Eve Losman

Real‐Time Identification of Serious Infection in Geriatric Patients Using Clinical Information System Surveillance

OBJECTIVES: To develop and characterize an automated syndromic surveillance mechanism for early identification of older emergency department (ED) patients with possible life‐threatening infection.

Potentially inappropriate medication utilization in the emergency department visits by older adults: analysis from a nationally representative sample.

OBJECTIVES The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage. METHODS The data examined during the study were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). This study utilized the nationally representative ED data from 2000-2006 NHAMCS surveys. Our sample included older adults (age 65 years and greater) who were treated in the ED and discharged home. Estimated frequencies of PIM-associated ED visits were calculated. A multivariable logistic regression model was created to assess demographic, clinical, and hospital factors associated with PIM administration and to assess temporal trends. RESULTS Approximately 19.5 million patients, or 16.8% (95% confidence interval [CI]=16.1% to 17.4%) of eligible ED visits, were associated with one or more PIMs. The five most common PIMs were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine. The total number of medications prescribed or administered during the ED visit was most strongly associated with PIM use. Other covariates associated with PIM use included rural location outside of the Northeast, being seen by a staff physician only (and not by a resident or intern), presenting with an injury, and the combination of female sex and age 65-74 years. There was a small but significant decrease in the proportion of visits associated with a PIM over the study period. CONCLUSIONS Potentially inappropriate medication administration in the ED remains common. Given rising concerns about preventable complications of medical care, this area may be of high priority for intervention. Substantial regional and hospital type (teaching versus nonteaching) variability appears to exist.

The Multiple Mini-Interview for Emergency Medicine Resident Selection

BACKGROUND The Multiple Mini-Interview (MMI) uses multiple, short-structured contacts to evaluate communication and professionalism. It predicts medical school success better than the traditional interview and application. Its acceptability and utility in emergency medicine (EM) residency selection are unknown. OBJECTIVE We theorized that participants would judge the MMI equal to a traditional unstructured interview and it would provide new information for candidate assessment. METHODS Seventy-one interns from 3 programs in the first month of training completed an eight-station MMI focused on EM topics. Pre- and post-surveys assessed reactions. MMI scores were compared with application data. RESULTS EM grades correlated with MMI performance (F[1, 66] = 4.18; p < 0.05) with honors students having higher scores. Higher third-year clerkship grades were associated with higher MMI performance, although this was not statistically significant. MMI performance did not correlate with match desirability and did not predict most other components of an application. There was a correlation between lower MMI scores and lower global ranking on the Standardized Letter of Recommendation. Participants preferred a traditional interview (mean difference = 1.36; p < 0.01). A mixed format (traditional interview and MMI) was preferred over a MMI alone (mean difference = 1.1; p < 0.01). MMI performance did not significantly correlate with preference for the MMI. CONCLUSIONS Although the MMI alone was viewed less favorably than a traditional interview, participants were receptive to a mixed-methods interview. The MMI does correlate with performance on the EM clerkship and therefore can measure important abilities for EM success. Future work will determine whether MMI performance predicts residency performance.

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.

Themed monthly evaluations: a focus on individual competencies

What problems were addressed? Doctor training programmes must document house officer competency. Many programmes struggle to innovatively evaluate such competency and give meaningful feedback to their trainees. Checkbox-style global assessment forms with a space for comments are employed in many programmes. These are easy for faculty staff to fill in, but tend to group resident doctors (residents) into general categories (very good, good, fair) and strong or weak performance in one area can impact ratings in another (the halo effect). In an effort to better assess competency in the workplace of clinical practice and to encourage more free text comments, we elected to pilot themed monthly evaluations. Our programme postulated that having faculty members focus specifically on a single core competency each month in rotation would provide us with a better assessment of residents’ skills and behaviours and would generate better formative feedback for our trainees. We chose to focus on interpersonal and communication skills in our initial pilot. The Accreditation Council for Graduate Medical Education’s definition of this competency is: ‘Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.’ These are essential skills for the emergency medicine clinician, who needs to work effectively in a multiprofessional team to provide safe and effective patient care. In addition, given that time to interact with patients and their families is limited, good communication is imperative. What was tried? Firstly, we recognised that residents and faculty members may not understand what behaviour constitutes competent communication. Therefore, we provided them with information on the key components of good interpersonal and communication skills. Then, faculty members were asked to directly observe residents’ behaviour as they interacted with patients, families and the health care team. Faculty members completed the usual global assessment form and additionally were asked to comment specifically on the residents’ interpersonal and communication skills. The evaluations for the 19 residents in the department were reviewed; 13 received comments on their interpersonal and communication skills. The majority of the residents received brief comments such as: ‘Communication is clear and engaging, both with staff and patients.’ Two comments included constructive feedback such as: ‘Communication with families is usually adequate but would benefit from better demonstration of your empathy.’ Typically, there were no comments regarding communication skills unless there was an egregious problem that month. What lessons were learned? The implementation of a themed communication evaluation month allowed the majority of residents to receive some feedback regarding this crucial skill. However, most of the feedback lacked depth and failed to provide meaningful points for reflection for the residents. Nonetheless, most faculty members did respond to the directive to focus their attention on an area that is usually taken for granted. We noted that many faculty members felt ill equipped to deeply evaluate residents in this area. Our next initiative is to identify the expert communicators in the department to focus on communication skills training and feedback. Continued faculty training in providing constructive written comments should also improve this process. Themed monthly evaluations are a way to focus our assessment of the competence of individual residents.