The Power of an Active Shooter Simulation: Changing Ethical Beliefs.

INTRODUCTION: During a hospital-based active shooter (AS) event, clinicians may be forced to choose between saving themselves or their patients. The Hartford Consensus survey of clinicians and the public demonstrated mixed feelings on the role of doctors and nurses in these situations. Our objective was to evaluate the effect of simulation on ethical dilemmas during a hospital-based AS simulation. The objective was to determine whether a hospital-based AS event simulation and debrief would impact the ethical beliefs of emergency physicians relating to personal duty and risk. METHODS: Forty-eight emergency physicians and physicians-in-training participated in this cohort study based in an urban academic hospital. Simulation scenarios presented ethical dilemmas for participants (eg, they decided between running a code or hiding from a shooter). Surveys based upon the Hartford Consensus were completed before and after the simulation. Questions focused on preparedness and ethical duties of physicians to their patients during an AS incident. We evaluated differences using a chi-squared test. RESULTS: Preparedness for an AS event significantly improved after the simulation (P = 0.0001). Pre-simulation, 56% of participants felt that doctors/nurses have a special duty like police to protect patients who cannot hide/run, and 20% reported that a provider should accept a very high/high level of personal risk to protect patients who cannot hide/run. This was similar to the findings of the Hartford Consensus. Interestingly, post-simulation, percentages decreased to 25% (P = 0.008) and 5% (P = 0.041), respectively. CONCLUSION: Simulation training influenced ethical beliefs relating to the duty of emergency physicians during a hospital-based AS incident. In addition to traditional learning objectives, ethics should be another important design consideration for planning future simulations in this domain.

Protocolized Laboratory Screening for the Medical Clearance of Psychiatric Patients in the Emergency Department: A Systematic Review.

OBJECTIVE: Emergency department (ED) patients with psychiatric chief complaints undergo medical screening to rule out underlying or comorbid medical illnesses prior to transfer to a psychiatric facility. This systematic review attempts to determine the clinical utility of protocolized laboratory screening for the streamlined medical clearance of ED psychiatric patients by determining the clinical significance of individual laboratory results. METHODS: We searched PubMed, Embase, and Scopus using the search terms "emergency department, psychiatry, diagnostic tests, laboratories, studies, testing, screening, and clearance" up to June 2017 for studies on adult psychiatric patients. This systematic review follows the recommendations of Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. The quality of each study was rated according to the Newcastle-Ottawa quality assessment scale. RESULTS: Four independent reviewers identified 2,847 publications. We extracted data from three studies (n = 629 patients). Included studies defined an abnormal test result as any laboratory result that falls out of the normal range. A laboratory test result was deemed as "clinically significant" only when patient disposition or treatment plan was changed because of that test result. Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%). CONCLUSIONS: The prevalence of clinically significant laboratory test results were low, suggesting that according to the available literature, routine laboratory testing does not significantly change patient disposition. Due to the paucity of available research on this subject, we could not determine the clinical utility of protocolized laboratory screening tests for medical clearance of psychiatric patients in the ED. Future research on the utility of routine laboratory testing is important in a move toward shared decision making and patient-centered health care.

Development of a content valid tool for assessing end-of-life communication in acute care settings.

BACKGROUND: Current recommendations throughout the literature require that physicians demonstrate proficiency in handling end-of-life care issues. However, current training and assessment tools are not easily translated to acutely decompensating emergency department patients with whom the practitioner is not familiar. Without these tools, robust assessment of physician performance cannot occur. OBJECTIVE: To develop a content valid instrument to measure the critical care communication skills of emergency physicians in order to facilitate education and assessment of end-of-life communication skills in a time-sensitive acute care setting. METHODS: A two-step modified Delphi methodology with emergency medicine palliative care subject matter experts was used. First, an extensive review of the literature was conducted to elucidate broad communication domains important to end-of-life care. Next, subject matter experts were asked open-ended questions to ascertain critical skills and behaviors that characterized these broad domains. Finally, both questions and domains were ranked as to their importance and relevance to end-of-life communication in an emergency department setting. RESULTS: Literature review identified five domains of end-of-life care: (1) seek information, (2) assess life values, (3) educate family, (4) extend care in a consistent manner, and (5) respond to family questions and concerns. Within each domain, the expert panel identified subdomains with related behavioral examples that were consistently rated as important to end-of-life care for emergency practitioners. CONCLUSION: The resulting assessment tool provides a list of skill domains with specific descriptors and clear behavioral examples that can be used as both a teaching and assessment tool. This represents an essential first step that will allow further validation of the assessment tool, ultimately producing a valid and reliable measure of physician skill in emergency medicine end-of-life care.

Barriers to screening colonoscopy for low-income Latino and white patients in an urban community health center.

BACKGROUND: Colonoscopy is a screening modality for the early detection of colonic polyps and cancers but is underutilized, particularly among minorities. OBJECTIVE: To identify potential barriers to screening colonoscopy among low income Latino and white non-Latino patients in an urban community health center. DESIGN, PARTICIPANTS, AND APPROACH: We conducted semistructured interviews with a convenience sample of patients 53 to 70 years old, eligible for colorectal cancer screening that spoke English or Spanish. Open-ended questions explored knowledge, beliefs, and experience with or reasons for not having screening colonoscopy. We performed content analysis of transcripts using established qualitative techniques. RESULTS: Of 40 participants recruited, 57% were women, 55% Latino, 20% had private health insurance, and 40% had a prior colonoscopy. Participants described a wide range of barriers categorized into 5 major themes: (1) System barriers including scheduling, financial, transportation, and language difficulties; (2) Fear of pain or complications of colonoscopy and fear of diagnosis (cancer); (3) Lack of desire or motivation, including "laziness" and "procrastination"; (4) Dissuasion by others influencing participants' decision regarding colonoscopy; and (5) Lack of provider recommendation including not hearing about colonoscopy or not understanding the preparation instructions. CONCLUSIONS: Understanding of the range of barriers to colorectal cancer screening can help develop multimodal interventions to increase colonoscopy rates for all patients including low-income Latinos. Interventions including systems improvements and navigator programs could address barriers by assisting patients with scheduling, insurance issues, and transportation and providing interpretation, education, emotional support, and motivational interviewing.