Cemal B. Sozener

Reporting Achievement of Medical Student Milestones to Residency Program Directors: An Educational Handover.

PROBLEM Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear-as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. APPROACH A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. OUTCOMES In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. NEXT STEPS An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions.

Model for Developing Educational Research Productivity: The Medical Education Research Group.

Introduction Education research and scholarship are essential for promotion of faculty as well as dissemination of new educational practices. Educational faculty frequently spend the majority of their time on administrative and educational commitments and as a result educators often fall behind on scholarship and research. The objective of this educational advance is to promote scholarly productivity as a template for others to follow. Methods We formed the Medical Education Research Group (MERG) of education leaders from our emergency medicine residency, fellowship, and clerkship programs, as well as residents with a focus on education. First, we incorporated scholarship into the required activities of our education missions by evaluating the impact of programmatic changes and then submitting the curricula or process as peer-reviewed work. Second, we worked as a team, sharing projects that led to improved motivation, accountability, and work completion. Third, our monthly meetings served as brainstorming sessions for new projects, research skill building, and tracking work completion. Lastly, we incorporated a work-study graduate student to assist with basic but time-consuming tasks of completing manuscripts. Results The MERG group has been highly productive, achieving the following scholarship over a three-year period: 102 abstract presentations, 46 journal article publications, 13 MedEd Portal publications, 35 national didactic presentations and five faculty promotions to the next academic level. Conclusion An intentional focus on scholarship has led to a collaborative group of educators successfully improving their scholarship through team productivity, which ultimately leads to faculty promotions and dissemination of innovations in education.

The impact of emergency physician turnover on planning for prospective clinical trials

Introduction Emergency physician (EP) turnover is a significant issue that can have strong economic impact on hospital systems, as well as implications on research efforts to test and improve clinical practice. This work is particularly important to researchers planning randomized trials directed toward EPs because a large degree of turnover within a physician group would attenuate the effectiveness of the desired intervention. We sought to determine the incidence and factors associated with EP workforce changes. Methods: In an attempt to determine EP turnover and workforce change, data from the INSTINCT (INcreasing Stroke Treatment through INterventional behavior Change Tactics) trial were used. The INSTINCT trial is a prospective, cluster-randomized, controlled trial evaluating a targeted behavioral intervention to increase appropriate use of tissue plasminogen activator in acute ischemic stroke. Individual EPs staffing each of the study hospitals were identified at baseline and 18 months. Surveys were sent to EPs at both intervals. Models were constructed to investigate relationships between physician/hospital characteristics and workforce change. Results: A total of 278 EPs were identified at baseline. Surveys were sent to all EPs at baseline and 18 months with a response rate of 72% and 74%, respectively. At 18 months, 37 (15.8%) had left their baseline hospital and 66 (26.3%) new EPs were working. Seven EPs switched hospitals within the sample. The total number of EPs at 18 months was 307, a 10.8% overall increase. Among the 24 hospitals, 6 had no EP departures and 5 had no new arrivals. The median proportion of EP workforce departing by hospital was 16% (interquartile range [IQR] = 4%–25%; range = 0%–73%), and the median proportion added was 21% (IQR = 7%–41%; range = 0%–120%). None of the evaluated covariates investigating relationships between physician/hospital characteristics and workforce change were significant. Conclusion: EP workforce changes over an 18-month period were common. This has implications for emergency department directors, researchers, and individual EPs. Those planning research involving interventions upon EPs should account for turnover as it may have an impact when designing clinical trials to improve performance on healthcare delivery metrics for time-sensitive medical conditions such as stroke, acute myocardial infarction, or trauma.

Impact of regional pre-hospital emergency medical services in treatment of patients with acute ischemic stroke

Stroke is a major public health concern afflicting an estimated 795,000 Americans annually. The associated morbidity and mortality is staggering. Early treatment with thrombolytics is beneficial. The window for treatment is narrow and minimization of the time from symptom onset to treatment is vital. The general population is not well informed as to the warning signs or symptoms of stroke, leading to substantial delays in emergency medical services (EMS) activation. Ambulance transport of stroke patients to the hospital has demonstrated improvements in key benchmarks such as door to physician evaluation, door to CT initiation, and increased thrombolytic treatment. Pre‐hospital notification of the impending arrival of a stroke patient allows for vital preparation in the treating emergency department, and improving timely evaluation and treatment upon arrival of the stroke patient. EMS systems are a vital component of the management of stroke patients, and resources used to improve these systems are beneficial.

Establishing Recommendations for Stroke Systems in the Thrombectomy Era: The Upstate New York Stakeholder Proceedings.

Background and Purpose— The American Heart Association/American Stroke Association and Department of Health Stroke Coverdell Program convened a stakeholder meeting in upstate NY to develop recommendations to enhance stroke systems for acute large vessel occlusion. Methods— Prehospital, hospital, and Department of Health leadership were invited (n=157). Participants provided goals/concerns and developed recommendations for prehospital triage and interfacility transport, rating each using a 3-level impact (A [high], B, and C [low]) and implementation feasibility (1 [high], 2, and 3 [low]) scale. Six weeks later, participants finalized recommendations. Results— Seventy-one stakeholders (45% of invitees) attended. Six themes around goals/concerns emerged: (1) emergency medical services capacity, (2) validated prehospital screening tools, (3) facility capability, (4) triage/transport guidelines, (5) data capture/feedback tools, and (6) facility competition. In response, high-impact (level A) prehospital recommendations, stratified by implementation feasibility, were (1) use of online medical control for triage (6%); (2) regional transportation strategy (31%), standardized emergency medical services checklists (18%), quality metrics (14%), standardized prehospital screening tools (13%), and feedback for performance improvement (7%); and (3) smartphone application algorithm for screening/decision-making (6%) and ambulance-based telemedicine (6%). Level A interfacility transfer recommendations were (1) standardized transfer process (32%)/timing goals (16%)/regionalized systems (11%), performance metrics (11%), image sharing capabilities (7%); (2) provider education (9%) and stroke toolbox (5%); and (3) interfacility telemedicine (7%) and feedback (2%). Conclusions— The methods used and recommendations generated provide models for stroke system enhancement. Implementation may vary based on geographic need/capacity and be contingent on establishing standard care practices. Further research is needed to establish optimal implementation strategies.

Hypertensive emergency presenting as blurry vision in a patient with hypertensive chorioretinopathy

A 42-year-old man presented with 3 weeks of blurry vision in the right eye. His exam was significant for decreased vision in the right eye, diffuse retinopathy in both eyes, and serous retinal detachment in the right eye. The patient was found to be hypertensive with blood pressure of 256/160 mmHg. He was diagnosed with hypertensive emergency with end-organ damage due to features of hypertensive chorioretinopathy. He was admitted with abnormal urinalysis, elevated troponin, and abnormal EKG. After appropriate control of his blood pressure, his vision and his labs normalized. Hypertensive emergencies can be manifested first in the eyes. When the choroid is associated, the hypertensive event is often more acute and associated with increased morbidity. It is imperative to obtain a fundus exam in any patient with elevated blood pressure and concomitant vision complaints.

Sleep apnea screening is uncommon after stroke

OBJECTIVE/BACKGROUND To assess (1) pre and post-stroke screening for sleep apnea (SA) within a population-based study without an academic medical center, and (2) ethnic differences in post-stroke sleep apnea screening among Mexican Americans (MAs) and non-Hispanic whites (NHWs). PATIENTS/METHODS MAs and NHWs with stroke in the Brain Attack Surveillance in Corpus Christi project (2011-2015) were interviewed shortly after stroke about the pre-stroke period, and again at approximately 90 days after stroke in reference to the post-stroke period. Questions included whether any clinical provider directly asked about snoring or daytime sleepiness or had offered polysomnography. Logistic regression tested the association between these outcomes and ethnicity both unadjusted and adjusted for potential confounders. RESULTS Among 981 participants, 63% were MA. MAs in comparison to NHWs were younger, had a higher prevalence of hypertension, diabetes, and never smoking, a higher body mass index, and a lower prevalence of atrial fibrillation. Only 17% reported having been offered SA diagnostic testing pre-stroke, without a difference by ethnicity. In the post-stroke period, only 50 (5%) participants reported being directly queried about snoring; 86 (9%) reported being directly queried about sleepiness; and 55 (6%) reported having been offered polysomnography. No ethnic differences were found for these three outcomes, in unadjusted or adjusted analyses. CONCLUSIONS Screening for classic symptoms of SA, and formal testing for SA, are rare within the first 90 days after stroke, for both MAs and NHWs. Provider education is needed to raise awareness that SA affects most patients after stroke and is associated with poor outcomes.

Incorporation of a Graduate Student Writer into a Productive Research Team

Author(s): Fischer, Jonathan P; House, Joseph B; Hopson, Laura R; Perry, Marcia A; Theyyuni, Nikhil; Wolff, Margaret S; Sozener, Cemal B; Santen, Sally A

Incidentally Discovered Foley Catheter Placement Into a Transplanted Kidney.

Although unusual, placement of a Foley catheter into the renal pelvis or ureter has been reported. Proposed predisposing factors for errant placement include pre-existing hydronephrosis or congenital ureteral orifice enlargement. We report a case where aberrant placement of a Foley catheter into the renal pelvis of a transplanted kidney was detected by ultrasound in a patient being evaluated for acute kidney injury. The Foley had been in place for 2 weeks. This is the only reported case we are aware of involving accidental catheterization of a transplants renal pelvis.

153: AN EDUCATIONAL SESSION INCREASES THE UNDERSTANDING OF ALL ASPECTS OF INTERFACILITY PATIENT TRANSFERS

Introduction: Emergency medicine residents and critical care fellows have only limited instruction on the challenges surrounding inter-facility patient transfers, which includes legal considerations (such as EMTALA), knowledge of particularities of the local EMS systems (equipment, provider qualification, protocols) and adequate communication with prehospital providers and the involved physicians at the receiving facility. Methods: Emergency medicine residents and critical care fellows (in Surgery, Internal Medicine, Anesthesiology and Pediatric critical care programs) at a tertiary care academic medical center participated in a hour lecture/interactive instruction on the medical and legal aspects of inter-facility patient transfers. This was followed by a discussion of case-based scenarios. Prior to the educational intervention, participants filled out a survey that tested their knowledge in these areas, including the legal background for patient transfers, liability associated with transfer, qualification of prehospital personnel, as well as equipment and standing orders used when transporting critically ill patients. Two to three weeks later, all participants filled out a follow up survey. Using case scenarios, these critical areas were tested and the participants provided information on how the educational session had affected their experiences and confidence regarding patient transfers in their daily work life. Results: Participants had generally poor knowledge of the legal aspects of inter-facility patient transfers, though emergency medicine residents were more knowledgeable of EMTALA-related regulations than critical care fellows. Both groups also had limited understanding of the clinical and legal scope of practice of prehospital providers involved in patient transports. Participants rated their knowledge as poor to average on the pre-test. On follow up, participants were noted to have a significantly improved knowledge base, with respect to both the medical and the legal aspects of inter-facility pateitnt transfers. They felt more comfortable in accepting and facilitating patient transfers and felt that the educational intervention had affected their practice in a positive way (improved communication with transferring facilities, better ability to judge the appropriateness and feasibility of transfers). Conclusions: A one-hour educational intervention objectively increased emergency medicine residents’ and critical care fellows’ understanding of the medical and legal aspects of inter-facility patient transfers. Participants also felt much more comfortable with patient transfers in their daily practice.