Evaluating the Effect of Emergency Residency Training on Productivity in the Emergency Department

Background

Resident productivity, defined as patients seen per unit time, is one measure that is used to assess the performance and educational progress of residents in the emergency department (ED). One published study suggested that emergency residency training (EM) does not improve productivity compared with that in other specialties, including internal medicine (IM).

Objectives

This study assesses how EM and IM trainees perform in the ED and illustrates how resident productivity changes through the academic year.

Methods

A retrospective review of attending physicians and residents working 8-h shifts in the higher acuity zone of a large-volume, tertiary, academic health care center was performed for July 2009, October 2009, January 2010, and April 2010. The total number of patients seen primarily and admitted during each shift was recorded. ED volume was approximated by the number of patients seen by the attending physician, and acuity was approximated by admission rate. A mixed model regression assessed the impact of year and type of residency training (e.g., EM1, EM2, IM1, and IM2), ED volume, and acuity on resident productivity (number of patients per shift). The study was granted waiver of informed consent by our institutional review board.

Results

We reviewed 936 shifts. After adjusting for acuity and ED volume, the EM1 group had a significant increase in patients per shift over the year, from 6.11 in July to 10.3 in April (p < 0.001). No other group increased productivity significantly.

Conclusions

The first EM training year leads to a significant change in productivity that separates EM from IM residents. This contradicts the previous assertion that non-EM residents have the same productivity as EM residents in the ED.     

Implementation of transvaginal ultrasound in an emergency department residency program: an analysis of resident interpretation

Background

Emergency physicians are increasingly performing transvaginal ultrasound (TVUS) to rule out ectopic pregnancy. However, little is known about appropriate educational pathways to train emergency medicine residents in TVUS.

Study Objectives

To evaluate the ability of Emergency Medicine (EM) residents who underwent a training program in TVUS to detect the presence or absence of an intrauterine pregnancy (IUP) in patients of < 13 weeks gestation with vaginal bleeding or abdominal pain, as compared to the final interpretation of each study as determined by the Emergency Department (ED) Director of Ultrasound.

Methods

This was a prospective, observational study in a single residency program. Training included a lecture, competency examination, and 10 supervised TVUSs. The EM residents then performed TVUSs with the goal of determining the presence or absence of an IUP without input from an attending physician. Correlation with the ED Director of Ultrasound was assessed for the cohort, and stratified by year of training. Results: There were 22 residents who performed 75 TVUSs over 17 months. Correlation with the ED Director of Ultrasound was 93.3%. Differences in correlation with the ED Director of Ultrasound were noted when compared by year of training: post-graduate year (PGY)-3 (93.3%), PGY-2 (92.1%), and PGY-1 (100%); p < 0.001.

Conclusion

Residents were able to perform TVUSs to determine the presence or absence of an IUP in patients in whom the diagnosis of ectopic pregnancy was being considered with a high degree of correlation with the ED Director of Ultrasound after a brief training program. Correlation with the ED director of ultrasound was influenced by year of training.     

Staffing of the ED by non–emergency medicine-trained personnel: the VA experience

Study objective

VA (Veteran's Affairs) emergency departments (EDs) are generally staffed with physicians trained in internal medicine (IM), although recently, a movement has begun toward hiring emergency medicine (EM)-trained staff. At our institution, the ED is staffed by physicians of both specialties. This study examines the frequency of unscheduled return visits to the ED in an effort to compare the quality of emergency care given by physicians trained in IM and EM.

Methods

The record of all visits to a VA hospital ED during a 90-day period were examined, and all those visits resulting in a return ED visit within the 30 subsequent days were noted.

Results

The charts of 2891 consecutive ED patients were examined. The rate of revisits was significantly higher for the IM than for the EM-trained physicians (8.9% vs 5.5%, respectively; P < .001). The IM-trained physicians had a significantly higher rate of admissions upon revisit within 30 days than did the EM-trained physicians (3.5% vs 1.9%, respectively; P = .014). The IM-trained staff had lower initial hospitalization rates than the EM physicians (20% vs 43%, respectively; P < .0001).

Conclusions

The IM-trained physicians were less likely to hospitalize patients, although this can be partially explained by the lower acuity of patients during the hours that they covered. The IM-trained physicians were significantly more likely to have a patient return after discharge and also more likely to have a patient return in need of hospitalization. This may reflect a difference in training for the rapid diagnosis and risk stratification of ED patients.     

Epinephrine use and outcomes in anaphylaxis patients transported by emergency medical services

Background

Anaphylaxis is a potentially life-threatening allergic reaction that may require emergency medical system (EMS) transport. Fatal anaphylaxis is associated with delayed epinephrine administration. Patient outcome data to assess appropriateness of EMS epinephrine administration are sparse.

Objectives

The objectives of this study are to (1) determine the frequency of epinephrine administration in EMS-transported patients with allergic complaints, (2) identify predictors of epinephrine administration, and (3) determine frequency of emergency department (ED) epinephrine administration after EMS transport.

Methods

A cohort study was conducted from over 5 years. A total of 59 187 EMS transports of an Advanced Life Support (ALS) ambulance service were studied.

Results

One hundred and three patient transports for allergic complaints were analyzed. Fifteen patients received EMS epinephrine, and epinephrine was recommended for 2 additional patients who refused, for a total of 17 (17%) patients for whom epinephrine was administered or recommended. Emergency medical system epinephrine administration or recommendation was associated with venom as a trigger (29% vs 8%; odds ratio [OR], 4.70; 95% confidence interval [CI], 1.28-17.22; P = .013), respiratory symptoms (88% vs 52%; OR, 6.83; 95% CI, 1.47-31.71; P = .006), and fulfillment of anaphylaxis diagnostic criteria (82% vs 49%; OR, 3.50; 95% CI, 0.94-13.2; P = .0498). Four (4%) patients received epinephrine after ED arrival.

Conclusion

Low rates of epinephrine administration were observed. The association of EMS administration of epinephrine with respiratory symptoms, fulfillment of anaphylaxis diagnostic criteria, and low rate of additional epinephrine administration in the ED suggest that ALS EMS administered epinephrine based on symptom severity. Additional studies of EMS anaphylaxis management including ED management and outcomes are needed.     

The impact of emergency department overcrowding on resident education

Background

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

Objectives

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

Materials and Methods

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

Results

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N (p = 0.047).

Conclusions

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.     

A Brief Educational Intervention Is Effective in Teaching the Femoral Nerve Block Procedure to First-Year Emergency Medicine Residents

Background

Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure.

Objectives

We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session.

Methods

First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months.

Results

A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency.

Conclusion

A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.     

Does ED crowding decrease the number of procedures a physician in training performs? A prospective observational study

Purpose

The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding.

Methods

In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away.

Results

There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06).

Conclusions

Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.     

Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills

Background

Graduates of Emergency Medicine (EM) residency training programs are expected to be proficient in ultrasound. However, best practices for teaching residents ultrasonography has yet to be determined.

Study Objectives

To determine if a dedicated Emergency Department (ED) ultrasound rotation objectively improves residents’ EM ultrasound knowledge, interpretation accuracy, and clinical decision-making based on ultrasound findings.

Methods

EM residents completing a required ED-based ultrasound rotation were prospectively studied. Before the start of the rotation, each resident completed a 20-question pre-test. At the end of the rotation, residents completed a 20-question post-test. Both tests covered physics, trauma (focused assessment with sonography for trauma), first-trimester pregnancy, aorta, biliary, echocardiography, and vascular sonography, using a multiple-choice format. In both tests, ultrasound images were included in 11 of the 20 questions. The questions were divided into three categories: knowledge-based (8 questions), interpretation (9 questions), and clinical decision-making (3 questions), for both tests. Scores on pre-tests and post-tests were compared using a Wilcoxon signed-rank test.

Results

During the 2-year study period, 21 residents completed the rotation. The median pre-test score was 16 (interquartile range [IQR] 14.5–17), compared to a median post-test score of 19 (IQR 18–20), p < 0.001.

Conclusions

A dedicated ED ultrasound rotation improves residents’ EM ultrasound knowledge and interpretation accuracy based on ultrasound findings, as measured by improvement on ultrasound test scores.     

Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system

Background

Previous studies have demonstrated lower mortality among patients transported to single urban trauma centers by private vehicle (PV) compared with Emergency Medical Services (EMS). We sought to describe the characteristics and outcomes of injured patients transported by PV in a state trauma system compared to patients transported by EMS.

Methods

We performed a retrospective cohort study of state trauma registry data for patients admitted to all Pennsylvania trauma centers over 5 years (1/2003 to 12/2007). Our primary exposure of interest was prehospital mode of transport and our primary outcome of interest was in-hospital mortality. Unadjusted analyses were performed as were adjusted analyses controlling for injury severity. Data are presented as percents, odds ratios (ORs), and 95% confidence intervals.

Results

Of the 91 132 patients analyzed, 9.6% were transported to the emergency department by PV and 90.4% by EMS. Overall Injury Severity Score (ISS) was 13.3 ± 11.0 (ISS for EMS 13.7 ± 11.3, PV 9.2 ± 7.1, P < .001), and 6.6% of patients died (EMS 7.1%, PV 1.5%, P < .001). After adjusting for injury severity, patients transported by EMS were more likely to die than PV patients (OR 1.9 [95% CI 1.5-2.4]). This effect persisted in blunt, penetrating, advanced life support, and basic life support subgroups, but not in the severely injured (ISS > 15, ISS > 25) subgroups.

Conclusions

Nearly 10% of injured patients arrive at trauma centers by private vehicle. Transport of injured patients by EMS was associated with higher mortality than PV transport. This may reflect the effects of prehospital time, prehospital interventions, or other confounders.     

Safety and compliance with an emergency medical service direct psychiatric center transport protocol

Objectives

To evaluate compliance and safety of an emergency medical service (EMS) triage protocol that allows paramedics to transport patients directly to psychiatric emergency services.

Methods

A psychiatric patient diversion protocol was developed for our system. Protocol compliance was evaluated the following 3 ways: (1) psychiatric facility intake forms completed by mental health workers on patients transported by EMS directly to a psychiatric emergency service (PES) bypassing the ED, (2) hospital records for patients who were redirected from PES to the ED for medical evaluation, (3) retrospective analysis of ambulance charts. Study outcomes included protocol noncompliance rate, protocol failure rate, and any morbidity associated with either noncompliance or protocol failure. Data were analyzed using proportions and 95% confidence intervals (CI).

Results

A total of 174 patients were directly transported to PES bypassing ED medical clearance. The protocol effectively screened for medical issues in 96% of cases. Protocol noncompliance occurred in 51 cases for a frequency of 29% (CI, 22%-36%). One patient in the paramedic noncompliance group required hospital admission. There was protocol failure in 5 (2.9%; 95% CI, 0.9-6.6) of the patients who fit all protocol requirements for transport to PES but required secondary transport to the ED. All were subsequently transferred back to PES. Nine patients (5.2%; CI, 2.7%-9.5%) required secondary transfer to the ED. No patient had critical or life-threatening problems.

Conclusions

Emergency medical service providers showed a poor level of compliance with vital sign criteria, but the protocol provided a high level of safety.     

State of affairs of emergency medicine in the Veterans Health Administration

Background

The Veterans Health Administration (VHA) has reformed its emergency medical services.

Objectives

This study updates an overview of emergency medicine within VHA.

Methods

This is a cross-sectional survey of VHA medical facilities offering emergency medical care.

Results

Sixty-eight percent (95/140) of facilities had emergency departments (EDs) only, 12% (16/140) had both ED and urgent care centers (UCCs), and 16% (23/140) had only UCCs. The mean (SD) ED/UCC census was 13?371 (7664). A mean (SD) of 53% (27%) of facility admissions were admitted through ED/UCCs. The median of all ED/UCC admissions admitted to intensive care unit level care was 11% (interquartile range, 7-16). Of physicians with any board certification, 16% (209/1331) of physicians had emergency medicine board certification.

Conclusions

Emergency medical care is now available at most VHA facilities. The specialty of emergency medicine has an important but minority presence within clinical emergency medical care at VHA.     

An association between occupancy rates in the emergency department and rates of violence toward staff

Background

Studies have explored possible causes of violent acts in the emergency department (ED), however, the association of violence with ED crowding has not been studied. Although the total number of violent acts would be expected to increase, it is not clear if the rate of violent acts also increases as occupancy levels rise.

Objective

The purpose of this study was to determine if there is an association between occupancy rates in the ED and rates of violence toward staff.

Methods

This was a retrospective chart review study. Violent incidents in a community, Level I trauma center ED were identified from review of orders of emergency detainment, adverse event forms, physical restraint logs, and pharmacy records from January 1, 2005 to June 1, 2008. Occupancy rates for all days were calculated and violent vs. non-violent days were compared using a standard two-sample t-test. Logistic regression analysis was then used to investigate other factors associated with violent incidents.

Results

A rate of violence of 1.3 incidents per 1000 patients was found. When comparing the occupancy rates of violent days (mean 95%, SD 26%) with non-violent days (mean 86%, SD 24%), a statistically significant association was found (p < 0.0001). Multivariate logistic regression confirmed a significant association between crowding and violence toward staff (odds ratio 4.290, 95% confidence interval 2.137–8.612).

Conclusion

These results suggest another possible negative effect that crowding has on ED staff and physicians. Policies and recommendations regarding ED operating procedures and staff safety during times of higher occupancy levels should be discussed.     

The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED

Objectives

To determine the diagnostic accuracy of emergency physician performed point-of care ultrasound (POCUS) for detecting long bone fractures compared to standard radiography.

Methods

This was a single-blinded, prospective observational study of patients presenting to two emergency departments (ED) with trauma to long bones. The study used a convenience sample of patients seen during the study investigators' scheduled clinical shifts. Patients presenting to the ED with complaints of long bone trauma were included in the study when a study investigator was available in the ED. POCUS examinations of injured long bones were performed using a standard protocol. The investigators documented their interpretation prior to radiographs being performed. After standard radiographs were performed, the final radiology reading by a radiology attending physician was obtained from the medical record.

Results

One-hundred six patients were enrolled into the study, and 147 long bone POCUS examinations were performed. Forty-two fractures were present by radiographs and the prevalence of fractures was 29%. The sensitivity was 90.2% (4/41, 95% CI: 76.9-97.3) and specificity was 96.1% (4/102, 95% CI: 90.3-98.9). The positive likelihood ratio was 23.0 (95% CI: 8.8-60.5), and the negative likelihood ratio was 0.102 (95% CI: 0.040, 0.258). The positive predictive value was 90.2% (4/41, 95% CI: 76.9-97.3) and the negative predictive value was 96.1% (4/102, 95% CI: 90.3-98.9).

Conclusions

Emergency physicians can accurately evaluate long bone fractures in the ED using POCUS. In particular, long bone fractures can be excluded with a high degree of confidence.     

Agreement between emergency medical services and expert blood pressure measurements

Background

Emergency Medical Services (EMS)-measured blood pressures (BPs) are utilized for administering medications in the field and for triage decisions. Retrospective work has demonstrated poor agreement between EMS and Emergency Department (ED) BP but has lacked a valid, reliable reference standard.

Study Objectives

To compare EMS BP measurements with those of trained research assistants (RA) and observe measurement technique for sources of error.

Methods

A prospective study was performed with a large urban EMS. BP measurements were made by RA within 5 min of patients presenting to the ED. EMS personnel were asked about technique. EMS personnel were then observed while RA simultaneously measured BP. Analysis was performed using methods outlined by Bland and Altman.

Results

There were 100 patients enrolled for each phase. In the first phase, the mean difference in systolic BP was −3.8 ± 18.6 mm Hg (95% confidence interval [CI] −8.3 to 0.59), and the mean difference in diastolic BP was 0.42 ± 13.8 mm Hg (95% CI −3.3 to 4.1). In the second phase, the mean difference in systolic BP was −4.6 ± 10.1 mm Hg (95% CI −6.6 to −2.6) and the mean difference in diastolic BP was −3.6 ± 10.6 mm Hg (95% CI −3.6 to −0.2). EMS personnel failed to properly place the cuff or deflate it 2–3 mm Hg/s in over 90% of the readings. They failed to properly inflate the cuff in 74% of the patients, and failed to properly place the stethoscope in 40%. EMS personnel demonstrated a significant preference for the terminal digit of “0” (p < 0.0001).

Conclusions

EMS and expert BP measurements showed smaller discrepancies than those previously noted, especially with simultaneous measurements. However, EMS demonstrated poor adherence to American Heart Association recommendations for measuring BP. EMS also showed terminal digit preference.     

Impact of checklists on peri-intubation care in ED trauma patients

Background

Checklists have successfully been used in intensive care units (ICUs) to improve metrics of critical care. Proper peri-intubation care including use of appropriate induction agents and postintubation sedation is crucial when performing endotracheal intubation (ETI) on critically ill patients, especially in the emergency department (ED). We sought to evaluate the impact of checklists on peri-intubation care in ED trauma patients.

Methods

We performed a retrospective review of all trauma patients intubated in the ED of an urban, level 1 academic center from November 2010 to October 2012. As part of a quality improvement project, a peri-intubation checklist was instituted on November 1, 2011 to guide peri-intubation care.Using a predesign and postdesign, we compared peri-intubation parameters using parametric and nonparametric statistics when appropriate to evaluate the impact of a checklist on peri-intubation care.We also evaluated outcome measures including mortality and lengths of stay.

Results

During the 2-year study period, 187 trauma patients underwent ETI in the ED, 90 prechecklist and 97 postchecklist. Rapid sequence intubation (RSI) use was greater with the checklist than without (90.7% vs 75.6%, P = .005). No difference was found between the number of ETI attempts per patient, hemodynamic parameters (heart rate, blood pressure, and oxygen saturation), postintubation anxiolysis, median number of ventilator days, length of ED stay, length of ICU stay, or mortality.

Conclusion

Peri-intubation checklists result in higher rates of RSI in ED trauma patients but do not alter other measured metrics of peri-intubation care.     

Consultation in the emergency department: a qualitative analysis and review

Background

No studies have evaluated the consultation process or attempted to define a standardized approach that could improve communication and patient outcomes.

Objective

To perform a qualitative analysis of emergency medicine (EM) consultation to reveal its complexity and elucidate strategies and frameworks for physician-to-physician communication.

Methods

Data were collected in three phases: informal interviews conducted in an emergency department (ED), 10-question surveys given to a subset of EM and specialty physicians, and semi-structured 1-h group interviews using open-ended questions to further explore issues and trends elicited from the survey responses. In addition, we conducted an extensive literature search focused on health care and business consultation and communication.

Results

Seventy-six percent (29 of 38) of emergency and specialty physicians completed the 10-question survey in its entirety. Three themes were identified from the survey responses: organizational skills, interpersonal and communication skills, and medical knowledge. Of 95 total comments, 41 (43%) focused on organizational skills, 26 (27%) on interpersonal and communication skills, and 28 (30%) on medical knowledge. There were 29 comments regarding poor consultations: 15 issues with organization, 6 with interpersonal and communication skills, and 8 with medical knowledge. The literature search revealed several models and types of consultation, but no standard algorithm currently exists.

Conclusions

We recommend focusing on organizational skills, interpersonal and communication skills, and medical knowledge when teaching ED consultation and present a conceptual framework of the Five Cs Consultation Model: contact, communication, core question, collaboration, and closing the loop.     

Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department

Background

Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade. This approach may be ideally suited for the ED environment, where one injection could control pain for many hours.

Objectives

We hypothesized that an ultrasound-guided fascia iliaca compartment block (UFIB) would provide analgesia for patients presenting to the ED with pain from HFx and that this procedure could be performed safely by emergency physicians (EP) after a brief training.

Methods

In this prospective, observational, feasibility study, a convenience sample of 20 cognitively intact patients with isolated HFx had a UFIB performed. Numerical pain scores, vital signs, and side effects were recorded before and after administration of the UFIB at pre-determined time points for 8 h.

Results

All patients reported decreased pain after the nerve block, with a 76% reduction in mean pain score at 120 min. There were no procedural complications.

Conclusion

In this small group of ED patients, UFIB provided excellent analgesia without complications and may be a useful adjunct to systemic pain control for HFx.     

Developing a Curriculum for Emergency Medicine Residency Orientation Programs

Background

New residents enter emergency medicine (EM) residency programs with varying EM experiences, which makes residency orientation programs challenging to design. There is a paucity of literature to support best practices.

Objective

We report on a curriculum development project for EM residency orientation using the Kern Model.

Curriculum

Components of the revised curriculum include administrative inculcation into the program; delivering skills and knowledge training to ensure an entering level of competence; setting expectations for learning in the overall residency curriculum; performing an introductory performance evaluation; and socialization into the program.

Results

Post-implementation resident surveys found the new curriculum to be helpful in preparing them for the first year of training.

Conclusions

The Kern Model was a relevant and useful method for redesigning a new-resident orientation curriculum.