An Intensive Approach to Improving Diversity, Equity, and Inclusion in an Academic Emergency Department.

A healthcare workforce that demonstrates cultural competence and humility while reflecting the diversity of the surrounding community has the potential to significantly benefit the patient population it serves. In this context and given numerous societal influences and the events of 2020, the leadership of the Department of Emergency Medicine at Albany Medical Center recognized the need to promote diversity, equity, and inclusion (DEI) in multiple areas. These included premedical education, medical education, postgraduate medical education, faculty development, staff satisfaction, and patient care. The department formed a DEI taskforce that developed an ongoing, multipronged, interdisciplinary approach to address these important aspects of our work and clinical environment with the goals of improving staff wellbeing, reducing burnout, and promoting the health of our community. Our experience is shared here to illustrate how a small, dedicated team can implement a variety of DEI initiatives quickly and with relatively little cost at a large academic medical center.

Is Emergency Medicine the Right Choice for Me?

One of the hardest decisions a medical student has to make is the choice of specialty. Many studies have explored what influences the choice of emergency medicine (EM) as a specialty. In this article, we elaborate on the most important incentives, including the diversity in patients' presentations, having a defined and flexible schedule, the plasticity in choosing and changing a practice location, and the acuity of care and trauma experience. Additionally, we tackle some of the challenges that emergency physicians face. For instance, having to follow a different thought process than most other physicians, as well as the patients' quality and expectations. We also address some of the concerns regarding the specialty, specifically burnout, stress, and the fear associated with maintaining a career in EM. Finally, we provide students interested in EM with some resources that can provide them with further guidance to decide whether EM is the right choice for them.

History and physical exam predictors of intracranial injury in the elderly fall patient: A prospective multicenter study.

OBJECTIVES: A prior single-center study demonstrated historical and exam features predicting intracranial injury (ICI) in geriatric patients with low-risk falls. We sought to prospectively validate these findings in a multicenter population. METHODS: This is a prospective observational study of patients ≥65 years presenting after a fall to three EDs. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. Fall mechanism, head strike history, headache, loss of consciousness (LOC), anticoagulants/antiplatelet use, dementia, and signs of head trauma were recorded. Radiographic imaging was obtained at the discretion of treating physicians. Patients were called at 30 days to determine outcome in non-imaged patients. RESULTS: 723 patients (median age 83, interquartile range 74-88) were enrolled. Although all patients were at baseline mental status, 76 had GCS <15, and 154 had dementia. 406 patients were on anticoagulation/antiplatelet agents. Fifty-two (7.31%) patients had traumatic ICI. Two study variables were helpful in predicting ICI: LOC (odds ratio (OR) 2.02) and signs of head trauma (OR 2.6). The sensitivity of these items was 86.5% (CI 73.6-94) with a specificity of 38.8% (CI 35.1-42.7). The positive predictive value in this population was 10% (CI 7.5-13.3) with a negative predictive value of 97.3% (CI 94.4-98.8). Had these items been applied as a decision rule, 273 patients would not have undergone CT scanning, but 7 injuries would have been missed. CONCLUSION: In low-risk geriatric fall patients, the best predictors of ICI were physical findings of head trauma and history of LOC.

Are Emergency Medicine Residents Prepared to Meet the Ethical Challenges of Clinical Practice? Findings from an Exploratory National Survey.

BACKGROUND: Although the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine require clinical ethics education in residency training, instruction varies widely. We assessed the educational preparedness of trainees in emergency medicine to address ethics challenges common to their field. METHODS: The survey assessed two outcomes: 1) knowledge of specific ethical challenges and 2) perceived educational preparedness, across five ethics areas: 1) informed consent and decisional-capacity assessment, 2) surrogate decision making, 3) interpretation of advanced directives, 4) withdrawing and/or withholding life support, and 5) presumed consent for emergency treatment. Clinical vignettes, revised through expert panel review and pilot testing, were utilized to evaluate these areas. The final instrument was administered via Web link to emergency medicine residents and recent graduates through adverts within Emergency Medicine Residency Association and Society for Academic Emergency Medicine (SAEM) newsletters and social media platforms. Additionally, targeted e-mails through the Council of Residency Directors in Emergency Medicine, the Clerkship Directors of Emergency Medicine, and the SAEM Ethics Committee listservs encouraged survey distribution. Analyses involved one-way analysis of variance for overall knowledge scores and chi-square tests for categorical outcomes. Multivariable regression models tested associations between respondent characteristics and outcomes. RESULTS: There were 302 participants of which 34% reported having a dedicated ethics module within their residency curriculum. The mean (±SD) knowledge score was 59.7% (±12.8%); assessing decisional capacity was the most difficult topic for respondents as only 1% both correctly addressed the general issue and identified the correct plan of action. Participants having a dedicated ethics module perceived themselves better prepared, although there was no association between having a dedicated ethics module and knowledge scores. CONCLUSIONS: Gaps in clinical ethics knowledge appear prevalent among emergency medicine trainees, and few programs have dedicated ethics modules. Greater study is needed to understand and remedy clinical ethics knowledge shortfalls.

Prospective Validation and Refinement of a Decision Rule to Obtain Chest X-ray in Patients With Nontraumatic Chest Pain in the Emergency Department.

OBJECTIVES: The objective was to prospectively validate and refine previously published criteria to determine the potential utility of chest x-ray (CXR) in the evaluation and management of patients presenting to the emergency department (ED) with nontraumatic chest pain (CP). METHODS: A prospective observational study was performed of patients presenting to three EDs in the United States with a chief complaint of nontraumatic CP. Previously defined high-risk history and examination elements were combined into a refined decision rule and these elements were recorded for each patient by the ED physician. CXR results were reviewed and analyzed to determine the presence of clinically significant findings including pneumonia, pleural effusion, pneumothorax, congestive heart failure, or the presence of a new mass. Odds ratios for each history and examination element were analyzed as well as sensitivity, specificity, and negative predictive value (NPV) of the rule overall. RESULTS: A total of 1,111 patients were enrolled and 1,089 CXRs were analyzed. There were 70 (6.4%) patients with clinically relevant findings on CXR. The refined decision rule had a sensitivity of 92.9% (confidence interval [CI] = 83.4%-97.3%) and specificity of 30.4% (CI = 27.6%-33.4%) to predict clinically relevant findings on CXR, with a NPV of 98.4% (CI = 96.1%-99.4%). Five CXRs with clinically significant findings would have been missed by application of the refined rule (three pneumonias and two pleural effusions). Applying these criteria as a CXR decision rule to this population would have reduced CXR utilization by 28.9%. CONCLUSIONS: This study validates previous research suggesting a low clinical yield for CXR in the setting of nontraumatic CP in the ED. This refined clinical decision rule has a favorable sensitivity and NPV in a patient population with low incidence of disease. Further validation is needed prior to use in practice.

Society for Academic Emergency Medicine Statement on Plagiarism.

The integrity of the research enterprise is of the utmost importance for the advancement of safe and effective medical practice for patients and for maintaining the public trust in health care. Academic societies and editors of journals are key participants in guarding scientific integrity. Avoiding and preventing plagiarism helps to preserve the scientific integrity of professional presentations and publications. The Society for Academic Emergency Medicine (SAEM) Ethics Committee discusses current issues in scientific publishing integrity and provides a guideline to avoid plagiarism in SAEM presentations and publications.

How Do Emergency Medicine Residency Programs Structure Their Clinical Competency Committees? A Survey.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) recently has mandated the formation of a clinical competency committee (CCC) to evaluate residents across the newly defined milestone continuum. The ACGME has been nonproscriptive of how these CCCs are to be structured in order to provide flexibility to the programs. OBJECTIVES: No best practices for the formation of CCCs currently exist. We seek to determine common structures of CCCs recently formed in the Council of Emergency Medicine Residency Directors (CORD) member programs and identify unique structures that have been developed. METHODS: In this descriptive study, an 18-question survey was distributed via the CORD listserv in the late fall of 2013. Each member program was asked questions about the structure of its CCC. These responses were analyzed with simple descriptive statistics. RESULTS: A total of 116 of the 160 programs responded, giving a 73% response rate. Of responders, most (71.6%) CCCs are chaired by the associate or assistant program director, while a small number (14.7%) are chaired by a core faculty member. Program directors (PDs) chair 12.1% of CCCs. Most CCCs are attended by the PD (85.3%) and selected core faculty members (78.5%), leaving the remaining committees attended by any core faculty. Voting members of the CCC consist of the residency leadership either with the PD (53.9%) or without the PD (36.5%) as a voting member. CCCs have an average attendance of 7.4 members with a range of three to 15 members. Of respondents, 53.1% of CCCs meet quarterly while 37% meet monthly. The majority of programs (76.4%) report a system to match residents with a faculty mentor or advisor. Of respondents, 36% include the resident's faculty mentor or advisor to discuss a particular resident. Milestone summaries (determination of level for each milestone) are the primary focus of discussion (93.8%), utilizing multiple sources of information. CONCLUSIONS: The substantial variability and diversity found in our CORD survey of CCC structure and function suggest that there are myriad strategies that residency programs can use to match individual program needs and resources to requirements of the ACGME. Identifying a single protocol for CCC structure and development may prove challenging.

Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

Ethical issues in the response to Ebola virus disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.

Conflicts of interest in human subjects research: special considerations for academic emergency physicians.

Trust in the doctor-patient or investigator-subject relationship is vital to the practice of medicine and advancement through biomedical research. Individual and environmental factors can make this trust more difficult to establish in the emergency department (ED). To perform research ethically and maintain this trust, it is important to minimize and manage conflicts of interest in human subjects research. While principle-based ethics are an important starting point, the virtue of the individual investigator is required to assure that the interests and safety of research participants are prioritized over the interests of the investigator or the medical community at large. SAEM Ethics Committee 2009-2010 Objective 4: "Based on the results of the didactic session presented at the annual meeting, develop a guide to assist SAEM members in the recognition of potential conflicts of interest in the practice of academic emergency medicine".

Industry relations with emergency medicine graduate medical education programs.

A panel of physicians from the Society for Academic Emergency Medicine (SAEM) Graduate Medical Education (GME), Ethics, and Industry Relations Committees were asked by the SAEM Board of Directors to write a position paper on the relationship of emergency medicine (EM) GME with industry. Using multiple sources as references, the team derived a set of guidelines that all EM GME training programs can use when interacting with industry representatives. In addition, the team used a question-answer format to provide educators and residents with a practical approach to these interactions. The SAEM Board of Directors endorsed the guidelines in June 2009.