 patients in the clearance group and 36 patients in the
non-clearance group. The 28-day mortality rates were 15.2% in the lactate clearance group and
36.1% in the non-clearance group (p<0.01). Vasopressor support was initiated more often in the nonclearance
group (61.1%) than in the clearance group (36.8%, p<0.01) and mechanical ventilation
was used in 66.7% of the non-clearance group and 36.3% of the clearance group (p=0.001).
Conclusion: Patients who do not clear their lactate in the ED have significantly higher mortality than
those with decreasing lactate levels. Our results are confirmatory of other literature supporting that
lactate clearance may be used to stratify mortality-risk among patients with severe sepsis or septic
shock.

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Critical Care

A Simulation-based Randomized Controlled Study of Factors Influencing Chest Compression Depth

Volume 16, Issue 7, December 2015.
Kelsey P. Mayrand, BS, et al.

Introduction: Current resuscitation guidelines emphasize a systems approach with a strong
emphasis on quality cardiopulmonary resuscitation (CPR). Despite the American Heart Association
(AHA) emphasis on quality CPR for over 10 years, resuscitation teams do not consistently meet
recommended CPR standards. The objective is to assess the impact on chest compression depth of
factors including bed height, step stool utilization, position of the rescuer’s arms and shoulders relative
to the point of chest compression, and rescuer characteristics including height, weight, and gender.
Methods: Fifty-six eligible subjects, including physician assistant students and first-year emergency
medicine residents, were enrolled and randomized to intervention (bed lowered and step stool
readily available) and control (bed raised and step stool accessible, but concealed) groups. We
instructed all subjects to complete all interventions on a high-fidelity mannequin per AHA guidelines.
Secondary end points included subject arm angle, height, weight group, and gender.
Results: Using an intention to treat analysis, the mean compression depths for the intervention
and control groups were not significantly different. Subjects positioning their arms at a 90-degree
angle relative to the sagittal plane of the mannequin’s chest achieved a mean compression
depth significantly greater than those compressing at an angle less than 90 degrees. There was
a significant correlation between using a step stool and achieving the correct shoulder position.
Subject height, weight group, and gender were all independently associated with compression depth.
Conclusion: Rescuer arm position relative to the patient’s chest and step stool utilization during
CPR are modifiable factors facilitating improved chest compression depth.

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Alcohol Use as Risk Factors for Older Adults’ Emergency Department Visits: A Latent Class Analysis

Volume 16, Issue 7, December 2015.
Namkee G. Choi, PhD, et al.

Introduction: Late middle-aged and older adults’ share of emergency department (ED) visits is increasing
more than other age groups. ED visits by individuals with substance-related problems are also increasing.
This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by
examining their health/mental health status and alcohol use patterns.
Methods: Data came from the 2013 National Health Interview Survey’s Sample Adult file (n=15,713).
Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis
(LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/
moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year
ED visits as indicators.
Results: LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk
group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/
mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and,
despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3
(37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4
(7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had
the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits,
with the highest proportion of Blacks and the lowest proportions of college graduates and employed
persons, indicating significant roles of these risk factors.
Conclusion: Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant
contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce
unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses
self-management.

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Correlation of the National Emergency Medicine M4 Clerkship Examination with USMLE Examination Performance

Volume 16, Issue 7, December 2015.
Luan E. Lawson, MD, MAEd, et al.

Introduction: Assessment of medical students’ knowledge in clinical settings is complex yet
essential to the learning process. Clinical clerkships use various types of written examinations to
objectively test medical knowledge within a given discipline. Within emergency medicine (EM), a new
national standardized exam was developed to test medical knowledge in this specialty. Evaluation
of the psychometric properties of a new examination is an important issue to address during test
development and use. Studies have shown that student performance on selected standardized
exams will reveal students’ strengths and/or weaknesses, so that effective remedial efforts can be
implemented. Our study sought to address these issues by examining the association of scores on
the new EM national exam with other standardized exam scores.
Methods: From August 2011 to April 2013, average National EM M4 examination scores of fourthyear
medical students taken at the end of a required EM clerkship were compiled. We examined
the correlation of the National EM M4 examination with the scores of initial attempts of the United
States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) examinations.
Correlation coefficients and 95% confidence intervals of correlation coefficients are reported. We
also examined the association between the national EM M4 examination score, final grades for the
EM rotation, and USMLE Step 1 and Step 2 CK scores.
Results: 133 students were included in the study and achieved a mean score of 79.5 SD 8.0 on
the National EM M4 exam compared to a national mean of 79.7 SD 3.89. The mean USMLE Step
1 score was 226.8 SD 19.3. The mean USMLE Step 2 CK score was 238.5 SD 18.9. National EM
M4 examination scores showed moderate correlation with both USMLE Step 1 (mean score=226.8;
correlation coefficient=0.50; 95% CI [0.28-0.67]) and USMLE Step 2 CK (mean score=238.5;
correlation coefficient=0.47; 95% CI [0.25-0.65]). Students scoring below the median on the national
EM M4 exam also scored well below their colleagues on USMLE exams.
Conclusion: The moderate correlation of the national EM M4 examination and USMLE Step 1 and
Step 2 CK scores provides support for the utilization of the CDEM National EM M4 examination as
an effective means of assessing medical knowledge for fourth-year medical students. Identification of
students scoring lower on standardized exams allows for effective remedial efforts to be undertaken
throughout the medical education process.

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Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country

Volume 16, Issue 7, December 2015.
Kevin R. Schwartz, MD, et al.

Introduction: Increasingly, pediatric and emergency medicine (EM) residents are pursuing clinical
rotations in low-income countries. Optimal pre-departure preparation for such rotations has not yet been
established. High-fidelity simulation represents a potentially effective modality for such preparation. This
study was designed to assess whether a pre-departure high-fidelity medical simulation curriculum is
effective in helping to prepare residents for clinical rotations in a low-income country.
Methods: 43 pediatric and EM residents planning clinical rotations in Liberia, West Africa, participated in a
simulation-based curriculum focused on severe pediatric malaria and malnutrition and were then assessed
by survey at three time points: pre-simulation, post-simulation, and after returning from work abroad.
Results: Prior to simulation, 1/43 (2%) participants reported they were comfortable with the diagnosis
and management of severe malnutrition; this increased to 30/42 (71%) after simulation and 24/31 (77%)
after working abroad. Prior to simulation, 1/43 (2%) of residents reported comfort with the diagnosis and
management of severe malaria; this increased to 26/42 (62%) after simulation and 28/31 (90%) after
working abroad; 36/42 (86%) of residents agreed that a simulation-based global health curriculum is more
useful than a didactic curriculum alone, and 41/42 (98%) felt a simulator-based curriculum should be
offered to all residents planning a clinical trip to a low-income country.
Conclusion: High-fidelity simulation is effective in increasing residents’ self-rated comfort in management
of pediatric malaria and malnutrition and a majority of participating residents feel it should be included as
a component of pre-departure training for all residents rotating clinically to low-income countries.

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Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety

Volume 16, Issue 6, November 2015.
Emily L. Aaronson, MD, et al.

Introduction: Morbidity and mortality conferences (M+M) are a traditional part of residency training
and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective
was to determine the goals, structure, and the prevalence of practices that foster strong safety
cultures in the M+Ms of U.S. emergency medicine (EM) residency programs.
Methods: The authors conducted a national survey of U.S. EM residency program directors. The
survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding;
Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare
Research & Quality Safety Culture survey.
Results: There was an 80% (151/188) response rate. The primary objectives of M+M were
discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and
identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous
case submission, with 10% (15/151) maintaining complete anonymity during the presentation and
21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a
formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of
programs report regular debriefing with residents who have had their cases presented.
Conclusion: The structure and goals of M+Ms in EM residencies vary widely. Many programs lack
features of M+M that promote a non-punitive response to error, such as anonymity. Other programs
lack features that support strong safety cultures, such as following up on systems issues or reporting
back to residents on improvements. Further research is warranted to determine if M+M structure is
related to patient safety culture in residency programs.

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Are Live Ultrasound Models Replaceable? Traditional versus Simulated Education Module for FAST Exam

Volume 16, Issue 6, November 2015.
Suzanne Bentley, MD, MPH, et al.

Introduction: The focused assessment with sonography for trauma (FAST) is a commonly used and
life-saving tool in the initial assessment of trauma patients. The recommended emergency medicine
(EM) curriculum includes ultrasound and studies show the additional utility of ultrasound training for
medical students. EM clerkships vary and often do not contain formal ultrasound instruction. Time
constraints for facilitating lectures and hands-on learning of ultrasound are challenging. Limitations
on didactics call for development and inclusion of novel educational strategies, such as simulation.
The objective of this study was to compare the test, survey, and performance of ultrasound between
medical students trained on an ultrasound simulator versus those trained via traditional, hands-on
patient format.
Methods: This was a prospective, blinded, controlled educational study focused on EM clerkship
medical students. After all received a standardized lecture with pictorial demonstration of image
acquisition, students were randomized into two groups: control group receiving traditional training
method via practice on a human model and intervention group training via practice on an ultrasound
simulator. Participants were tested and surveyed on indications and interpretation of FAST and training
and confidence with image interpretation and acquisition before and after this educational activity.
Evaluation of FAST skills was performed on a human model to emulate patient care and practical skills
were scored via objective structured clinical examination (OSCE) with critical action checklist.
Results: There was no significant difference between control group (N=54) and intervention group
(N=39) on pretest scores, prior ultrasound training/education, or ultrasound comfort level in general
or on FAST. All students (N=93) showed significant improvement from pre- to post-test scores and
significant improvement in comfort level using ultrasound in general and on FAST (p<0.001). There
was no significant difference between groups on OSCE scores of FAST on a live model. Overall, no
differences were demonstrated between groups trained on human models versus simulator.
Discussion: There was no difference between groups in knowledge based ultrasound test scores,
survey of comfort levels with ultrasound, and students’ abilities to perform and interpret FAST on
human models.
Conclusion: These findings suggest that an ultrasound simulator is a suitable alternative method
for ultrasound education. Additional uses of ultrasound simulation should be explored in the future.

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Teaching and Assessing ED Handoffs: A Qualitative Study Exploring Resident, Attending, and Nurse Perceptions

Volume 16, Issue 6, November 2015.
Moira Flanigan, BA, et al.

Introduction: The Accreditation Council for Graduate Medical Education requires that residency
programs ensure resident competency in performing safe, effective handoffs. Understanding
resident, attending, and nurse perceptions of the key elements of a safe and effective emergency
department (ED) handoff is a crucial step to developing feasible, acceptable educational
interventions to teach and assess this fundamental competency. The aim of our study was to identify
the essential themes of ED-based handoffs and to explore the key cultural and interprofessional
themes that may be barriers to developing and implementing successful ED-based educational
handoff interventions.
Methods: Using a grounded theory approach and constructivist/interpretivist research paradigm, we
analyzed data from three primary and one confirmatory focus groups (FGs) at an urban, academic
ED. FG protocols were developed using open-ended questions that sought to understand what
participants felt were the crucial elements of ED handoffs. ED residents, attendings, a physician
assistant, and nurses participated in the FGs. FGs were observed, hand-transcribed, audiorecorded
and subsequently transcribed. We analyzed data using an iterative process of theme and
subtheme identification. Saturation was reached during the third FG, and the fourth confirmatory
group reinforced the identified themes. Two team members analyzed the transcripts separately and
identified the same major themes.
Results: ED providers identified that crucial elements of ED handoff include the following: 1) Culture
(provider buy-in, openness to change, shared expectations of sign-out goals); 2) Time (brevity,
interruptions, waiting); 3) Environment (physical location, ED factors); 4) Process (standardization,
information order, tools).
Conclusion: Key participants in the ED handoff process perceive that the crucial elements of
intershift handoffs involve the themes of culture, time, environment, and process. Attention to these
themes may improve the feasibility and acceptance of educational interventions that aim to teach
and assess handoff competency.

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The Impact of Medical Student Participation in Emergency Medicine Patient Care on Departmental Press Ganey Scores

Volume 16, Issue 6, November 2015.
Aaron W. Bernard, MD, et al.

Introduction: Press Ganey (PG) scores are used by public entities to gauge the quality of patient
care from medical facilities in the United States. Academic health centers (AHCs) are charged
with educating the new generation of doctors, but rely heavily on PG scores for their business
operation. AHCs need to know what impact medical student involvement has on patient care and
their PG scores.
Purpose: We sought to identify the impact students have on emergency department (ED) PG scores
related to overall visit and the treating physician’s performance.
Methods: This was a retrospective, observational cohort study of discharged ED patients who
completed PG satisfaction surveys at one academic, and one community-based ED. Outcomes
were responses to questions about the overall visit assessment and doctor’s care, measured on a
five-point scale. We compared the distribution of responses for each question through proportions
with 95% confidence intervals (CIs) stratified by medical student participation. For each question, we
constructed a multivariable ordinal logistic regression model including medical student involvement
and other independent variables known to affect PG scores.
Results: We analyzed 2,753 encounters, of which 259 (9.4%) had medical student involvement. For
all questions, there were no appreciable differences in patient responses when stratifying by medical
student involvement. In regression models, medical student involvement was not associated with
PG score for any outcome, including overall rating of care (odds ratio [OR] 1.10, 95% CI [0.90-1.34])
or likelihood of recommending our EDs (OR 1.07, 95% CI [0.86-1.32]). Findings were similar when
each ED was analyzed individually.
Conclusion: We found that medical student involvement in patient care did not adversely impact
ED PG scores in discharged patients. Neither overall scores nor physician-specific scores were
impacted. Results were similar at both the academic medical center and the community teaching
hospital at our institution.

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What is the Prevalence and Success of Remediation of Emergency Medicine Residents?

Volume 16, Issue 6, November 2015.
Mark Silverberg, MD

Introduction: The primary objective of this study was to determine the prevalence of remediation,
competency domains for remediation, the length, and success rates of remediation in emergency
medicine (EM).
Methods: We developed the survey in SurveymonkeyTM with attention to content and response
process validity. EM program directors responded how many residents had been placed on
remediation in the last three years. Details regarding the remediation were collected including
indication, length and success. We reported descriptive data and estimated a multinomial logistic
regression model.
Results: We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one
resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications
for remediation ranged from difficulties with one core competency to all six competencies (mean
1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%)
and professionalism (31.5%). Mean length of remediation was eight months (range 1-36 months).
Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In
8.7%, remediation was deemed “unsuccessful.” Training year at time of identification for remediation
(post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based
learning (PBLI) and professionalism were found to have statistically significant association with
unsuccessful remediation.
Conclusion: Remediation in EM residencies is common, with the most common areas being MK
and patient care. The majority of residents are successfully remediated. PGY level, length of time
spent in remediation, and the remediation of the competencies of PBLI and professionalism were
associated with unsuccessful remediation.

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Results from the First Year of Implementation of CONSULT: Consultation with Novel Methods and Simulation for UME Longitudinal Training

Volume 16, Issue 6, November 2015.
Keme Carter, MD, et al.

Introduction: An important area of communication in healthcare is the consultation. Existing literature
suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted
needs assessment of third-year students on their experience calling consultations, and based on these
results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner
levels that can be implemented as a longitudinal curriculum.
Methods: Baseline needs assessment data were gathered using a survey completed by third-year
students at the conclusion of the clinical clerkships. The survey assessed students’ knowledge of
the standardized consultation, experience and comfort calling consultations, and previous instruction
received on consultation communication. Implementation of the consultation curriculum began the
following academic year. Second-year students were introduced to Kessler’s 5 Cs consultation
model through a didactic session consisting of a lecture, viewing of “trigger” videos illustrating
standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness
was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort
with the consultation process. Fourth-year students participated in a consultation curriculum that
provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through
simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this
cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist.
Results: The targeted needs assessment of third-year students indicated that 93% of students
have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum,
second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and
reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum,
fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for
all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001).
Conclusion: While third-year medical students reported calling consultations, few felt comfortable
and formal training was lacking. A curriculum in consult communication for different levels of learners
can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior
to residency training.

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Does the Concept of the “Flipped Classroom” Extend to the Emergency Medicine Clinical Clerkship?

Volume 16, Issue 6, November 2015.
Corey Heitz, MD, et al.

Introduction: Linking educational objectives and clinical learning during clerkships can be difficult.
Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences,
some of which may not be relevant to recommended educational objectives. Students can be
directed to standardize their clinical experiences, and this improves performance on examinations.
We hypothesized that applying a “flipped classroom” model to the clinical clerkship would improve
performance on multiple-choice testing when compared to standard learning.
Methods: Students at two institutions were randomized to complete two of four selected EM
clerkship topics in a “flipped fashion,” and two others in a standard fashion. For flipped topics,
students were directed to complete chief complaint-based asynchronous modules prior to a shift,
during which they were directed to focus on the chief complaint. For the other two topics, modules
were to be performed at the students’ discretion, and shifts would not have a theme. At the end
of the four-week clerkship, a 40-question multiple-choice examination was administered with 10
questions per topic. We compared performance on flipped topics with those performed in standard
fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and
willingness of preceptors to allow a chief-complaint focus.
Results: Sixty-nine students participated; examination scores for 56 were available for analysis. For
the primary outcome, no difference was seen between the flipped method and standard (p=0.494.)
A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation
on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly
(3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol.
Conclusion: Preparation for a clinical shift with pre-assigned, web-based learning modules followed
by an attempt at chief-complaint-focused learning during a shift did not result in improvements in
performance on a multiple-choice assessment of knowledge; however, one third of participants did
not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned
learning as well as clinical experiences, and consider alternate measures of knowledge.

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Ready for Discharge? A Survey of Discharge Transition-of-Care Education and Evaluation in Emergency Medicine Residency Programs

Volume 16, Issue 6, November 2015.
Fiona E. Gallahue, MD, et al.

This study aimed to assess current education and practices of emergency medicine (EM) residents
as perceived by EM program directors to determine if there are deficits in resident discharge handoff
training. This survey study was guided by the Kern model for medical curriculum development.
A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM
physicians performed these steps and constructed a survey. The survey was distributed to program
residency directors via the CORD listserve and/or direct contact. There were 119 responses to the
survey, which were collected using an online survey tool. Over 71% of the 167 American College of
Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of
those responding, 42.9% of programs reported formal training regarding discharges during initial
orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of
programs reported that EM residents were not routinely evaluated on their discharge proficiency.
Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many
programs do not provide formal curriculum on the discharge transition of care or evaluate EM
residents on their discharge proficiency.

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Combined Versus Detailed Evaluation Components in Medical Student Global Rating Indexes

Volume 16, Issue 6, November 2015.
Kim L. Askew, MD, et al.

Introduction: To determine if there is any correlation between any of the 10 individual components
of a global rating index on an emergency medicine (EM) student clerkship evaluation form. If there
is correlation, to determine if a weighted average of highly correlated components loses predictive
value for the final clerkship grade.
Methods: This study reviewed medical student evaluations collected over two years of a required
fourth-year rotation in EM. Evaluation cards, comprised of a detailed 10-part evaluation, were
completed after each shift. We used a correlation matrix between evaluation category average
scores, using Spearman’s rho, to determine if there was any correlation of the grades between any
of the 10 items on the evaluation form.
Results: A total of 233 students completed the rotation over the two-year period of the study. There
were strong correlations (>0.80) between assessment components of medical knowledge, history
taking, physical exam, and differential diagnosis. There were also strong correlations between
assessment components of team rapport, patient rapport, and motivation. When these highly
correlated were combined to produce a four-component model, linear regression demonstrated
similar predictive power in terms of final clerkship grade (R2
=0.71, CI95=0.65–0.77 and R2
=0.69,
CI95=0.63–0.76 for the full and reduced models respectively).
Conclusion: This study revealed that several components of the evaluation card had a high degree
of correlation. Combining the correlated items, a reduced model containing four items (clinical skills,
interpersonal skills, procedural skills, and documentation) was as predictive of the student’s clinical
grade as the full 10-item evaluation. Clerkship directors should be aware of the performance of their
individual global rating scales when assessing medical student performance, especially if attempting
to measure greater than four components.

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Effect of Doximity Residency Rankings on Residency Applicants’ Program Choices

Volume 16, Issue 6, November 2015.
Aimee M. Rolston, MD, MS, et al.

Introduction: Choosing a residency program is a stressful and important decision. Doximity
released residency program rankings by specialty in September 2014. This study sought to
investigate the impact of those rankings on residency application choices made by fourth year
medical students.
Methods: A 12-item survey was administered in October 2014 to fourth year medical students
at three schools. Students indicated their specialty, awareness of and perceived accuracy of the
rankings, and the rankings’ impact on the programs to which they chose to apply. Descriptive
statistics were reported for all students and those applying to Emergency Medicine (EM).
Results: A total of 461 (75.8%) students responded, with 425 applying in one of the 20 Doximity
ranked specialties. Of the 425, 247 (58%) were aware of the rankings and 177 looked at them. On
a 1-100 scale (100=very accurate), students reported a mean ranking accuracy rating of 56.7 (SD
20.3). Forty-five percent of students who looked at the rankings modified the number of programs to
which they applied. The majority added programs. Of the 47 students applying to EM, 18 looked at
the rankings and 33% changed their application list with most adding programs.
Conclusion: The Doximity rankings had real effects on students applying to residencies as almost
half of students who looked at the rankings modified their program list. Additionally, students found
the rankings to be moderately accurate. Graduating students might benefit from emphasis on more
objective characterization of programs to assess in light of their own interests and personal/career
goals.

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