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.     

Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department

Objective: To quantify the number of patients seen per hour by non–emergency medicine (non–EM) residents in a university hospital ED.
Methods: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24–hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non–EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated.
Results: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0. 95 ± 0. 20 patients/ hour, with a range from 0. 58 to 1. 75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey–Kramer test (α = 0. 05).
Conclusion: The rate at which non–EM residents work up patients is consistent with previously reported rates for EM residents.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.     

Bedside Teaching in the Emergency Department

Bedside teaching is a valuable instructional method that facilitates the development of history and physical examination skills, the modeling of professional behaviors, and the direct observation of learners. The emergency department (ED) is an ideal environment for the practice of bedside teaching, because its high patient volume, increased acuity of illness, and variety of pathology provide plentiful patient-centered teaching opportunities. Unfortunately, the pressures of ED overcrowding at many institutions now limit the available time for formal bedside teaching per patient. This article will discuss the historical decline of bedside teaching on the wards, address obstacles to its use in the ED, and reestablish its specific benefits as a unique educational tool. The authors propose several practical strategies to increase bedside teaching by academic emergency physicians (EPs). These techniques emphasize careful preparation and a focused teaching approach to overcome the inherent challenges of a typically busy ED shift.     

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.     

An Emergency Department Intervention to Increase Booster Seat Use for Lower Socioeconomic Families

Objectives: To evaluate the effectiveness of booster seat education within an emergency department (ED) setting for families residing in lower socioeconomic neighborhoods.
Methods: This was a prospective, randomized study of families with children aged 4 to 7 years and weighing 40 to 80 lb who presented to a pediatric ED without a booster seat and resided in lower socioeconomic communities. Subjects were randomly assigned to one of three groups: 1) received standard discharge instructions, 2) received five-minute booster seat training, and 3) received five-minute booster seat training and free booster seat with installation. Automobile restraint practices were obtained initially and by telephone at one month.
Results: A total of 225 children were enrolled. Before randomization in the study, 79.6% of parents reported that their child was usually positioned in the car with a lap/shoulder belt and 13.3% with a lap belt alone. Some parents (16.4%) had never heard of a booster seat, and 44.9% believed a lap belt was sufficient restraint. A total of 147 parents (65.3%) were contacted for follow-up at one month. Only one parent (1.3%) in the control group and four parents (5.3%) in the education group purchased and used a booster seat after their ED visit, while 55 parents (98.2%) in the education and installation group reported using the booster seat; 42 (75.0%) of these parents reported using the seat 100% of the time.
Conclusions: Education in a pediatric ED did not convince parents to purchase and use booster seats; however, the combination of education with installation significantly increased booster seat use in this population.     

Integration of Digital Imaging into Emergency Medicine Education

Medical education has adopted the use of digital photography and other computer technology, which has changed the face of the classroom. Today's presentations couple a computer and digital projection system to create powerful teaching tools. Integration of quality medical images enhances presentations in a way never before possible and at a much lower cost. Changes to presentations can occur rapidly, at a fraction of the cost of slides. However, obtaining quality digital images for presentations is problematic. Services are available on the Internet that offer images for sale, but the cost to obtain images is high. Many institutions of higher learning provide images on the Internet for free, but the quality, number of available images, server capacity, and issues of consent limit the availability of these images. The authors describe their experience in collecting more than 20,000 clinical photographs, and provide examples of their use in emergency medicine education.     

Emergency Department Utilization by Noninstitutionalized Elders

OBJECTIVES: To the best of the authors' knowledge, no nationally representative, population-based study has characterized the proportion of elders using the emergency department (ED) and factors associated with ED use by elders. This article describes the proportion of elder Medicare beneficiaries using the ED and identifies attributes associated with elder ED users as compared with nonusers. METHODS: The 1993 Medicare Current Beneficiary Survey was used, a national, population-based, cross-sectional survey of Medicare beneficiaries linked with Medicare claims data. The study population was limited to 9,784 noninstitutionalized individuals aged 66 years or older. The Andersen model of health service utilization was used, which explains variation in ED use through a combination of predisposing (demographic and social), enabling (access to care), and need (comorbidity and health status) characteristics. RESULTS: Eighteen percent of the sample used the ED at least once during 1993. Univariate analysis showed ED users were older; were less educated and lived alone; had lower income and higher Charlson Comorbidity Index scores; and were less satisfied with their ability to access care than nonusers (p < 0.01, chi-square). Logistic regression identified older age, less education, living alone, higher comorbidity scores, worse reported health, and increased difficulties with activities of daily living as factors associated with ED use (p < 0.05). Need characteristics predicted ED use with the greatest accuracy. CONCLUSIONS: The proportion of elder ED users is slightly higher than previously reported among Medicare beneficiaries. Need (comorbidity and health status) characteristics predict ED utilization with the greatest accuracy.     

An Educator''s Guide to Teaching Emergency Medicine to Medical Students

There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine. Emergency medicine (EM) educators are in a unique position to provide students with basic life support skills, guidance in assessing the undifferentiated patient, and exposure to the specialty of EM during all years of medical school. Emergency physicians can become involved in a variety of education experiences that can supplement the preclinical curriculum and provide access to our specialty at an early stage. A well-designed course in the senior year allows students to develop critical thinking and patient management skills that are necessary for any medical career path. It can ensure that all medical students are exposed to the skills essential for evaluating and stabilizing the acutely ill patient. To implement this type of course, learning objectives and evaluation methods must be set when the curriculum is developed. An effective course combines didactic and clinical components that draw on the strengths of the teaching institution and faculty of the department. A structured clerkship orientation session and system for feedback to students are essential in nurturing the development of student learners. This article provides an approach to assist the medical student clerkship director in planning and implementing EM education experiences for students at all levels of training, with an emphasis on the senior-year rotation.     

The Paradox of the Nested Pediatric Emergency Department

Objectives: Nested pediatric emergency departments (nPEDs) are defined as dedicated treatment areas operating during peak pediatric hours within general emergency departments (EDs). This study examined three staffing models for nPEDs and their impact on pediatric encounters. Methods: Three models were applied to children younger than 37 months presenting to the ED of an urban community hospital over one year. In the nPED, physicians cared only for nPED patients. In the restricted (rPED) model, physicians cared only for pediatric patients presenting outside nPED hours. In the total ED (tED) model, physicians treated all pediatric patients regardless of time. Full-time equivalent pediatric encounters, potential neonatal lumbar punctures, and illness severity were determined for all models. Statistical analysis was performed by analysis of variance and chi-square test. Results: For the 3,389 eligible ED visits, the number of annual patient encounters per full-time equivalent was 1,236 for the nPED, 805 for the tED, and 336 for the rPED (p < 0.001). Physicians practicing only in the nPED treated 3.7 times the number of children younger than 37 months than did physicians in the rPED model and 1.5 times the number than did physicians in the tED model. Spending 10% of total practice hours in the nPED would increase pediatric encounters 26% for rPED physicians, while practicing 25% of time in the nPED would increase pediatric encounters 67% and equate to 45% of nPED encounters. An nPED physician could expect to perform 17 neonatal lumbar punctures, compared with ten for a tED physician and four for an rPED physician (p < 0.001). There was no significant difference in severity of illness for the three models. Conclusions: Physicians practicing in facilities that include an nPED must dedicate some portion of their practice to the nPED to maintain equivalent pediatric encounters.     

Preferences for EMS Transport andPediatric Emergency Department Care

Objectives. To characterize the reasons pediatric emergency department (PED), patients access emergency medical services (EMS) for transport to the pediatric ED. To describe the acceptability of other modes of transport andalternative sites of care. Methods. We included a convenience sample of the responsible adults accompanying pediatric patients who arrived via EMS to the PED of an academic medical center. We administered a survey to evaluate why they chose EMS andtheir feelings about alternative modes of transport (e.g., medical van, taxi) or alternative sites of care (e.g., urgent care center, primary care physician's office, or getting an appointment within 24 hours). Results. One hundred thirthy-eight surveys were completed. Pediatric patients averaged eight years of age. Trauma (44%) andseizures (17%) were the chief complaints. The primary reasons for EMS use were perceived medical necessity (54%) andsecurity of transport by EMS (17%). Only transport by EMS was found to be acceptable. The responsible adults expressed acceptance of the PED (median = 7, 1 = not acceptable, 7 = very acceptable) as a destination, more than their child's primary care doctor's (median = 4), urgent care centers (median = 3), or no transport anda physician appointment within 24 hours (median = 1). Conclusions. Adults access the EMS system for children because of concerns regarding the acuity of illness andfor the security of EMS transport. They were generally uninterested in transport by any mode other than EMS. However, they would accept transport to alternative sites for immediate care.     

MyEDCare: Evaluation of a Smartphone-Based Emergency Department Discharge Process

Background  Poor comprehension and low compliance with post-ED (emergency department) care plans increase the risk of unscheduled ED return visits and adverse outcomes. Despite the growth of personal health records to support transitions of care, technological innovation''s focus on the ED discharge process has been limited. Recent literature suggests that digital communication incorporated into post-ED care can improve patient satisfaction and care quality. Objectives  We evaluated the feasibility of utilizing MyEDCare, a text message and smartphone-based electronic ED discharge process at two urban EDs. Methods  MyEDCare sends text messages to patients'' smartphones at the time of discharge, containing a hyperlink to a Health Insurance Portability and Accountability Act (HIPAA)-compliant website, to deliver patient-specific ED discharge instructions. Content includes information on therapeutics, new medications, outpatient care scheduling, return precautions, as well as results of laboratory and radiological diagnostic testing performed in the ED. Three text messages are sent to patients: at the time of ED discharge with the nurse assistance for initial access of content, as well as 2 and 29 days after ED discharge. MyEDCare was piloted in a 9-month pilot period in 2019 at two urban EDs in an academic medical center. We evaluated ED return visits, ED staff satisfaction, and patient satisfaction using ED Consumer Assessment of Healthcare Providers and Systems (ED-CAHPS) patient satisfaction scores. Results  MyEDCare enrolled 27,713 patients discharged from the two EDs, accounting for 43% of treat-and-release ED patients. Of the treat-and-release patients, 27% completed MyEDCare discharge process, accessing the online content at the time of ED discharge. Patients discharged via MyEDCare had fewer 72-hour, 9-day, and 30-day unscheduled return ED visits and reported higher satisfaction related to nursing care. Conclusion  EDs and urgent care facilities may consider developing a HIPAA-compliant, text message, and smartphone-based discharge process, including the transmission of test results, to improve patient-centered outcomes.     

Embedding Medical Student Computer Tutorials into a Busy Emergency Department

Objectives
To explore medical students' use of computer tutorials embedded in a busy clinical setting; to demonstrate that such tutorials can increase knowledge gain over and above that attributable to the clinical rotation itself.
Methods
Six tutorials were installed on a computer placed in a central area in an emergency department. Each tutorial was made up of between 33 and 85 screens of information that include text, graphics, animations, and questions. They were designed to be brief (10 minutes), focused, interactive, and immediately relevant. The authors evaluated the intervention using quantitative research methods, including usage tracking, surveys of faculty and students, and a randomized pretest-posttest study.
Results
Over 46 weeks, 95 medical students used the tutorials 544 times, for an overall average of 1.7 times a day. The median time spent on completed tutorials was 11 minutes (average [SD], 14 [±12] minutes). Seventy-four students completed the randomized study. They completed 65% of the assigned tutorials, resulting in improved examination scores compared with the control (effect size, 0.39; 95% confidence interval = 0.15 to 0.62). Students were positively disposed to the tutorials, ranking them as "valuable." Fifty-four percent preferred the tutorials to small group teaching sessions with a preceptor. The faculty was also positive about the tutorials, although they did not appear to integrate the tutorials directly into their teaching.
Conclusions
Medical students on rotation in a busy clinical setting can and will use appropriately presented computer tutorials. The tutorials are effective in raising examination scores.