Patient Education in the Emergency Department

The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost-efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis that ED-based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED-based patient education, and suggests possibilities for future research.     

The Impact of a Brief Expectation Survey on Parental Satisfaction in the Pediatric Emergency Department

Objectives
To determine the effect of physician knowledge of parental expectations on satisfaction with emergency department (ED) care.
Methods
This was a prospective, controlled, interventional trial involving parents of children presenting to a children's hospital ED. Parents completed an expectation survey on arrival, which was either immediately placed back in the enrollment envelope (control) or shown to the physician caring for the child (intervention). The physician was instructed to initial the expectation survey to acknowledge receipt of the survey. Parents then completed a satisfaction survey at discharge. The primary outcomes were differences in satisfaction with physician review of the expectation survey, as measured by 1) parental ratings of overall care and 2) their willingness to recommend the ED to others. A third (baseline) group completed only a satisfaction survey at discharge.
Results
A total of 614 (66%) of the 930 enrolled parents completed the study. Intention-to-treat analysis did not show a significant increase in parental satisfaction ratings for either overall care or recommend the ED; however, only 42% of the intervention group surveys had documented physician review. When these initialed surveys were compared with the control group in a per-protocol analysis, there was a significant improvement in parental satisfaction. There were no differences between the control and baseline groups, indicating no effect of the expectation survey completion on satisfaction.
Conclusions
Physician knowledge of written parental expectations may improve parental satisfaction during an ED visit. Further work is needed to overcome the barriers to physician review of the expectation survey to maximize parent satisfaction.     

Advanced Opportunities for Student Education in Emergency Medicine

Many medical students are excited about emergency medicine (EM) following a standard clerkship and seek out additional learning opportunities. An advanced EM elective may accomplish several educational goals, including development of clinical skills in evaluating the undifferentiated patient, broader exploration of the field of EM, and more focused study of one particular aspect of EM. Previously cited examples include pediatric EM, medical toxicology, occupational medicine, sports medicine, and EM research. Numerous other EM specialty courses for senior medical students are emerging, as reflected in the “Undergraduate Rotations” listings on the Society for Academic Emergency Medicine. A few examples drawn from the list include emergency ultrasound, international EM, wilderness medicine, disaster medicine, geriatric EM, and hyperbaric medicine. Educators aspiring to develop, or in the process of developing, an advanced EM elective may benefit from a brief overview of necessary course considerations, including didactic format, the clinical role of the medical student in the emergency department, and involvement with patient procedures. Suggestions are made regarding additional educational opportunities, including follow‐up of patients seen in the emergency department and development of an emergency department radiology case file. This article also addresses several related concerns, including suggested prerequisites, administration and cost considerations, appropriate didactic topics, and methods for evaluating students. Several EM subspecialty areas, namely pediatric EM, medical toxicology, and out‐of‐hospital care, are specifically discussed. Formal advanced cardiac life support training is also often included in an advanced EM elective and is briefly discussed. The overall intent of this article is to provide medical student educators with resources and ideas to assist them in developing a unique advanced EM elective.     

Emergency Medicine in Undergraduate Education

Abstract. Society has a right to expect that all physicians possess basic knowledge of emergency care and the skills to manage acute problems. Competency in the care of acutely ill and injured patients is one of the fundamental exit goals of most medical schools as mandated by the Liaison Committee on Medical Education. Several groups have called for strengthening the general components of undergraduate medical education, and surveys during the early years of the development of the field of emergency medicine (EM) showed that only a small percentage of schools required significant education in EM. This paper defines the goals and objectives of undergraduate EM education in order to help guide the development of curricular offerings as the role of EM in undergraduate medical school education increases. This paper was developed by the SAEM Education Committee and presents this committee's beliefs on what all graduating medical students should know about assessment and treatment of acutely sick and injured patients. It also suggests methods by which acquisition of this information can occur in medical school education.     

Neurologic Education in Emergency Medicine Training Programs

Objectives: Neurologic complaints are a frequent cause of emergency department visits. The morbidity and mortality of neurologic complaints such as headache and stroke can be extensive. Thus, emergency medicine residency programs should ensure adequate training in such neurologic emergencies. The authors sought to determine what methods are being used to educate residents on neurologic emergencies. Methods: A two‐page survey was mailed to directors of all 126 accredited emergency medicine residency programs in the United States. The number and types of lectures to residents, required rotations, and electives offered were assessed. Means, standard deviations (SDs), and proportions are used to describe the data. Ninety‐five percent confidence intervals of proportions (95% CIs) were calculated. Results: The response rate was 78% (98 of 126). Programs had a mean (± SD) of 5.4 (± 1.0) hours of didactic lectures per week, with a mean of 12.0 (± 5.9) lecture hours devoted to neurologic emergencies annually. A neurology rotation was required for 16 of the 92 programs providing these data (17.4%; 95% CI = 10.6% to 27.0%), and a neurosurgery rotation was required for 14 of these 92 programs (15.2%; 95% CI = 8.9% to 24.6%). One program (1.1%; 95% CI = 0.1% to 6.8%) required both a neurology and a neurosurgery rotation, and one program (1.1%; 95% CI = 0.1% to 6.8%) required either a neurology or a neurosurgery rotation. On 15 of the 32 required neurologic rotations (46.9%; 95% CI = 29.5% to 65.0%), time was spent only in the intensive care unit. The remaining 17 rotations used outpatient clinic and general floor neurology settings. Electives in neurology, neurosurgery, or neuroradiology were available for 32 programs (32.7%; 95% CI = 24.2% to 42.4%) but were seldom used. Conclusions: Currently, the primary method of educating residents to treat neurologic emergencies is through didactic lectures, as opposed to clinical rotations in neurology or neurosurgery. Improving resident education in neurologic emergencies within the current educational format must focus on improving didactic lectures in neurologic topics. Expanding clinical rotations or electives to enhance education in neurologic emergencies also warrants future attention.     

The Effect of Emergency Department Crowding on Education: Blessing or Curse?

Emergency department (ED) crowding is a national crisis that contributes to medical error and system inefficiencies. There is a natural concern that crowding may also adversely affect undergraduate and graduate emergency medicine (EM) education. ED crowding stems from a myriad of factors, and individually these factors can present both challenges and opportunities for education. Review of the medical literature demonstrates a small body of evidence that education can flourish in difficult clinical environments where faculty have a high clinical load and to date does not support a direct deleterious effect of crowding on education. To provide a theoretical framework for discussing the impact of crowding on education, the authors present a conceptual model of the effect of ED crowding on education and review possible positive and negative effects on each of the six recognized Accreditation Council for Graduate Medical Education (ACGME) core competencies.     

Brief Educational Sessions to Promote Health App Use

The increase in smartphone ownership by underserved populations provides a unique opportunity to use technology to improve health. Health apps are often free and have programs to empower individuals to engage in health promotion and self-management of chronic illnesses. To promote the use of health apps in an underserved community, investigators provided brief educational sessions to teach individuals to how access and use health apps. Educational sessions increased health app knowledge, comfort in using health apps, and likelihood of using health apps.     

Global Health Education in Emergency Medicine Residency Programs

Background

Interest in global health and international electives is growing among Emergency Medicine (EM) residents in the United States (US). The majority of EM residency programs offer opportunities for international electives. The degree of participation among residents and type of support provided by the residency program, however, remains unclear.

Study Objectives

To explore the current state of global health education among EM residents who participate in international electives.

Methods

A 12-question survey was e-mailed to the program directors of the 192 EM residency programs in the US. The survey included questions about the number of residents participating in international electives and the types of preparation, project requirements, supervision, and feedback participating residents receive.

Results

The response rate was 53% with 102 responses. Seventy-five of 102 (74%) programs reported that at least one resident participated in an international elective in the 2010–2011 academic year. Forty-three programs (42%) report no available funding to support any resident on an international elective. Residents receive no preparation for international work in 41 programs (40%). Only 25 programs (26%) required their residents to conduct a project while abroad. Forty-nine programs (48%) reported no formal debriefing session, and no formal feedback was collected from returning residents in 57 of 102 (59%) programs.

Conclusion

The majority of EM residencies have residents participating in international electives. However, the programs report variable preparation, requirements, and resident supervision. These results suggest a need for an expanded and more structured approach to international electives undertaken by EM residents.     

Predictors of Success in Emergency Medicine Ultrasound Education

OBJECTIVES: To compare emergency medicine resident performance on an ultrasound-oriented, American Board of Emergency Medicine-styled written examination with the following variables in resident education: number of ultrasound scans performed, presence of a formal, structured ultrasound rotation, presence of a mandatory ultrasound rotation, number of hours of didactic ultrasound education, and percentage of ultrasound education taught by emergency physicians. METHODS: This was a prospective cohort study involving 14 residency programs. A 60-question multiple-choice test was completed by individual residents and returned for scoring. RESULTS: 262 residents completed the study. Average score was 39.1/60 +/- 6.5 (65%). Scores improved as residency year increased (year 1: 36.6, year 2: 39.3, year 3: 42.6) (p < 0.005). Scores improved as number of scans performed increased from 34.3 (57%) for those residents who had performed 0-10 scans to 45.4 (76%) for those with >150 scans (p < 0.005). The presence of an ultrasound rotation at an emergency medicine residency program also produced a statistically significant increase in test score (OR 1.82; 95% CI = 1.29 to 2.55). Residents at programs spending the least time (6 to 15 hours) on didactic education throughout the residency predicted examination failure (OR 0.60; 95% CI = 0.39 to 0.93). Increasing the amount of resident ultrasound teaching by emergency physicians improved the score, but this did not reach significance (p = 0.357). CONCLUSIONS: Improved resident performance on an ultrasound written examination was associated with increasing resident year, number of scans performed, and the presence of an ultrasound rotation at the residency program. Increasing the number of didactic hours spent on ultrasound each year beyond 15 hours showed no improvement in resident performance.     

Dedicated Asthma Center Improves the Quality of Care and Resource Utilization for Pediatric Asthma: A Multicenter Study

OBJECTIVES: To determine the relative effectiveness of pediatric asthma care among patients treated by a dedicated asthma center (AC) vs children who use the emergency department (ED) as a site of primary asthma care. METHODS: A retrospective case-control design was used. A random sample of AC cases was selected from a designated comprehensive AC over a 12-month period. Concurrent ED control patients were identified from all cases of pediatric asthma from five urban hospitals based on two or more ED visits. Cases and controls were matched (1:2) based on age and National Heart, Lung, and Blood Institute (NHLBI) asthma severity of illness classification. A telephone survey was administered to the caregivers of all enrolled patients in the study sample. RESULTS: Four elements of pediatric asthma care were examined: quality, access, hospital utilization, and functional impact of disease. Demographic data were similar between the ED cases and the AC controls. In terms of quality of care, the AC patients were more likely to use maintenance antiinflammatory medications, 60.2% vs 22.5% (OR = 5.3; 95% CI = 2.9 to 9.7) and more likely to be taking medications at school, 71.4% vs 48.1% (OR = 2.7; 95% CI = 1.5 to 4.7). In terms of access to care, the AC families were more likely to have a physician to call to assist with outpatient management, 98.2% vs 65.0% (OR = 25.3; 95% CI = 9.0 to 76.9). Frequent ED utilization (> or = 1 visit/month) was less likely in the AC patients, 9.2% vs 22.0% (OR = 0.35; 95% CI = 0.16 to 0.79) and school absenteeism was lower as well (9.5 +/- 6.7 days vs 16.6 +/- 10.3, p < 0.001). Additionally, the caregivers of the AC patients missed fewer workdays (4.7 +/- 2.8 vs 7.4 +/- 4.1; p = 0.03). CONCLUSIONS: Significant disparities in quality, access, resource utilization, and functional impact exist between AC and ED patients. Emergency physicians have a unique opportunity to improve the public health by directing ED patients toward pediatric AC treatment.     

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.     

现代教育技术在急诊医学教育中的应用

本文通过论述现代教育技术和急诊医学教育的关系,探索通过应用先进的现代教育技术尝试新的急诊医学的教学形式,构建完整的急诊医学教育资源信息库,以逐步形成先进的急诊医学教学新模式。     

No Relationship between Emergency Department Activity and Triage Categorization

Objective: To examine the consistency of Australasian National Triage Scale (NTS) categorization in a large hospital ED, especially in relation to daily activity.
Methods: This was a prospective, observational study of the relationship between NTS category, presenting features, and disposition in a large Australian adult ED. The "admission rate" was defined as the percentage of presentations whose dispositions were recorded as admitted to hospital, transferred to another hospital for admission, or died in the ED. A "busy" weekday was defined as one during which >140 presentations were recorded in the 24 hours from midnight. For a "busy" weekend day, a figure of 100 presentations in 24 hours was used. "Nonbusy" days were defined as those during which presentation numbers were less than or equal to these thresholds.
Results: Data describing triage and disposition were available for 94,681 presentations in the 2-year period, representing 100% of ED presentations. "Busy" weekday admission rates in the 5 triage categories were 93.2%, 67.6%, 43.6%, 15.4%, and 1.6%, respectively. "Nonbusy" weekday admission rates were 91.4%, 68.3%, 43.7%, 15.6%, and 2.0%. Weekend days had a higher admission rate in NTS category 4 and 5 patients, but none of the differences between "busy" and "nonbusy" days reached statistical significance at the 0.05 level. Admission rates varied according to the time of day of presentation and increased with age, but did not change significantly over the 2 years of the study.
Conclusions: In this ED, triage categorization according to the Australasian NTS does not vary with daily activity and has been consistent over time. Further study in other settings is required, particularly to identify variation dependent on the presenting population.