Jessica L. Smith

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation

INTRODUCTION High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulations ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulations role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

What Does Remediation and Probation Status Mean? A Survey of Emergency Medicine Residency Program Directors

OBJECTIVES Emergency medicine (EM) residency program directors (PDs) nationwide place residents on remediation and probation. However, the Accreditation Council for Graduate Medical Education and the EM PDs have not defined these terms, and individual institutions must set guidelines defining a change in resident status from good standing to remediation or probation. The primary objective of this study was to determine if EM PDs follow a common process to guide actions when residents are placed on remediation and probation. METHODS An anonymous electronic survey was distributed to EM PDs via e-mail using SurveyMonkey to determine the current practice followed after residents are placed on remediation or probation. The survey queried four designations: informal remediation, formal remediation, informal probation, and formal probation. These designations were compared for deficits in the domains of medical knowledge (MK) and non-MK remediation. The survey asked what process for designation exists and what actions are triggered, specifically if documentation is placed in a residents file, if the graduate medical education (GME) office is notified, if faculty are informed, or if resident privileges are limited. Descriptive data are reported. RESULTS Eighty-one of 160 PDs responded. An official policy on remediation and/or probation was reported by 41 (50.6%) programs. The status of informal remediation is used by 73 (90.1%), 80 (98.8%) have formal remediation, 40 (49.4%) have informal probation, and 79 (97.5%) have formal probation. There was great variation among PDs in the management and definition of remediation and probation. Between 81 and 86% of programs place an official letter into the residents file regarding formal remediation and probation. However, only about 50% notify the GME office when a resident is placed on formal remediation. There were no statistical differences between MK and non-MK remediation practices. CONCLUSIONS There is significant variation among EM programs regarding the process of remediation and probation. The definition of these terms and the actions triggered are variable across programs. Based on these findings, suggestions toward a standardized approach for remediation and probation in GME programs are provided.

What is the prevalence and success of remediation of emergency medicine residents

Introduction The primary objective of this study was to determine the prevalence of remediation, competency domains for remediation, the length, and success rates of remediation in emergency medicine (EM). Methods We developed the survey in Surveymonkey™ with attention to content and response process validity. EM program directors responded how many residents had been placed on remediation in the last three years. Details regarding the remediation were collected including indication, length and success. We reported descriptive data and estimated a multinomial logistic regression model. Results We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications for remediation ranged from difficulties with one core competency to all six competencies (mean 1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%) and professionalism (31.5%). Mean length of remediation was eight months (range 1–36 months). Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In 8.7%, remediation was deemed “unsuccessful.” Training year at time of identification for remediation (post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based learning (PBLI) and professionalism were found to have statistically significant association with unsuccessful remediation. Conclusion Remediation in EM residencies is common, with the most common areas being MK and patient care. The majority of residents are successfully remediated. PGY level, length of time spent in remediation, and the remediation of the competencies of PBLI and professionalism were associated with unsuccessful remediation.

Defining uniform processes for remediation, probation, and termination in residency training

It is important that residency programs identify trainees who progress appropriately, as well as identify residents who fail to achieve educational milestones as expected so they may be remediated. The process of remediation varies greatly across training programs, due in part to the lack of standardized definitions for good standing, remediation, probation, and termination. The purpose of this educational advancement is to propose a clear remediation framework including definitions, management processes, documentation expectations and appropriate notifications. Informal remediation is initiated when a resident’s performance is deficient in one or more of the outcomes-based milestones established by the Accreditation Council for Graduate Medical Education, but not significant enough to trigger formal remediation. Formal remediation occurs when deficiencies are significant enough to warrant formal documentation because informal remediation failed or because issues are substantial. The process includes documentation in the resident’s file and notification of the graduate medical education office; however, the documentation is not disclosed if the resident successfully remediates. Probation is initiated when a resident is unsuccessful in meeting the terms of formal remediation or if initial problems are significant enough to warrant immediate probation. The process is similar to formal remediation but also includes documentation extending to the final verification of training and employment letters. Termination involves other stakeholders and occurs when a resident is unsuccessful in meeting the terms of probation or if initial problems are significant enough to warrant immediate termination.

Influence of clinical experience and productivity on emergency medicine faculty teaching scores.

BACKGROUND Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience. OBJECTIVE To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians. METHODS We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008-2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases. RESULTS For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r (2)  =  0.01, P  =  .96, patients per hour: r (2)  =  0.00, P  =  .76), or between teaching scores and total clinical hours with residents (r (2)  =  0.07, P  =  .19). There was a significant negative relationship between years of experience and teaching scores (r (2)  =  0.27, P < .01). CONCLUSIONS Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

Calling All Curators: A Novel Approach to Individualized Interactive Instruction

With the increasing influence of the “Free Open Access Medical Education” (FOAM or FOAMed) movement, it is critical that medical educators be engaged with FOAM in order to better inform and direct their learners, who likely regularly consume these materials. In 2012, the Accreditation Council for Graduate Medical Education (ACGME)/Residency Review Committee (RRC) began to permit 20% of emergency medicine (EM) residents’ didactics hours to be earned outside of weekly conference, as “Individualized Interactive Instruction” (III) credits.1 We describe a digital course in EM, “Asynchrony,” as an approach to FOAM to meet these III standards. Asynchrony is geared toward EM residents using FOAM and other online learning tools, curated by faculty into narrative, topic-specific educational modules. Each module requires residents to complete a topic assignment, participate in a discussion board, and pass a quiz to earn ACGME-approved III didactic credit; all of this is tracked and filed in an online learning management system.

The Intersection of Gender and Resuscitation Leadership Experience in Emergency Medicine Residents: A Qualitative Study

The objective was to examine emergency medicine (EM) residents’ perceptions of gender as it intersects with resuscitation team dynamics and the experience of acquiring resuscitation leadership skills.

A novel curriculum to optimize emergency medicine residents' exposure to pediatrics

Recognizing the profound impact that emergency medicine residency graduates have on the quality of the emergency care of children, residency training programs must provide a broad clinical experience and training in pediatric care. Traditionally, part of this training has included a hospital ward rotation in inpatient pediatrics. However, these experiences may be perceived by learners as being educationally low-yield in terms of direct applicability to the practice of emergency medicine. This educational innovation describes the development of a novel curriculum for teaching pediatrics to emergency medicine residents. Rather than focusing on tasks disconnected from emergency medicine practice, residents provide the initial clinical care for patients in the emergency department in a professional setting situated to mirror their ultimate professional practice. The innovation involves longitudinal patient follow-up, with mentored supervision and discussion to reinforce learning. The curriculum includes dedicated Pediatric ED time, deliberate inpatient and phone follow-up, ward rounds, focused pediatric topics, and direct observation assessment and feedback on pediatric clinical skills. This novel curriculum emphasizes the importance of situated learning, and is one component of a longitudinal teaching plan for pediatrics within an emergency medicine residency.

Remediation Strategies for Systems-Based Practice and Practice-Based Learning and Improvement Milestones

D iscrepancies are noted in the electronic health record of a patient. The resident copied and pasted sections of another patient’s chart, including the medication list, which almost led to an adverse outcome. This is not the first time the resident has made this error. Upon discussion with the resident and the program director, it is clear that workarounds jeopardizing patient safety have been a recurring concern. How should the program director approach the remediation process for this resident’s deficiencies in systems-based practice and practice-based learning and improvement? In 2013, the Accreditation Council for Graduate Medical Education (ACGME) introduced outcomesbased milestones, describing the expected evolution of resident physicians through the core competencies that link skills, knowledge, and behaviors to different levels of achievement. While the vast majority of program directors will encounter a ‘‘problem resident,’’ there is a paucity of literature addressing best practices for remediation when residents do not demonstrate the expected proficiency for their level of training. In particular, systems-based practice (SBP), which incorporates patient safety and the ability to work effectively within the greater health care system, along with practice-based learning and improvement (PBLI), which addresses the ability to continuously engage in performance improvement, are 2 competencies that share content themes across subspecialties and are consistently noted to be difficult to assess and remediate. Furthermore, recent studies have shown that residents in pediatrics and internal medicine feel least competent or adequately trained in these areas. The Council of Emergency Medicine Residency Directors Remediation Task Force was developed with the goal of providing emergency medicine (EM) programs with the tools necessary to identify struggling residents and to collate best practices in remediation. The authors of this article are part of the SBP-PBLI subcommittee of the task force; we aim to offer recommendations for the SBP and PBLI competencies of multiple specialties to assist program directors in the development of remediation plans specific to the common themes in these milestones. We completed a PubMed review of remediation methods in these subcompetencies across all medical specialties, and identified 28 relevant articles. Consensus was obtained from all members of the subcommittee on specific methods to address substandard performance for proficiency levels 1 through 4 in each of the EM subcompetencies (references were used when available, and are provided in the online supplemental material).

Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation.

Introduction Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department. Methods We developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation. Results Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0–1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. Conclusion EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0–1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.