Joseph Turner

Beating the Spread: Developing a Simulation Analog for Contagious Body Fluids.

Introduction Effective models simulating the spread of contagion from provider to other patients, visitors, and rooms in a physically simulated emergency department setting have not been reported, and the effect of personal protective equipment (PPE) on reducing such spread in a simulated emergency department environment has not been quantified. Methods We developed a physical model for the spread of an Ebola-like virus. The scenario involved 3 computerized mannequins. One case was a febrile patient after Ebola exposure. Four residents (group A) had only masks and gloves and were initially unaware of exposure history, whereas 4 residents (group C) had known exposure history and had full PPE present in the room. Infected mannequins and surrounding surfaces were coated with Glo Germ, a UV tracer. Fluorescence to UV light was recorded after each scenario. Both tracer groups were compared with a control group (group B) in which no tracer was used to account for background fluorescence. Results There was transfer of contagion to providers, other patients, nurse and family member confederates, and other treatment rooms. Half of group C used full PPE, and half used partial PPE. There were 3 contaminations in group C with full PPE use, 15 contaminations in group C with partial PPE, and 65 contaminations in group A. Conclusions The UV tracer seems to be a useful analog of contaminated bodily fluids because it spread easily and its spread decreased with the use of barrier methods. This model could be used in future studies to measure the effectiveness of different forms of PPE and to study the effectiveness of provider education on appropriately donning and doffing PPE.

Introducing medical students into the emergency department: The impact upon patient satisfaction

Introduction Performance on patient satisfaction surveys is becoming increasingly important for practicing emergency physicians and the introduction of learners into a new clinical environment may impact such scores. This study aimed to quantify the impact of introducing fourth-year medical students on patient satisfaction in two university-affiliated community emergency departments (EDs). Methods Two community-based EDs in the Indiana University Health (IUH) system began hosting medical students in March 2011 and October 2013, respectively. We analyzed responses from patient satisfaction surveys at each site for seven months before and after the introduction of students. Two components of the survey, “Would you recommend this ED to your friends and family?” and “How would you rate this facility overall?” were selected for analysis, as they represent the primary questions reviewed by the Center for Medicare Services (CMS) as part of value-based purchasing. We evaluated the percentage of positive responses for adult, pediatric, and all patients combined. Results Analysis did not reveal a statistically significant difference in the percentage of positive response for the “would you recommend” question at both clinical sites with regards to the adult and pediatric subgroups, as well as the all-patient group. At one of the sites, there was significant improvement in the percentage of positive response to the “overall rating” question following the introduction of medical students when all patients were analyzed (60.3% to 68.2%, p=0.038). However, there was no statistically significant difference in the “overall rating” when the pediatric or adult subgroups were analyzed at this site and no significant difference was observed in any group at the second site. Conclusion The introduction of medical students in two community-based EDs is not associated with a statistically significant difference in overall patient satisfaction, but was associated with a significant positive effect on the overall rating of the ED at one of the two clinical sites studied. Further study is needed to evaluate the effect of medical student learners upon patient satisfaction in settings outside of a single health system.

Effect of an Educational Intervention on Medical Student Scripting and Patient Satisfaction: A Randomized Trial

Introduction Effective communication between clinicians and patients has been shown to improve patient outcomes, reduce malpractice liability, and is now being tied to reimbursement. Use of a communication strategy known as “scripting” has been suggested to improve patient satisfaction in multiple hospital settings, but the frequency with which medical students use this strategy and whether this affects patient perception of medical student care is unknown. Our objective was to measure the use of targeted communication skills after an educational intervention as well as to further clarify the relationship between communication element usage and patient satisfaction. Methods Medical students were block randomized into the control or intervention group. Those in the intervention group received refresher training in scripted communication. Those in the control group received no instruction or other intervention related to communication. Use of six explicit communication behaviors were recorded by trained study observers: 1) acknowledging the patient by name, 2) introducing themselves as medical students, 3) explaining their role in the patient’s care, 4) explaining the care plan, 5) providing an estimated duration of time to be spent in the emergency department (ED), and 6) notifying the patient that another provider would also be seeing them. Patients then completed a survey regarding their satisfaction with the medical student encounter. Results We observed 474 medical student-patient encounters in the ED (231 in the control group and 243 in the intervention group). We were unable to detect a statistically significant difference in communication element use between the intervention and control groups. One of the communication elements, explaining steps in the care plan, was positively associated with patient perception of the medical student’s overall communication skills. Otherwise, there was no statistically significant association between element use and patient satisfaction. Conclusion We were unable to demonstrate any improvement in student use of communication elements or in patient satisfaction after refresher training in scripted communication. Furthermore, there was little variation in patient satisfaction based on the use of scripted communication elements. Effective communication with patients in the ED is complicated and requires further investigation on how to provide this skill set.

Preparing Emergency Medicine Residents as Teachers: Clinical Teaching Scenarios

Introduction Preparing residents for supervision of medical students in the clinical setting is important to provide high-quality education for the next generation of physicians and is mandated by the Liaison Committee on Medical Education as well as the Accreditation Council for Graduate Medical Education. This requirement is met in variable ways depending on the specialty, school, and setting where teaching takes place. This educational intervention was designed to allow residents to practice techniques useful while supervising medical students in simulated encounters in the emergency department and increase their comfort level with providing feedback to students. Methods The four role-playing scenarios described here were developed for second-year residents in emergency medicine at the Indiana University School of Medicine. Residents participated in the scenarios prior to serving as a supervisor for fourth-year medical students rotating on the emergency medicine clerkship. For each scenario, a faculty member observed the simulated interaction between the resident and the simulated student. The residents were surveyed before and after participating in the scenarios to determine the effectiveness of the instruction. Results Residents reported that they were more comfortable supervising students, evaluating their performance, and giving feedback after participating in the scenarios. Discussion Participation in these clinical teaching scenarios was effective at making residents more comfortable with their role as supervisors of fourth-year students taking an emergency medicine clerkship. These scenarios may be useful as part of a resident-as-teacher curriculum for emergency medicine residents.

Effect of Socioeconomic Status Bias on Medical Student–Patient Interactions Using an Emergency Medicine Simulation

Implicit bias in clinical decision making has been shown to contribute to healthcare disparities and results in negative patient outcomes. Our objective was to develop a high‐fidelity simulation model for assessing the effect of socioeconomic status (SES) on medical student (MS) patient care.

Does Colchicine Improve Pain in an Acute Gout Flare

TUDY SELECTION he authors included all andomized controlled trials and ontrolled clinical trials on the enefits and harms of colchicine in dult patients with acute gout ares, identified by the presence f monosodium urate crystals in oint aspirate or patients fulfilling tandard criteria. The major utcomes included benefits, efined as 50% or greater eduction in pain at 12, 24, 36, or 8 hours; reduction of joint nflammation; and total number of dverse events.

Board 371 - Research Abstract A Comparison of Evaluation Metrics for High-Fidelity ACLS-Based Simulation Cases for PGY-1 and PGY-3 Level Emergency Medicine Residents: A Pilot Study (Submission #1012)

Introduction/Background High-fidelity simulation is increasingly being used as a medical educational assessment tool, especially in light of the Next Accreditation System (NAS), which commonly recommends the use of simulation to gather data for Emergency Medicine milestone assessment.1 Currently, there are no universally accepted metrics for evaluating clinician performance in the simulation environment. Furthermore, there is no baseline data characterizing the expected performance on specific cases according to training level. The objective of this pilot study is to develop a set of 6 ACLS-based cases and compare clinician performance using three different evaluation metrics A secondary objective is to compare case performance between PGY-1 and PGY-3 Emergency Medicine (EM) residents. Our hypothesis was that the metrics tested would demonstrate a difference in clinical performance between the two groups of learners, as they were interns just beginning residency and third years just prior to completion of residency. Methods Six cases with critical actions (CA) were developed by a multi-institutional EM faculty group. Each of the cases was piloted by 25 residents at the lead institution (13 PGY-1s during their first two months of internship and 12 PGY-3s during their last two months of residency). Learners participated as single providers in each case, completed all six cases in a randomized order and then received an individual debriefing for the entire session. Sessions were videotaped for independent review by two faculty observers. Data included the total number of CAs achieved, time-to each critical action (TCA) and a previously validated clinical performance evaluation (CPE) score.2 The CPE score is comprised of eight criteria, each with an 8-point possible score [8 being “excellent” and a 1 being “poor”]. The reported CPE scores are the average of the 8 values for each case that were then averaged for both reviewers. Descriptive statistics, Wilcoxon rank sum tests and repeated measures analyses of variance using generalized estimating equations are reported. Results For all of the cases, the mean proportion of CAs performed was 0.94 by the PGY-1s and 0.91 by the PGY-3s (p>0.05). For TCA, 11 CAs were analyzed and only two were found to have a significant difference: the PGY-1s had a time to second defibrillation attempt of 236 seconds compared with 291 seconds for the PGY-3s and the PGY-3s had a time to epinephrine ordered of 112 seconds compared to 164 for the PGY-1s (p<0.05). The overall mean CPE scores were 5.72 for PGY-1s and 6.38 for PGY-3s (p<0.05). The mean difference in CPE scores between the faculty observers was -0.39 (95%CI -0.55 - -0.23). Conclusion Of the three evaluation metrics tested, CPE showed a small but significant difference between training levels. Surprisingly, PGY-1 residents showed superior performance on certain metrics tested. Further studies are needed to define the optimal evaluation system for use in simulation education and optimal teaching strategies for retention of ACLS protocols. References 1. Beeson, M. The Emergency Medicine Milestone Project. http://www.acgme-nas.org/assets/pdf/Milestones/EmergencyMedicineMilestones.pdf. Accessed on July 17th, 2013. 2. Gordon J, Tancredi D, Binder W, Wilkerson W, Shaffer D: Assessment of a clinical performance evaluation tool for use in a simulator-based testing environment: A pilot study. Academic Medicine 2003;78(10 Suppl):S45-47. Disclosures None.

Board 259 Program Innovations Abstract A Novel Simulation Program to Train Paramedic Students in Safe EMS Patient Handoff (Submission #411)

Introduction/Background Emergency medical services (EMS) patient handoffs are a critical step in patient care and safety. Approximately 28 million such handoffs occur every year in the United States.1 Despite the importance of safe handoff to patient care, very little exists in formally accredited EMS or paramedic science education regarding the appropriate information to convey to hospital based patient care teams. While the effective use of simulation in paramedic education has been previously described,2,3 the essential step of patient handoff has been largely ignored. We developed and successfully implemented an interprofessional simulation program focused on safe patient handoff. Methods A focus group of emergency medicine faculty, nursing faculty and paramedic science educators came together to develop a program for teaching paramedic science students safe and effective handoffs. The selected educational tool for patient handoff was previously validated and contains the following information: Identification, Mechanism/medical complaint, Injuries/information relative to complaint, Signs/vitals including GCS, Treatment and trends, Allergies, Medications, Background history, and Other (IMIST-AMBO).4 Paramedic students received a didactic session on IMIST-AMBO and were then brought to the simulation center to practice communication and other patient management skills. The simulation began in the center’s Transport Room, featuring a decommissioned ambulance with a manikin representing a patient who had been in a high speed motor vehicle collision. After receiving initial “on scene” information from a confederate first-responder, teams of two paramedic students assumed care of the manikin for a 10 minute transport period. Upon arrival at the hospital, the students had to successfully unload the patient and transport him down the hall to a simulated emergency department room. Emergency medicine residents and nursing students, who until that point were blind to the use of paramedic students, were waiting in the room. The paramedic students transferred care to the team, communicating what they believed was pertinent information. The remainder of the case was completed with paramedic students providing additional assistance to the emergency department team. Following each case a structured debrief session was conducted featuring all members of the patient care team. The debriefing focused on communication issues as part of the patient handoff. All participants completed pre-session and post-session surveys regarding attitudes toward interprofessional communication and overall satisfaction with the simulation. Results: Conclusion A total of 12 paramedic students, 19 emergency medicine residents and 16 nursing students participated in the simulation. In the post-session survey, 44/47 participants (93.6%) agreed or strongly agreed that the in room experience was valuable for preparing them to work with other healthcare providers and 43/47 participants (91.5%) agreed or strongly agreed that the debriefing was valuable. Importantly, 44/47 participants (93.6%) agreed or strongly agreed that the experience enhanced their understanding of the importance of “clear, concise, and respectful” communication during paramedic-physician handoffs. Amongst the primary target audience of paramedic students, 100% agreed or strongly agreed with that statement. In open-ended feedback, paramedic students described the experience as “very beneficial” and noted that it seemed realistic. This model demonstrates an effective educational method for teaching safe patient handoff. Further studies more accurately quantifying the educational benefit will likely follow and have the potential to impact paramedic science education at other institutions. With the clear importance of safe and effective handoff in overall patient care, this could benefit our patients. Furthermore, safe patient transitions are not limited to paramedic-physician handoff in the emergency department and this simulation-based educational model could be easily adapted to provide training for multiple healthcare providers. References 1. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS ### ###, Washington, DC, 2012. Available at www.ems.go. 2. Boyle et al. “Contemporary simulation education for undergraduate paramedic students” Emerg Med J. 2007 Dec;24(12):854-7. 3. Leikin et al. “Simulation applications in emergency medical services” Dis Mon. 2011 Nov;57(11):723-33. 4. Ledema et al. “Design and trial of a new ambulance-to-emergency department handover protocol: ’IMIST-AMBO’.” BMJ Qual Saf. 2012 Aug;21(8):627-33. Disclosures None.