Effects of Brief Mental Skills Training on Emergency Medicine Residents' Stress Response During a Simulated Resuscitation: A Prospective Randomized Trial.

BACKGROUND: Acute stress impairs physician decision-making and clinical performance in resuscitations. Mental skills training, a component of the multistep, cognitive-behavioral technique of stress inoculation, modulates stress response in high-performance fields. OBJECTIVE: We assessed the effects of mental skills training on emergency medicine (EM) residents' stress response in simulated resuscitations as well as residents' perceptions of this intervention. METHODS: In this prospective, educational intervention trial, postgraduate year-2 EM residents in seven Chicago-area programs were randomly assigned to receive either stress inoculation training or not. One month prior to assessment, the intervention group received didactic training on the "Breathe, Talk, See, Focus" mental performance tool. A standardized, case-based simulation was used for assessment. We measured subjective stress response using the six-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6). Objective stress response was measured through heart rate (HR) and heart rate variability (HRV) monitoring. We measured subjects' perceptions of the training via survey. RESULTS: Of 92 eligible residents, 61 participated (25 intervention; 36 control). There were no significant differences in mean pre-/post-case STAI-6 scores (-1.7 intervention, 0.4 control; p = 0.38) or mean HRV (-3.8 milliseconds [ms] intervention, -3.8 ms control; p = 0.58). Post-assessment surveys indicated that residents found this training relevant and important. CONCLUSION: There was no difference in subjective or objective stress measures of EM resident stress response after a didactic, mental performance training session, although residents did value the training. More extensive or longitudinal stress inoculation curricula may provide benefit.

A Positive Depression Screen Is Associated with Emergency Medicine Resident Burnout and Is not Affected by the Implementation of a Wellness Curriculum.

INTRODUCTION: While burnout is occupation-specific, depression affects individuals comprehensively. Research on interventions for depression in emergency medicine (EM) residents is limited. OBJECTIVES: We sought to obtain longitudinal data on positive depression screens in EM residents, assess their association with burnout, and determine whether implementation of a wellness curriculum affected the rate of positive screens. METHODS: In February 2017, we administered the Maslach Burnout Inventory and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire two-question depression screen at 10 EM residencies. At five intervention sites, a year-long wellness curriculum was then introduced while five control sites agreed not to introduce new wellness initiatives during the study period. Study instruments were re-administered in August 2017 and February 2018. RESULTS: Of 382 residents, 285 participated in February 2017; 40% screened positive for depression. In August 2017, 247/386 residents participated; 27.9% screened positive for depression. In February 2018, 228/386 residents participated; 36.2% screened positive. A positive depression screen was associated with higher burnout. There were similar rates of positive screens at the intervention and control sites. CONCLUSION: Rates of positive depression screens in EM residents ranged between 27.9% and 40%. Residents with a positive screen reported higher levels of burnout. Rates of a positive screen were unaffected by introduction of a wellness curriculum.

The Implementation of a National Multifaceted Emergency Medicine Resident Wellness Curriculum Is Not Associated With Changes in Burnout.

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements effective 2017 state that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. OBJECTIVES: The authors sought to determine if the implementation of a multifaceted wellness curriculum improved resident burnout as measured by the Maslach Burnout Inventory (MBI). METHODS: We performed a multicenter educational interventional trial at 10 emergency medicine (EM) residencies. In February 2017, we administered the MBI at all sites. A year-long wellness curriculum was then introduced at five intervention sites while five control sites agreed not to introduce new wellness initiatives during the study period. The MBI was readministered in August 2017 and February 2018. RESULTS: Of 523 potential respondents, 437 (83.5%) completed at least one MBI assessment. When burnout was assessed as a continuous variable, there was a statistically significant difference in the depersonalization component favoring the control sites at the baseline and final survey administrations. There was also a higher mean personal accomplishment score at the control sites at the second survey administration. However, when assessed as a dichotomous variable, there were no differences in global burnout between the groups at any survey administration and burnout scores did not change over time for either control or intervention sites. CONCLUSIONS: In this national study of EM residents, MBI scores remained stable over time and the introduction of a multifaceted wellness curriculum was not associated with changes in global burnout scores.

Protocolized use of Factor Eight Inhibitor Bypassing Activity (FEIBA) for the reversal of warfarin induced coagulopathy.

INTRODUCTION: Coagulopathy due to warfarin in patients with major bleeding was traditionally reversed with fresh frozen plasma and intravenous (IV) vitamin K, but prothrombin complex concentrates (PCC) are increasingly used in the treatment of these patients. Factor Eight Inhibitor Bypassing Activity (FEIBA) is an activated four-factor PCC most commonly used in patients with hemophilia. We aimed to evaluate the efficacy and safety of FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major bleeding, by measuring the percentage of patients who achieved target INR ≤ 1.5 and the incidence of thrombotic adverse events (TAE). METHODS: In this prospective observational study, we enrolled patients presenting to the Emergency Department (ED) with warfarin associated coagulopathy (INR > 1.5) and major bleeding. Patients received FEIBA using an INR based dosing strategy and IV vitamin K. RESULTS: In 43 patients, median initial INR was 4.0 (2.7, 7.3 interquartile range (IQR)). Median time to result the second INR was 45 min (38, 55 IQR) and the median INR was 1.4 (1.3, 1.6 IQR). Out of the 43 patients, 93% achieved the target INR of ≤1.5. In-hospital mortality was 40% (17 patients). There were 11 TAEs in 6 patients (14%); 4 events in 2 patients (5%) were attributed to FEIBA. CONCLUSION: A protocolized use of FEIBA and IV vitamin K resulted in the efficacious reversal of warfarin-induced coagulopathy in patients with major bleeding. TAEs occurred in 14% of patients and were attributed to FEIBA in 5% of patients.

Comparing the Maslach Burnout Inventory to Other Well-Being Instruments in Emergency Medicine Residents.

BACKGROUND: The Maslach Burnout Inventory (MBI) is considered the "gold standard" for measuring burnout, encompassing 3 scales: emotional exhaustion, depersonalization, and personal accomplishment. Other well-being instruments have shown utility in various settings, and correlations between MBI and these instruments could provide evidence of relationships among key variables to guide well-being efforts. OBJECTIVE: We explored correlations between the MBI and other well-being instruments. METHODS: We fielded a multicenter survey of 9 emergency medicine (EM) residencies, administering the MBI and 4 published well-being instruments: a quality-of-life assessment, a work-life balance rating, an appraisal of career satisfaction, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire 2 question screen. Consistent with the Maslach definition, burnout was defined by high emotional exhaustion (> 26) and high depersonalization (> 12). RESULTS: Of 334 residents, 261 (78%) responded. Residents who reported lower quality of life had higher emotional exhaustion (ρ = -0.437, P < .0001), higher depersonalization (ρ = -0.18, P < .005), and lower personal accomplishment (ρ = 0.347, P < .001). Residents who reported a negative work-life balance had emotional exhaustion (P < .001) and depersonalization (P < .009). Positive career satisfaction was associated with lower emotional exhaustion (P < .0001), lower depersonalization (P < .005), and higher personal accomplishment (P < .05). A positive depression screen was associated with higher emotional exhaustion, higher depersonalization, and lower personal achievement (all P < .0001). CONCLUSIONS: Our multicenter study of EM residents demonstrated that assessments using the MBI correlate with other well-being instruments.

Development of an Emergency Medicine Wellness Curriculum.

Burnout, the triad of emotional exhaustion, depersonalization, and low personal accomplishment, begins early in medical education and the prevalence continues to increase over time among U.S. physicians. The Accreditation Council for Graduate Medical Education (ACGME) now requires that programs and sponsoring institutions have the same responsibility to address well-being as they do other aspects of resident competence. Yet, there are no studies published in the emergency medicine (EM) literature that discuss the development and institution of a formal wellness curriculum. The authors conducted a needs analysis among EM residents with the aim of creating a multifaceted 12-month wellness curriculum. The needs analysis determined that residents are not comfortable with their knowledge of wellness principles. In response, the authors developed a curriculum by integrating components of published non-EM wellness curricula and online academic wellness programs with commonly accepted domains of wellness. The curriculum was subsequently introduced at five EM residencies. This curriculum represents an example of successful multi-institution collaboration to meet an ACGME Common Program Requirement.

Taking Advantage of the Teachable Moment: A Review of Learner-Centered Clinical Teaching Models.

When working in a chaotic Emergency Department (ED) with competing priorities, clinical teaching may be sacrificed for the sake of patient flow and throughput. An organized, efficient approach to clinical teaching helps focus teaching on what the learner needs at that moment, incorporates regular feedback, keeps the department on track, and prevents over-teaching. Effective clinical teaching in a busy environment is an important skill for senior residents and faculty to develop. This review will provide a critique and comparison of seven structured teaching models to better prepare readers to seize the teachable moment.

Entrustment Decision Making in Clinical Training.

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

The American Board of Emergency Medicine Maintenance of Certification Summit.

BACKGROUND: The American Board of Emergency Medicine (ABEM) convened a summit of stakeholders in Emergency Medicine (EM) to critically review the ABEM Maintenance of Certification (MOC) Program. OBJECTIVE: The newly introduced American Board of Medical Specialties (ABMS) 2015 MOC Standards require that the ABMS Member Boards, including ABEM, "engage in continual quality monitoring and improvement of its Program for MOC …" ABEM sought to have the EM community participate in the quality improvement process. DISCUSSION: A review of the ABMS philosophy of MOC and requirements for MOC were presented, followed by an exposition of the ABEM MOC Program. Roundtable discussions included strengths of the program and opportunities for improvement; defining, teaching, and assessing professionalism; identifying and filling competency gaps; and enhancing relevancy and adding value to the ABEM MOC Program. CONCLUSIONS: Several suggestions to improve the ABEM MOC Program were discussed. ABEM will consider these recommendations when developing its next revision of the ABEM MOC Program.

The prevalence of methicillin-resistant Staphylococcus aureus colonization in emergency department fast track patients.

BACKGROUND: Over the past two decades, methicillin-resistant Staphylococcus aureus (MRSA) has evolved from a hospital-associated infection to a significant public health threat in the community, causing outbreaks of soft tissue infections in otherwise healthy individuals. The goal of this study was to determine the prevalence of nasal MRSA colonization in low acuity Emergency Department (ED) Fast Track patients in order to better characterize the epidemiology of this pathogen. METHODS: We conducted a cross-sectional study of a convenience sample of adult patients from our ED Fast Track. Nasal swabs were analyzed for MRSA using a polymerase chain reaction assay. Study participants completed a survey assessing traditional risk factors for CA-MRSA colonization. RESULTS: A total of 106 ED Fast Track patients were tested. Four (3.8%, 95% CI 1.5%-9.3%) were MRSA positive. Three traditional CA-MRSA risk factors (personal history of abscess, family history of abscess, and participation in contact sports) were examined. In patients with a positive MRSA nasal swab, only a personal prior history of abscess retained signifi cance (OR 33, 95% CI 1.7-676, P=0.02). CONCLUSION: This study found a higher prevalence of nasal MRSA colonization in low acuity ED Fast Track patients compared with historical community surveillance studies. A personal history of prior abscess was a signifi cant risk for CA-MRSA carriage.

The prevalence of methicillin-resistant Staphylococcus aureus colonization in emergency department fast track patients / 世界急诊医学杂志（英文）

@#BACKGROUND: Over the past two decades, methicillin-resistant Staphylococcus aureus (MRSA) has evolved from a hospital-associated infection to a significant public health threat in the community, causing outbreaks of soft tissue infections in otherwise healthy individuals. The goal of this study was to determine the prevalence of nasal MRSA colonization in low acuity Emergency Department (ED) Fast Track patients in order to better characterize the epidemiology of this pathogen. METHODS: We conducted a cross-sectional study of a convenience sample of adult patients from our ED Fast Track. Nasal swabs were analyzed for MRSA using a polymerase chain reaction assay. Study participants completed a survey assessing traditional risk factors for CA-MRSA colonization. RESULTS: A total of 106 ED Fast Track patients were tested. Four (3.8%, 95% CI 1.5%–9.3%) were MRSA positive. Three traditional CA-MRSA risk factors (personal history of abscess, family history of abscess, and participation in contact sports) were examined. In patients with a positive MRSA nasal swab, only a personal prior history of abscess retained significance (OR 33, 95% CI 1.7–676, P=0.02). CONCLUSION: This study found a higher prevalence of nasal MRSA colonization in low acuity ED Fast Track patients compared with historical community surveillance studies. A personal history of prior abscess was a significant risk for CA-MRSA carriage.

Antibiotic-induced serotonin syndrome.

Due to its broad spectrum of clinical presentations and to the large number of available serotonergic medications, serotonin syndrome (SS) remains an elusive diagnosis to many clinicians. SS results from the over-stimulation of serotonin receptors by a variety of mechanisms. New medications with the potential to cause SS are released regularly, and among them is the antibiotic linezolid. We present a case of SS in a 36-year-old woman that occurred after linezolid was added to a drug regimen that included lithium, venlafaxine, and imipramine.

Therapeutic hypothermia protocol in a community emergency department.

OBJECTIVES: Therapeutic hypothermia (TH) has been shown to improve survival and neurological outcome in patients resuscitated after out of hospital cardiac arrest (OHCA) from ventricular fibrillation/ventricular tachycardia (VF/VT). We evaluated the effects of using a TH protocol in a large community hospital emergency department (ED) for all patients with neurological impairment after resuscitated OHCA regardless of presenting rhythm. We hypothesized improved mortality and neurological outcomes without increased complication rates. METHODS: Our TH protocol entails cooling to 33°C for 24 hours with an endovascular catheter. We studied patients treated with this protocol from November 2006 to November 2008. All non-pregnant, unresponsive adult patients resuscitated from any initial rhythm were included. Exclusion criteria were initial hypotension or temperature less than 30°C, trauma, primary intracranial event, and coagulopathy. Control patients treated during the 12 months before the institution of our TH protocol met the same inclusion and exclusion criteria. We recorded survival to hospital discharge, neurological status at discharge, and rates of bleeding, sepsis, pneumonia, renal failure, and dysrhythmias in the first 72 hours of treatment. RESULTS: Mortality rates were 71.1% (95% CI, 56-86%) for 38 patients treated with TH and 72.3% (95% CI 59-86%) for 47 controls. In the TH group, 8% of patients (95% CI, 0-17%) had a good neurological outcome on discharge, compared to 0 (95% CI 0-8%) in the control group. In 17 patients with VF/VT treated with TH, mortality was 47% (95% CI 21-74%) and 18% (95% CI 0-38%) had good neurological outcome; in 9 control patients with VF/VT, mortality was 67% (95% CI 28-100%), and 0% (95% CI 0-30%) had good neurological outcome. The groups were well-matched with respect to sex and age. Complication rates were similar or favored the TH group. CONCLUSION: Instituting a TH protocol for OHCA patients with any presenting rhythm appears safe in a community hospital ED. A trend towards improved neurological outcome in TH patients was seen, but did not reach significance. Patients with VF appeared to derive more benefit from TH than patients with other rhythms.

Promoting diversity in emergency medicine: summary recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup.

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.

A prevalence study of methicillin-resistant Staphylococcus aureus colonization in emergency department health care workers.

STUDY OBJECTIVE: Few studies of the prevalence of nasal colonization of methicillin-resistant Staphylococcus aureus (MRSA) in emergency department (ED) health care workers have been conducted. To better understand the epidemiology of this pathogen, we seek to determine the MRSA nasal colonization rates in the ED health care workers in our hospital. METHODS: We conducted a prospective cohort study on a convenience sample of ED health care workers, including nurses, physicians, and technicians. Nasal swabs from subjects were analyzed with a polymerase chain reaction assay for the presence of MRSA. RESULTS: Of the 105 ED health care workers enrolled, a total of 16 (15%, 95% confidence interval 9.6% to 23%) were MRSA positive. No significant difference was observed in colonization rates between nurses, physicians, and technicians. CONCLUSION: Our ED health care workers demonstrated a high prevalence of nasal MRSA colonization compared with individuals in recent community surveillance and other studies involving ED staff.

A rapid quantitative turbimetric d-dimer assay has high sensitivity for detection of pulmonary embolism in the ED.

Many rapid d-dimer assays are commercially available with wide ranges of reported sensitivities, often based on small sample sizes. This has limited their intended use as rapid and inexpensive tests to evaluate pulmonary embolism in the low-risk patient. We sought to determine the sensitivity of the STA-Liatest D-Di d-dimer assay in our ED. We performed a retrospective analysis of 103 patients seen in our ED with the admitting diagnosis of known or suspected pulmonary embolism. These charts were assessed to establish if a d-dimer assay was performed within 24 hours. These charts were then reviewed to determine what diagnostic studies were performed and what final diagnosis was reached. Of the 103 charts identified, 55 had d-dimer assays performed within 24 hours. Of those, 38 were diagnosed with pulmonary embolism; none had negative d-dimer assays (<400 ng/mL). Using the exact method, the sensitivity of this assay was calculated to be 100% with a 95% confidence interval (CI) of 91.4% to 100%. Our results suggest that the STA-Liatest D-Di d-dimer assay could have an adequate sensitivity to be used to rule out pulmonary embolism in low-risk patients. Further prospective studies with larger sample sizes are required to validate this observation.