Carey D. Chisholm

How Do Physicians and Nurses Spend Their Time in the Emergency Department

STUDY OBJECTIVES To determine how emergency physicians and nurses spend their time on emergency department activities. METHODS An observational time-and-motion study was performed at a 36-bed ED with annual census of 84,000 in a central city teaching hospital sponsoring an emergency medicine residency program. Participants were emergency medicine faculty physicians, second- and third-year emergency medicine resident physicians, and emergency nurses. A single investigator followed individual health care providers for 180-minute periods and recorded time spent on various activities, type and number of activities, and distance walked. Activities were categorized as direct patient care (eg. history and physical examination), indirect patient care (eg. charting), or non-patient care (eg. break time). RESULTS On average, subjects spent 32% of their time on direct patient care, 47% on indirect patient care, and 21% on non-patient care Faculty physicians, residents, and emergency nurses differed in the time spent on these three categories of activities. Although the overall time spent on direct patient care activities was not significantly different, emergency nurses spent more of their time (2.2%) providing comfort measures (a subcategory of direct patient care) than did faculty physicians (.05%) or resident physicians (.03%). Emergency nurses spent 38.9% of their time performing indirect care, whereas faculty physicians spent 51.3% and resident physicians 53.7%. Resident physicians spent more time charting than did faculty physicians or emergency nurses (21.4%, 11.9%, and 6.9%, respectively). Emergency nurses spent more time on personal activities than did physicians, and faculty physicians walked less than either emergency nurses or resident physicians. CONCLUSION Emergency physicians and nurses spent almost half of their time on indirect patient care. Physicians spent significantly more time on indirect patient care activities and significantly less time on personal activities than did nurses.

Hand Washing Frequency in an Emergency Department

STUDY OBJECTIVE Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one ED and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience. DESIGN Observational. SETTING ED of an 1,100-bed tertiary referral, central city, private teaching hospital. PARTICIPANTS Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study. INTERVENTIONS An observer recorded the number of patient contacts and activities for each participant during three-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity. RESULTS Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (P < .0001) or resident physicians (P < .0001). Hand washes occurred after 28.4% of 272 clean contacts (SD, 2.34%), which was significantly less (P < .0001) than 50.0% of 46 dirty contacts (SD, 7.4%) and 64.8% of 91 gloved contacts (SD, 5.0%). The number of years of clinical experience was not significantly related to hand-washing frequency (P = .82). Soap and water were used in 126 of the hand washes, and an alcohol preparation was used in the remaining six. The average duration of soap-and-water hand washes was 9.5 seconds. CONCLUSION Compliance with hand washing recommendations was low in this ED. Nurses washed their hands significantly more often than either staff physicians or resident physicians, but the average hand-washing duration was less than recommended for all groups. Poor compliance in the ED may be due to the large number of patient contacts, simultaneous management of multiple patients, high illness acuity, and severe time constraints. Strategies for improving compliance with this fundamental method of infection control need to be explored because simple educational interventions have been unsuccessful in other health care settings.

An Evaluation of Emergency Medicine Resident Interaction Time with Faculty in Different Teaching Venues

OBJECTIVES To measure actual emergency medicine (EM) resident interaction time with faculty and to investigate the potential to use direct observation as an assessment tool for the core competencies. By 2006 all EM residencies must implement resident assessment techniques of the six Accreditation Council for Graduate Medical Education core competencies. Emergency medicine educators recommend direct observation as the optimal evaluation tool for patient care, systems-based practice, interpersonal and communication skills, and professionalism. Continuous faculty presence in the emergency department (ED) is widely believed to facilitate direct observation as an assessment technique. METHODS Observational study of EM resident-faculty interaction time during two-hour periods. Study venues included two EDs, two trauma services, inpatient medicine, adult and pediatric intensive care units (ICUs), and a pediatric outpatient clinic. Using a priori definitions, the authors categorized faculty-EM resident interaction time as direct observation of patient care, indirect patient care, or non-patient care activities, and calculated total faculty interaction time. Subjects were blinded to the nature of the study, and data gathering was encrypted. RESULTS Two hundred seventy observation periods of two hours each were conducted, sampling 32 EMR1, 33 EMR2-3, 41 EM, and 38 non-EM faculty. The mean total faculty interaction time ranged from a high of 30% (95% CI = 20% to 41%) in the pediatric ICU to a low of 10% (95% CI = 3% to 16%) on internal medicine wards. Overall, EM faculty interaction time was 20% (95% CI = 18% to 22%). Direct observation by faculty ranged from a high of 6% for EMR2-3s in the critical care areas of the ED (95% CI = 3% to 9%) to a low of 1% (95% CI = 0% to 2%) on internal medicine wards. Overall ED direct observation time was 3.6% (95% CI = 2.6% to 4.7%). Emergency department direct observation did not vary within EM resident training level or by ED site. Direct observation varied by treatment area within the EDs, with the critical care areas being substantially higher (6%) than the noncritical care areas (1%). CONCLUSIONS Faculty direct observation time of EM residents was low in all training venues studied. Direct observation was the highest in ED critical care areas and lowest on medicine ward rotations. Emergency medicine faculty involved simultaneously in routine ED teaching, supervision, and patient care rarely performed direct observation, despite their continuous physical presence. This finding suggests that alternative strategies may be required to assess core competencies through direct observation in the ED.

A Task Analysis of Emergency Physician Activities in Academic and Community Settings

STUDY OBJECTIVE We characterize and compare the work activities, including peak patient loads, associated with the workplace in the academic and community emergency department (ED) settings. This allows assessment of the effect of future ED system operational changes and identifies potential sources contributing to medical error. METHODS This was an observational, time-motion study. Trained observers shadowed physicians, recording activities. Data included total interactions, distances walked, time sitting, patients concurrently treated, interruptions, break in tasks, physical contact with patients, hand washing, diagnostic tests ordered, and therapies rendered. Activities were classified as direct patient care, indirect patient care, or personal time with a priori definitions. RESULTS There were 203 2-hour observation periods of 85 physicians at 2 academic EDs with 100,000 visits per year at each (N=160) and 2 community EDs with annual visits of 19,000 and 21,000 (N=43). Reported data present the median and minimum-maximum values per 2-hour period. Emergency physicians spent the majority of time on indirect care activities (academic 64 minutes, 29 to 91 minutes; community 55 min, 25 to 95 minutes), followed by direct care activities (academic 36 minutes, 6 to 79 minutes; community 41 minutes, 5 to 60 minutes). Personal time differed by location type (academic 6 minutes, 0 to 66 minutes; community 13 minutes, 0 to 69 minutes). All physicians simultaneously cared for multiple patients, with a median number of patients greater than 5 (academic 7 patients, 2 to 16 patients; community 6 patients, 2 to 12 patients). CONCLUSION Emergency physicians spend the majority of their time involved in indirect patient care activities. They are frequently interrupted and interact with a large number of individuals. They care for a wide range of patients simultaneously, with surges in multiple patient care responsibilities. Physicians working in academic settings are interrupted at twice the rate of their community counterparts.

Outpatient wound preparation and care: a national survey.

STUDY OBJECTIVE To sample the practice styles of emergency physicians caring for acute traumatic wounds. DESIGN Written survey. SETTING US emergency departments obtained from the American College of Emergency Physicians mailing list. SUBJECTS Randomly selected ACEP members. MAIN RESULTS One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations. CONCLUSION Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de facto standard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced (ie, soaking, scrubbing, use of full-strength hydrogen peroxide or full-strength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians.

The 2005 Model of the Clinical Practice of Emergency Medicine: The 2007 Update

2007 EM Model Review Task Force Harold A. Thomas, MD, Chair Michael S. Beeson, MD Louis S. Binder, MD Patrick H. Brunett, MD Merle A. Carter, MD Carey D. Chisholm, MD Douglas L. McGee, DO Debra G. Perina, MD Michael J. Tocci, MD From the American Board of Emergency Medicine, East Lansing, MI (Thomas, Perina); Council of Emergency Medicine Residency Directors, Lansing, MI (Brunett); Residency Review Committee for Emergency Medicine, Chicago, IL (Binder); Society for Academic Emergency Medicine, Lansing, MI (Chisholm, McGee); American College of Emergency Physicians, Dallas, TX (Beeson, Carter); and the Emergency Medicine Residents’ Association, Dallas, TX (Tocci).

High-pressure water injection injury to the hand.

An 84-year-old man presented with a high-pressure injection injury of the left thumb. The hand-held water gun involved generates less pressure than the grease and paint sprayers usually involved in these injuries. The patient was managed conservatively in the hospital with elevation, observation, and dressing changes. Surgical debridement was not required. This case points out a previously unrecognized hazard of these devices, particularly to older individuals with atrophic skin.

The 2011 model of the clinical practice of emergency medicine

The 2011 Model of the Clinical Practice of Emergency Medicine.

Plantar Puncture Wounds: Controversies and Treatment Recommendations

Future studies are needed to define the natural history of plantar puncture wounds; delineate optimal initial evaluation techniques; examine the role of broad-spectrum antimicrobials for prophylaxis; treatment, or both; and investigate optimal therapy for immunocompromised patients.

Radiographic Detection of Gravel in Soft Tissue

STUDY OBJECTIVE We sought to quantify the detectable size of varying compositions of gravel using a cadaveric chicken leg wound model and standard plain-film two-view radiographs. METHODS We conducted a randomized, blinded, descriptive study with the assistance of faculty from the emergency medicine and radiology residency programs of a private urban teaching hospital. A standardized wound was created in each of 160 cadaver chicken legs. Zero, one, or two pieces of gravel of four differing compositions, ranging in size from .25 to 2.0 mm, were inserted into the wounds as determined with computer-generated randomization. The legs were then radiographically imaged (anteroposterior and lateral views). Three faculty physicians independently interpreted the radiographs to determine the number of foreign bodies and rated the ease of visibility. We calculated sensitivity, specificity, and interobserver reliability. RESULTS The accuracy with which gravel was detected ranged from an average of 97.7% for 2-mm and 1-mm particles to less than 75% for .5-mm and .25-mm particles. Visibility ratings were also lower for particles in the smaller ranges. Sensitivity was greater for the emergency physicians than for the radiologists, but their specificity was lower. Salt-and-pepper gravel was the most easily identified foreign body. CONCLUSION In this wound model, gravel particles of less than 1 mm were not accurately identified.