Cherri Hobgood

Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration

Objectives The authors conducted a randomised controlled trial of four pedagogical methods commonly used to deliver teamwork training and measured the effects of each method on the acquisition of student teamwork knowledge, skills, and attitudes. Methods The authors recruited 203 senior nursing students and 235 fourth-year medical students (total N=438) from two major universities for a 1-day interdisciplinary teamwork training course. All participants received a didactic lecture and then were randomly assigned to one of four educational methods: didactic (control), audience response didactic, role play and human patient simulation. Student performance was assessed for teamwork attitudes, knowledge and skills using: (a) a 36-item teamwork attitudes instrument (CHIRP), (b) a 12-item teamwork knowledge test, (c) a 10-item standardised patient (SP) evaluation of student teamwork skills performance and (d) a 20-item modification of items from the Mayo High Performance Teamwork Scale (MHPTS). Results All four cohorts demonstrated an improvement in attitudes (F1,370=48.7, p=0.001) and knowledge (F1,353=87.3, p=0.001) pre- to post-test. No educational modality appeared superior for attitude (F3,370=0.325, p=0.808) or knowledge (F3,353=0.382, p=0.766) acquisition. No modality demonstrated a significant change in teamwork skills (F3,18=2.12, p=0.134). Conclusions Each of the four modalities demonstrated significantly improved teamwork knowledge and attitudes, but no modality was demonstrated to be superior. Institutions should feel free to utilise educational modalities, which are best supported by their resources to deliver interdisciplinary teamwork training.

Faculty development: academic opportunities for emergency medicine faculty on education career tracks.

Medical school faculty members who specialize in the scholarship of teaching have unique requirements for academic advancement in universities with clinician-educator series. While excellence in teaching is the cornerstone of achievement, attention to traditional academic pursuits improves the likelihood of a favorable review by the institutions promotion and tenure committee. The teaching portfolio is an effective means to document performance. Ongoing faculty development and sound mentoring relationships facilitate the academic advancement of clinician-educators.

Reducing Error in the Emergency Department: A Call for Standardization of the Sign-out Process

INTRODUCTION Since the increased recognition of medical error in the late 1990s, the medical profession has made significant efforts to eliminate both systemic and human error. As a result, many strategies have been implemented to reduce and eliminate error. These include national recommendations to limit resident work hours and encourage clear communication between providers, especially concerning the handoff of care. The transition of care has become a focus of error reduction because The Joint Commission (TJC) has found that 70% of all sentinel medical error events arise from communication breakdowns and 50% of these errors occur during the handoff of care. The emergency department (ED) is no exception. The simultaneous management of multiple ill patients, practitioner shift work, limited knowledge of patients’ preexisting medical conditions, high levels of diagnostic uncertainty, and high decision density make ED transfer of care especially vulnerable to error. Initial research and intervention efforts have focused on the transfer of care to the inpatient setting, with 29% of respondents in one study reporting adverse events occurring after transfer of patients from the ED to inpatient units. There has been increasing focus on the sign-out or transfer of care among emergency medicine providers because the American College of Emergency Physicians Section of Quality Improvement and Patient Safety has recently published a position article emphasizing the hazards involved in the sign-out process. Improvements in the sign-out process have the possibility of providing substantial advances in patient care and mitigating medicolegal risk. Standardization of this sign-out process provides a means for ensuring consistent high-quality sign-out. TJC has published specific recommendations on physician sign-out, including the need for standardization as part of the 2008 National Patient Safety Goals. Specifically, requirement (NPSG.02.05.01) addresses the handoff of patient care by recommending that a standardized process involving certain elements be implemented. Standardization of the sign-out process involves 2-way, open, and concise communication, teamwork, and additional strategies to avoid error. This

Death in the Field: Teaching Paramedics to Deliver Effective Death Notifications Using the Educational Intervention “GRIEV_ING”

Abstract Introduction. Emergency medical services (EMS) personnel are rarely trained in death notification despite frequently terminating resuscitation in the field. As research continues to validate guidelines for the termination of resuscitation (TOR) and reputable organizations such as NAEMSP lend support to such protocols, death notification in the field will continue to increase. We sought to test the hypothesis that a learning module, GRIEV_ING, which teaches a structured method for death notification, will improve the confidence, competency, and communication skills of EMS personnel in death notification. Methods. The GRIEV_ING didactic session consisted of a 90-minute education session composed of a didactic lecture, small group breakout session, and role-plays. This was both preceded and followed by a 15-minute case role-play using trained standardized survivors. To assess performance we used a pre–post design with 3 quantitative measures: confidence, competency, and, communication. Paramedics from the local EMS agency participated in the education as a part of continuing education. Pre–post differences were measured using a paired t-test and McNemars test. Results. Thirty EMS personnel consented and participated. Confidence and competency demonstrated statistically significant improvements: confidence (percent change in scores = 11.4%, p < 0.0001) and competency (percent change in scores = 13.9%, p = 0.0001). Communication skill scores were relatively unchanged in pre–post test analysis (percent change in scores = 0.4, p = 0.9). Conclusion. This study demonstrated that educating paramedics to use a structured communication model based on the GRIEV_ING mnemonic improved confidence and competence of EMS personnel delivering death notification. Key words: death; education; emergency medical services; emergency medical technician

Griev_Ing: Death Notification Skills and Applications for Fourth-Year Medical Students

Background and Purpose: Our study examined whether GRIEV_ING improved death notification skills of medical students, whether pretesting with simulated survivors primed learners and improved results of the intervention, and whether feedback on the simulated encounter improved student performance. Methods: GRIEV_ING training was given to 138 fourth-year medical students divided into three groups: exposure to simulated survivor (SS) with written feedback, exposure to SS but no feedback, and no exposure to SS before the training. Students were tested on self-confidence before and after the intervention and were rated by SSs on interpersonal communication and death notification skills. ANCOVA was performed, with gender and race covariates. Results: All groups improved on death notification competence and confidence at about the same rate. Competence significantly (p =.037) improved for the feedback group. Interpersonal communication scores declined for all groups. Conclusions: GRIEV_ING provides an effective model medical educators can use to train medical students to provide competent death notifications. Senior medical students are primed to learn death notification and do not require a preexposure.

Evaluation of Radiation Exposure to Pediatric Trauma Patients

BACKGROUND Pediatric trauma patients pose a diagnostic challenge to physicians. Computed tomography (CT) imaging identifies life-threatening injuries quickly and efficiently. CT radiation dose in pediatric trauma patients is a concern. STUDY OBJECTIVES We evaluated the cumulative effective dose of radiation received by pediatric blunt trauma patients and assessed characteristics of patients and studies received. METHODS We retrospectively identified pediatric blunt trauma patients at a Level I trauma center between January 1 and December 31, 2006 utilizing the North Carolina Trauma Registry. We searched the patient radiographic history for images in the 7 days after their trauma event. We calculated cumulative effective radiation dose using dose length product and age coefficients. We collected demographic information including age, sex, mechanism of injury, hospital length of stay, and discharge status. RESULTS Seventy-five pediatric blunt trauma patients with available radiographic records were included. The median age was 11.7 years; males comprised 64% of patients; median Injury Severity Score was 13.8; 64% were transfer patients; median number of CT scans during initial evaluation was 3.4 for directly seen patients and two for transferred patients. Mean effective ionizing radiation dose was 11.4 mSv for CT scans performed in the first 24 h. Sixteen percent of admitted patients had CT scans in the subsequent 6 days, with an average additional CT dose of 4 mSv. Average number of plain radiographs was five. CONCLUSIONS Pediatric blunt trauma patients receive a major radiation burden in their initial evaluation. Patients who are transferred from an outside facility endure an even higher dose of radiation.

Using screen-based simulation to improve performance during pediatric resuscitation.

OBJECTIVES To assess the ability of a screen-based simulation-training program to improve emergency medicine and pediatric resident performance in critical pediatric resuscitation knowledge, confidence, and skills. METHODS A pre-post, interventional design was used. Three measures of performance were created and assessed before and after intervention: a written pre-course knowledge examination, a self-efficacy confidence score, and a skills-based high-fidelity simulation code scenario. For the high-fidelity skills assessment, independent physician raters recorded and reviewed subject performance. The intervention consisted of eight screen-based pediatric resuscitation scenarios that subjects had 4 weeks to complete. Upon completion of the scenarios, all three measures were repeated. For the confidence assessment, summary pre- and post-test summary confidence scores were compared using a t-test, and for the skills assessment, pre-scores were compared with post-test measures for each individual using McNemars chi-square test for paired samples. RESULTS Twenty-six of 35 (71.3%) enrolled subjects completed the institutional review board-approved study. Increases were observed in written test scores, confidence, and some critical interventions in high-fidelity simulation. The mean improvement in cumulative confidence scores for all residents was 10.1 (SD +/-4.9; range 0-19; p < 0.001), with no resident feeling less confident after the intervention. Although overall performance in simulated codes did not change significantly, with average scores of 6.65 (+/-1.76) to 7.04 (+/-1.37) out of 9 possible points (p = 0.58), improvement was seen in the administering of appropriate amounts of IV fluids (59-89%, p = 0.03). CONCLUSIONS In this study, improvements in resident knowledge, confidence, and performance of certain skills in simulated pediatric cardiac arrest scenarios suggest that screen-based simulations may be an effective way to enhance resuscitation skills of pediatric providers. These results should be confirmed using a randomized design with an appropriate control group.

Association between Patient Race/Ethnicity and Perceived Interpersonal Aspects of Care in the Emergency Department

Objectives To determine if perceptions of interpersonal aspects of care in the emergency department (ED) vary by patient race/ethnicity. Methods Patients in a tertiary care academic ED responded to a 22-question survey focusing on interpersonal care aspects: affiliation, satisfaction, trust and participation. Scores for each of the four generated scales were compared in terms of race, ethnicity and other basic demographics. Results African-American patients demonstrated significantly lower mean scores for trust of healthcare providers than Caucasians and significantly lower levels of participation. African-American race/ethnicity continued to be a significant predictor of lower levels of trust (but not participation) after accounting for age, gender, education, household income, health insurance, healthcare received in last six months and route of referral to the ED. Conclusion Preliminary evidence suggests that African Americans may feel less trust toward their ED providers. Understanding this phenomenon and teaching providers how to reduce distrust may translate into better patient compliance/outcomes and reduce healthcare disparities.

International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine

There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals, and other experts in emergency medicine and international emergency medicine development to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. It is not designed to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant, not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available, and the goals of the institutions’ educational leadership.

Patient race/ethnicity, age, gender and education are not related to preference for or response to disclosure

Objective: The purpose of this study was to (a) characterise patients’ preferences for disclosure of medical errors and reporting, (b) assess patients’ responses to disclosure of error and (c) determine how these preferences differ by patient race/ethnicity, gender, age and level of education. Methods: A survey was conducted of consecutive patients presenting at any hour to a tertiary care academic emergency department. Inclusion criteria were: >21 years, competent to conduct the interview (ie, conscious, not demented, delirious, intoxicated or undergoing a psychiatric evaluation), initial Glasgow Coma Scale >12, and patient not transferred from another institution and not in state custody. A four-scenario survey was used to assess patients’ preferences for: disclosure, reporting and responses to disclosure. The responses to the scenarios were analysed using Somers D. Independent effects of study variables were assessed with a generalised estimating equation. Results: Of 512 eligible patients, 394 (77% response rate) participated, and 238/394 (61%) met the criteria for analysis. Overall, in 902 (98%) responses to the scenarios, participants wanted disclosure, in 404 (45%), they wanted the error reported and in 311 (35%) they were less likely to seek legal action if informed of the error. In all three categories there was no relation with race/ethnicity, gender, age and education, with the exception of an increased desire for reporting in younger patients and those with less education. Conclusions: Interventions that aim to assist doctors with disclosure of medical error must emphasise the uniformity of patient preferences for disclosure and the diminished likelihood of legal action following disclosure.