Ernest E. Wang

Comparison of checklist and anchored global rating instruments for performance rating of simulated pediatric emergencies.

Purpose: To compare the psychometric performance of two rating instruments used to assess trainee performance in three clinical scenarios. Methods: This study was part of a two-phase, randomized trial with a wait-list control condition assessing the effectiveness of a pediatric emergency medicine curriculum targeting general emergency medicine residents. Residents received 6 hours of instruction either before or after the first assessment. Separate pairs of raters completed either a dichotomous checklist for each of three cases or the Global Performance Assessment Tool (GPAT), an anchored multidimensional scale. A fully crossed person × rater × case generalizability study was conducted. The effect of training year on performance is assessed using multivariate analysis of variance. Results: The person and person × case components accounted for most of the score variance for both instruments. Using either instrument, scores demonstrated a small but significant increase as training level increased when analyzed using a multivariate analysis of variance. The inter-rater reliability coefficient was >0.9 for both instruments. Conclusions: We demonstrate that our checklist and anchored global rating instrument performed in a psychometrically similar fashion with high reliability. As long as proper attention is given to instrument design and testing and rater training, checklists and anchored assessment scales can produce reproducible data for a given population of subjects. The validity of the data arising for either instrument type must be assessed rigorously and with a focus, when practicable, on patient care outcomes.

Simulation and adult learning.

Simulation has been embraced by the medical community as an mportant method for improving clinical training and patient safety. ractitioners of simulation, or “simulationists,” use a recipe consisting of linically important medical cases, lessons learned from other high-reliability rganizations and industries, computer-driven full-body manikin simulators, ealistic procedural task trainers, and a dash of theatre to create memorable earning experiences that can be transferred directly to patient care. As Kyle nd Murray have succinctly observed, “Clinical simulation is pretend for the urpose of improving behaviors for someone else’s benefit.” Medical simulation had existed primarily in task trainer and full-body ow-fidelity forms until about 10-15 years ago. The first human patient imulator, Sim One, was developed in the late 1960s at the University of outhern California by J.S. Denson and Stephen Abrahamson and eatured in National Geographic and Life magazines. However, medcal simulation as a discipline really gained momentum during the 1990s o 2000s because of the convergence of several key factors:

Simulation center accreditation and programmatic benchmarks: a review for emergency medicine.

Simulation-based education has grown significantly over the past 10 years. As a result, more professional organizations are developing or implementing accreditation processes to help define minimum standards and best practices in simulation-based training. However, the benefits and potential pitfalls of sponsoring and implementing such programs have yet to be fully evaluated across specialties. The board of directors of the Society for Academic Emergency Medicine (SAEM) requested an evaluation of the potential to create an emergency medicine (EM)-based Simulation Consultation and Accreditation Service. In response to this request, the Simulation Accreditation and Consultation Work Group, a subgroup of the Committee on Technology in Medical Education (now Simulation Academy), was created. The work group was charged with: 1) reviewing current benchmarks and standards set by existing simulation accreditation programs; 2) analyzing current EM simulation program structures, including leadership, administrative, and financial components; and 3) proposing a potential model for EM-based simulation accreditation. This article outlines currently existing and proposed accreditation models and identifies components that support best practices. It then goes on to describe three general programmatic models to better understand how simulation training can be operationalized in EM. Finally, the work group uses this collective information to propose how an accreditation process, in concert with the SAEM Simulation Consultation Service, can enhance and advance EM simulation training.

Epistaxis simulator: an innovative design.

Introduction: This article provides directions for creating a cost-effective epistaxis simulator using an existing CPR Trainer and expired medical supplies. Methods: An epistaxis simulator was created and presented to attending Emergency Medicine physician-educators at Evanston Northwestern Healthcare as an adjunct for procedural training. The materials and methods for making the nosebleed simulator are outlined in this article. Results: We created an epistaxis model utilizing an older CPR Trainer, i.v. tubing, and a bag of normal saline. The model provided realistic epistaxis. This simulator is able to simulate a nosebleed’s response to proper positioning of nasal packing by creating hemostasis. Conclusions: Existing task trainers can be modified to provide learners with novel features that can expand the number of simulated clinical conditions.

Systems-based Practice: Summary of the 2010 Council of Emergency Medicine Residency Directors Academic Assembly Consensus Workgroup—Teaching and Evaluating the Difficult-to-teach Competencies

OBJECTIVES The development of robust Accreditation Council for Graduate Medical Education (ACGME) systems-based practice (SBP) training and validated evaluation tools has been generally challenging for emergency medicine (EM) residency programs. The purpose of this paper is to report the results of a consensus workgroup session of the 2010 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly with the following objectives: 1) to discuss current and preferred local and regional methods for teaching and assessing SBP and 2) to develop consensus within the CORD community using the modified Delphi method with respect to EM-specific SBP domains and link these domains to specific SBP educational and evaluative methods. METHODS Consensus was developed using a modified Delphi method. Previously described taxonomy generation methodology was used to create a SBP taxonomy of EM domain-specific knowledge, skills, and attitudes (KSA). The steps in the process consisted of: 1) an 11-question preconference survey, 2) a vetting process conducted at the 2010 CORD Academic Assembly, and 3) the development and ranking of domain-specific SBP educational activities and evaluation criteria for the specialty of EM. RESULTS Rank-order lists were created for preferred SBP education and evaluation methods. Expert modeling, informal small group discussion, and formal small group activities were considered to be the optimal methods to teach SBP. Kruskal-Wallis testing revealed that these top three items were rated significantly higher than self-directed learning projects and lectures (p = 0.0317). Post hoc test via permutation testing revealed that the difference was significant between expert modeling and formal small group activity (adjusted p = 0.028), indicating that expert modeling was rated significantly higher than formal small group activity. Direct observation methods were the preferred methods for evaluation. Multiple barriers to training and evaluation were elucidated. We developed a consensus taxonomy of domains that were felt to be most essential and reflective of the practice of EM: multitasking, disposition, and patient safety. Learning formats linked to the domains were created and specific examples of local best practices collected. Domain-specific anchors of observable actions for the three domains were created. CONCLUSIONS This consensus process resulted in the development of a taxonomy of EM-specific domains for teaching and observable tasks for evaluating SBP. The concept of SBP is interlinked with the other general competencies and difficult to separate. Rather than develop specific SBP evaluation tools to measure the competency directly, SBP competency evaluation should be considered one element of a coordinated effort to teach and evaluate the six ACGME general competencies.

Physiological Stress Responses of Emergency Medicine Residents During an Immersive Medical Simulation Scenario

igh-fidelity simulation is now considered a standard educational tool in any residency training programs. The Accreditation Council for Gradate Medical Education Residency Review Committee for Emergency edicine now allows procedural skills completed in a simulated envionment to count toward their overall procedural exposure during esidency training. The rationale is that these simulated experiences rovide a level of training realistic enough to allow the patient to perform etter in an actual patient experience. Research has also shown that roficiency demonstrated in simulated settings can translate accurately nto patient care and improve patient safety. Measuring the learner’s subjective experience, as compared to the real linical environment, is a challenge in the simulation environment. roponents of immersive medical simulation claim that participating in a cenario provides an emotional response that causes the trainees to espond to the situation as if it were real. This emotional response is onsidered an important factor contributing to the simulation’s effectiveess in embedding the experience in the learner’s memory. We attempted o objectively measure the learner’s physiological heart rate and blood ressure response to stress encountered in an immersive medical simuation involving a critically ill patient.

Resident response to integration of simulation-based education into emergency medicine conference.

OBJECTIVES Utilization of simulation-based training has become increasingly prevalent in residency training. The authors compared emergency medicine (EM) resident feedback for simulation sessions to traditional lectures from an EM residency didactic program. METHODS The authors performed a retrospective review of all written EM conference evaluations over a 29-month period. Evaluation questions were scored on a 1-9 Likert scale. RESULTS Lectures and simulation accounted for 77.6 and 22.4% of the conferences, respectively. Scored means (+/-standard deviations [SDs]) were as follows: overall, lecture 7.97 +/- 0.74 versus simulation 8.373 +/- 0.44 (p < 0.01); Question 1, lecture 7.97 +/- 0.74 versus simulation 8.40 +/- 0.43 (p < 0.005); Question 2, lecture 7.92 +/- 0.74 versus simulation 8.34 +/- 0.48 (p < 0.01); Question 3, lecture 8.01 +/- 0.77 versus simulation 8.26 +/- 0.51 (p < 0.15); and Question 4, lecture 8.00 +/- 0.75 versus simulation 8.42 +/- 0.46 (p < 0.01). There was no longitudinal decay of scores. CONCLUSIONS Emergency medicine residents scored simulation-based sessions higher than traditional lectures. The scores over time suggest that this preference for simulation can be sustainable long term. Residents perceive simulation as more desirable teaching method compared to the traditional lecture format.

Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.

Bilateral Acute Angle-Closure Glaucoma in a Migraine Patient Receiving Topiramate: A Case Report

BACKGROUND Patients with migraine headaches are frequently prescribed topiramate to treat their condition. CASE REPORT We present a case of bilateral acute angle-closure glaucoma occurring 2 days after topiramate therapy was increased for symptoms related to migraine. CONCLUSION Acute angle-closure glaucoma secondary to topiramate is an uncommon but serious adverse reaction that may result in severe morbidity such as permanent visual loss if not recognized in a timely manner. Treatment differs from primary acute angle-closure glaucoma in that discontinuation of topiramate is necessary for the glaucoma to resolve.

An innovative and inexpensive model for teaching cricothyrotomy.

Cricothyrotomy is considered an integral procedure in the practice of emergency medicine. The Accreditation Council for Graduate Medical Education requires residents in emergency medicine to demonstrate proficiency in this skill, but because cricothyrotomy is rarely encountered in the clinical setting, alternative methods to teach this high-stakes procedure become an important curricular component in residency training. We present an innovative and inexpensive method for teaching cricothyrotomy using animal trachea and synthetic skin.