Evolution of conflict management style during first year of paediatric residency.

BACKGROUND: First-year residents frequently encounter conflict during their training. Residents' conflict management strategies can influence patient safety, quality of care and perceptions of performance on competency evaluations. Existing literature inadequately describes how first-year resident conflict management styles evolve over time. OBJECTIVE: The objective of this study is to assess if and how conflict management styles change during first year of paediatric residency in the United States. METHODS: In 2021-2022, we conducted a non-experimental, longitudinal, survey study of first-year residents from 16 US-based paediatric residency programmes. Using the Thomas-Kilmann Conflict Mode Instrument, we scored first-year residents' use of five conflict management modes twice, 6 months apart. We calculated the percentage of first-year residents who experienced a change in predominant conflict management mode and assessed for changes in score and variance for each conflict management mode. RESULTS: Fifty-seven (18%) first-year residents participated in the first survey. Of those, 45 (14%) also completed the follow-up survey. Nonresponse bias analysis showed no significant difference in scores for early and late respondents or for second-survey respondents and non-respondents. Half of respondents experienced a change in predominant conflict management mode, but the distribution of predominant modes remained largely unchanged. When residents changed modes, they typically moved from one low-assertiveness mode, such as avoiding or accommodating, to the other. Only the use of the compromising conflict management mode significantly decreased. Variance did not significantly change. CONCLUSIONS: The overall lack of change in conflict management style may suggest the need for specific and focused educational interventions to help residents adjust their conflict handling strategies.

Importance of Mentoring on Workplace Engagement of Emergency Medicine Faculty: A Multi-institutional Study.

INTRODUCTION: Mentoring in emergency medicine (EM) has not been well studied despite a larger body of literature that has described the value of mentoring in academic medicine on career satisfaction and scholarly output. Over half of all EM faculty nationally are of junior faculty ranks. The aim of this study was to identify the frequency and types of mentoring in EM, how types of mentoring in EM differ by gender, and how mentoring correlates with workplace satisfaction for EM faculty. METHODS: Using descriptive statistics and chi-squared analysis, we analyzed data from a cohort of medical schools participating in the Association of American Medical Colleges StandPoint Faculty Engagement Survey. RESULTS: A total of 514 EM faculty from 26 medical schools replied to the survey. Nearly 80% of EM faculty reported receiving some sort of mentoring; 43.4% reported receiving formal mentoring; 35.4% reported receiving only informal mentoring; and 21.2% received no mentoring at all. Women EM faculty received formal mentoring at lower rates than men (36.2% vs 47.5%) even though they were more likely to report that formal mentoring is important to them. Workplace satisfaction was highest for faculty receiving formal mentoring; informally or formally mentored faculty reported higher workplace satisfaction than faculty who are not mentored at all. Unmentored faculty are less likely to stay at their medical school than those formally mentored (69.8 % vs 80.4%). CONCLUSION: Institutions and department chairs should focus on mentoring EM faculty, particularly women, to increase engagement and reduce attrition.

Faculty leadership development: A case study of a synergistic approach.

INTRODUCTION: Ongoing leadership development is essential for academic health center faculty members to respond to increasing environmental complexity. At the George Washington University School of Medicine and Health Sciences, an 8-month program, based on Conger's leadership development approach emphasizing conceptual understanding, skill building, feedback and personal growth was offered to mid-level faculty charged with developing educational programs, clinical services, and/or research initiatives. We studied how specific learning methods catering to different learning approaches contributed to improving leadership competencies. METHODS: Session and program evaluations, participant interviews, mentor surveys, and supervisor interviews were used for data collection. Themes were identified through open coding with use of constant comparative methods to help find patterns in the data. RESULTS: Readings and classroom modules provided a broadened, holistic understanding of leadership; role plays and action plans helped participants apply and practice leadership skills; self-assessments and feedback from peers and mentors provided specifics for focusing development efforts; and personal growth exercises provided opportunities to reflect and consider fresh perspectives. Anchoring learning methods around a real-time project led to improved leadership competencies and personal confidence as reported by participants, supervisors and mentors. CONCLUSION: A faculty leadership development program that integrates understanding, skill building, feedback and personal growth and connects multiple learning methods can provide the synergy to facilitate behavior change and organizational growth.

Engagement and Workplace Satisfaction of Emergency Medicine Faculty in the United States.

OBJECTIVES: The objective was to determine the drivers of workplace satisfaction and attrition for emergency medicine (EM) faculty in U.S. medical schools. METHODS: Dimensions of workplace satisfaction measured in the Association of American Medical Colleges StandPoint Faculty Engagement Survey from 36 U.S. Liaison Committee on Medical Accreditation-accredited medical schools were analyzed by multiple regression analysis to determine the factors associated with overall workplace satisfaction and intention to leave. These were compared to faculty from non-EM clinical departments. RESULTS: In total, 737 EM faculty (response rate 66%) completed the survey. Over 50% of EM faculty are less than 45 years old, of junior rank, and on a nontenure track, different than non-EM colleagues. Overall satisfaction with one's department as a place to work was 76% and one's medical school as a place to work was 69%, similar to other clinical faculty. Overall satisfaction is 87% for EM faculty with a formal mentor compared to 68% for those who do not. One's nature of work, departmental governance, collegiality and collaboration, and the clinical practice environment are significant factors in overall workplace satisfaction. EM faculty spend significantly more time on teaching and administrative tasks and less time on research than non-EM faculty. Overall functioning of the ED and ability to provide high-quality care in their practice environment is lower for EM than non-EM faculty. Survey dimensions were poor predictors of intention to leave. CONCLUSIONS: Overall EM faculty have high workplace satisfaction similar to other specialties. Ensuring strong departmental leadership, improving the clinical practice environment, and increasing access to a formal mentor may be effective strategies to improve workplace satisfaction for EM faculty.

We are All Leaders: Introducing Self-Leadership Concepts Through the Lens of Improving Diversity in the Health Care Workforce.

Introduction: Increasing faculty and leader diversity has been recommended as a way for health care organizations to achieve cultural competence in their patient care mission. Given the low numbers of underrepresented groups in medical school leadership positions, teaching diverse students and trainees the concept of leadership as influence may empower them to become more involved and bring diverse perspectives to their organizations. Methods: This 70-minute workshop consisted of a short presentation, a self-assessment, small- and large-group discussions, and case studies to: (1) describe the importance of diversity in medical school leadership, (2) define leadership, (3) define self-leadership, and (4) assess one's own self-leadership skills. The workshop was implemented at three US medical schools to diverse medical students and residents between September and December of 2019. Pre- and postworkshop evaluations were analyzed. Results: Greater than 95% of learners (n = 66) agreed that the workshop's learning objectives were met. Comments suggested participants appreciated learning about the lack of diversity among medical school leaders and the importance of cultivating their role in diversity in academic medicine. The case studies were highly rated and considered effective tools for learning. Discussion: This submission defined an empowering notion of leadership as influence. It taught learners that we can all lead (by influence) if we can improve our own self-leadership skills and become involved and bring diverse perspectives to health care organizations. Future research may focus on longer-term follow-up of participants to reassess their self-leadership skills and describe their level of involvement in their organizations.

Mosquito Community Composition, Seasonal Distributions, and Trap Bias in Northeastern Florida.

Mosquito control agencies monitor mosquito diversity and abundance through a variety of trap types. Although various long-term ecological data sets exist, little work has been done to address the sampling effort required to capture mosquito community diversity by trap type and few spatiotemporal distributions of vector species have been described. Here, we describe the seasonal distributions of vector species of importance, assess trapping effort needed to capture the diversity of the mosquito community, and use a partial redundancy analysis to identify trap bias from four commonly deployed adult mosquito traps in Volusia County, Florida. Collections were made with American Biophysics Corporation (ABC) light traps, Biogents Sentinel (BGS) traps, chicken coop exit traps, and gravid traps. We collected a total of 238,301 adult female mosquitoes belonging to 11 genera and 36 species, 12 of which we deemed to be vector species of epidemiological importance. We found that ABC traps not only yielded the greatest abundance and diversity but also captured several nonvector species. BGS and gravid traps yielded the highest proportions of vector species; exit traps recorded the lowest abundances and species richness. Wintertime abundances of several species demonstrated a need for year-round surveillance in the study area; partial redundancy analysis revealed that trap type explained a significant proportion of the variance in our data set, with certain vector species associated with specific trap types. Increased awareness regarding the amount of trapping effort needed to detect vector species diversity will help to optimize efforts in the field, leading to more effective resource allocation.

Development and Validation of the Pediatric Resuscitation and Escalation of Care Self-Efficacy Scale.

OBJECTIVES: To validate a scale to assess pediatric providers' resuscitation and escalation of care self-efficacy and assess which provider characteristics and experiences may contribute to self-efficacy. METHODS: Cross-sectional cohort study performed at an academic children's hospital. Pediatric nurses, respiratory therapists, and residents completed the Generalized Self-Efficacy Scale (GSES) and Pediatric Resuscitation Self-Efficacy Scale (PRSES) as well as a survey assessing their experiences with pediatric escalation of care. RESULTS: Four hundred participants completed the GSES and PRSES. A total of 338 completed the survey, including 262 nurses, 51 respiratory therapists, and 25 residents. Cronbach α for the PRSES was 0.905. A factor analysis revealed 2 factors within the scale, with items grouped on the basis of expertise required. Multiple logistic regression analyses controlling for GSES score, number of code blue events participated, number of code blue events activated, number of rapid response team events participated, number of rapid response team response events called, performance on a knowledge assessment of appropriate escalation of care, and years of experience demonstrated that PRSES performance was significantly associated with GSES scores and number of escalation of care events (code blue and rapid response) previously participated in (R 2 = 0.29, P < .001). CONCLUSIONS: The PRSES can be used to assess pediatric providers' pediatric resuscitation self-efficacy and could be used to evaluate pediatric escalation of care interventions. Pediatric resuscitation self-efficacy is significantly associated with number of previous escalation of care experiences. In future studies, researchers should focus on assessing the impact of increased exposures to escalation of care, potentially via mock codes, to accelerate the acquisition of resuscitation self-efficacy.

Leadership Development Programs at Academic Health Centers: Results of a National Survey.

PURPOSE: To identify the prevalence and characteristics of faculty leadership development programs (LDPs) offered by North American academic health centers (AHCs) and to uncover gaps in leadership training. METHOD: Faculty development/affairs deans of the 161 Association of American Medical Colleges member schools were surveyed in 2015 on their approach to faculty leadership training. For AHCs delivering their own training, the survey included questions about LDP participants, objectives, curriculum, delivery, resources, and evaluation. The literature on leadership and leadership development was used to develop a taxonomy of leadership competencies, which formed the basis of the survey questions related to program content. Survey results were analyzed with descriptive statistics and chi-square analysis for categorical data. RESULTS: Of the 94 respondents (response rate 58%), 93 provided some form of leadership training and 61 provided a formal internal faculty LDP. Content was variable and rarely based on a specific leadership competency model. Although programs described innovative approaches to learning, lectures and case discussions were the predominant approaches. Evaluation beyond participant satisfaction was uncommon. CONCLUSIONS: Faculty LDPs were common, with some programs describing elements informed by the leadership literature. However, nationally programs can improve by basing content on a leadership competency model, incorporating multiple approaches to teaching, and implementing more rigorous program evaluation.

Introducing Trainees to Academic Medicine Career Roles and Responsibilities.

Introduction: The future of academic medicine depends on attracting motivated trainees to the academic career path, but challenges to recruitment include unfamiliarity with academic career options. Methods: This workshop comprises a didactic session with small-group case discussion to enable trainees to learn how to: (1) define academic medical center roles and responsibilities, (2) assess the alignment of academic medical center roles with personal goals and interests, and (3) identify factors that support an academic medicine career trajectory. Workshop evaluations were collected at five academic medicine conferences for medical students and residents held across the U.S. Results: Among the 139 conference participants who completed an evaluation form, the majority had a statistically significant increase in confidence regarding their building a foundation for a career in academic medicine, and in identifying an academic medicine career role aligning with their own personal and professional interests. The majority strongly agreed or agreed that the workshop objectives were met. Trainees reported that the workshop was "illuminating," "informative," and "educational." Discussion: Improved understanding of academic medicine career roles and responsibilities can increase trainees' awareness of the opportunities in academic medicine and may support development of the next generation of academic physicians.

Developing and Implementing a Multisource Feedback Tool to Assess Competencies of Emergency Medicine Residents in the United States.

OBJECTIVES: Multisource feedback (MSF) has potential value in learner assessment, but has not been broadly implemented nor studied in emergency medicine (EM). This study aimed to adapt existing MSF instruments for emergency department implementation, measure feasibility, and collect initial validity evidence to support score interpretation for learner assessment. METHODS: Residents from eight U.S. EM residency programs completed a self-assessment and were assessed by eight physicians, eight nonphysician colleagues, and 25 patients using unique instruments. Instruments included a five-point rating scale to assess interpersonal and communication skills, professionalism, systems-based practice, practice-based learning and improvement, and patient care. MSF feasibility was measured by percentage of residents who collected the target number of instruments. To develop internal structure validity evidence, Cronbach's alpha was calculated as a measure of internal consistency. RESULTS: A total of 125 residents collected a mean of 7.0 physician assessments (n = 752), 6.7 nonphysician assessments (n = 775), and 17.8 patient assessments (n = 2,100) with respective response rates of 67.2, 75.2, and 77.5%. Cronbach's alpha values for physicians, nonphysicians, patients, and self were 0.97, 0.97, 0.96, and 0.96, respectively. CONCLUSIONS: This study demonstrated that MSF implementation is feasible, although challenging. The tool and its scale demonstrated excellent internal consistency. EM educators may find the adaptation process and tools applicable to their learners.

Acute appendicitis: transcript profiling of blood identifies promising biomarkers and potential underlying processes.

BACKGROUND: The diagnosis of acute appendicitis can be surprisingly difficult without computed tomography, which carries significant radiation exposure. Circulating blood cells may carry informative changes in their RNA expression profile that would signal internal infection or inflammation of the appendix. METHODS: Genome-wide expression profiling was applied to whole blood RNA of acute appendicitis patients versus patients with other abdominal disorders, in order to identify biomarkers of appendicitis. From a large cohort of emergency patients, a discovery set of patients with surgically confirmed appendicitis, or abdominal pain from other causes, was identified. RNA from whole blood was profiled by microarrays, and RNA levels were filtered by a combined fold-change (>2) and p value (<0.05). A separate set of patients, including patients with respiratory infections, was used to validate a partial least squares discriminant (PLSD) prediction model. RESULTS: Transcript profiling identified 37 differentially expressed genes (DEG) in appendicitis versus abdominal pain patients. The DEG list contained 3 major ontologies: infection-related, inflammation-related, and ribosomal processing. Appendicitis patients had lower level of neutrophil defensin mRNA (DEFA1,3), but higher levels of alkaline phosphatase (ALPL) and interleukin-8 receptor-ß (CXCR2/IL8RB), which was confirmed in a larger cohort of 60 patients using droplet digital PCR (ddPCR). CONCLUSIONS: Patients with acute appendicitis have detectable changes in the mRNA expression levels of factors related to neutrophil innate defense systems. The low defensin mRNA levels suggest that appendicitis patient's immune cells are not directly activated by pathogens, but are primed by diffusible factors in the microenvironment of the infection. The detected biomarkers are consistent with prior evidence that biofilm-forming bacteria in the appendix may be an important factor in appendicitis.

Educational technology improves ECG interpretation of acute myocardial infarction among medical students and emergency medicine residents.

INTRODUCTION: Asynchronous online training has become an increasingly popular educational format in the new era of technology-based professional development. We sought to evaluate the impact of an online asynchronous training module on the ability of medical students and emergency medicine (EM) residents to detect electrocardiogram (ECG) abnormalities of an acute myocardial infarction (AMI). METHODS: We developed an online ECG training and testing module on AMI, with emphasis on recognizing ST elevation myocardial infarction (MI) and early activation of cardiac catheterization resources. Study participants included senior medical students and EM residents at all post-graduate levels rotating in our emergency department (ED). Participants were given a baseline set of ECGs for interpretation. This was followed by a brief interactive online training module on normal ECGs as well as abnormal ECGs representing an acute MI. Participants then underwent a post-test with a set of ECGs in which they had to interpret and decide appropriate intervention including catheterization lab activation. RESULTS: 148 students and 35 EM residents participated in this training in the 2012-2013 academic year. Students and EM residents showed significant improvements in recognizing ECG abnormalities after taking the asynchronous online training module. The mean score on the testing module for students improved from 5.9 (95% CI [5.7-6.1]) to 7.3 (95% CI [7.1-7.5]), with a mean difference of 1.4 (95% CI [1.12-1.68]) (p<0.0001). The mean score for residents improved significantly from 6.5 (95% CI [6.2-6.9]) to 7.8 (95% CI [7.4-8.2]) (p<0.0001). CONCLUSION: An online interactive module of training improved the ability of medical students and EM residents to correctly recognize the ECG evidence of an acute MI.

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.

Bedside Teaching on Time to Disposition Improves Length of Stay for Critically-ill Emergency Departments Patients.

INTRODUCTION: We tested the effect of a brief disposition process intervention on residents' time to disposition and emergency department (ED) length of stay (LOS) in high acuity ED patients. METHODS: This was a quasi-experimental study design in a single teaching hospital where ED residents are responsible for administrative bed requests for patients. Enrollment was performed for intervention and control groups on an even-odd day schedule. Inclusion criteria were ED patients triaged as Emergency Severity Index (ESI) 1 and 2. In the intervention group, the attending physician prompted the resident to make the disposition immediately after the evaluation of resuscitation patients. In the control group, the attending physicians did not intervene in the disposition process unless more than 2 hours passed without a disposition. Main outcomes were time to disposition and total ED LOS. RESULTS: A total of 104 patients were enrolled; 53 (51%) in the intervention group and 51 (49%) in the control group. After controlling for ESI and resident training year, mean disposition time was significantly shorter in the intervention group by 41.4 minutes (95% CI: 32.6-50.1). LOS was also shorter in the intervention group by 93.3 minutes (95% CI: 41.9-144.6). CONCLUSION: Prompting residents to enter administrative disposition orders in high acuity patients is associated with significant reduction in both time to disposition and ED LOS.

Asynchronous web-based learning, a practical method to enhance teaching in emergency medicine.

UNLABELLED: Abstract Objective: To compare medical knowledge acquisition among emergency medicine (EM) residents who attend weekly core content lectures with those absent but asynchronously viewing the same lectures in a Web-based electronic platform. SUBJECTS AND METHODS: During the study period all EM residents attending or absent from weekly educational conferences were given a quiz on the covered material. During Phase 1, absentees were not given supplemental educational content for missed lectures. During Phase 2, absentees were sent a link to an online multimedia module containing an audiovisual recording of the actual missed lecture with presentation slides. Scores between attendees and absentees during both phases were compared using a repeated-measures analysis to evaluate the effect of the supplemental online module on knowledge acquisition. RESULTS: Thirty-nine EM residents (equally distributed in postgraduate years 1-4) were studied during a 15-week period. Overall and after adjusting for sex and postgraduate year level, both lecture attendance (b=27; 95% confidence interval, 22-32; p<0.0001) and Web-based learning (b=32; 95% confidence interval, 26-37; p<0.0001) were associated with significant increases in test scores compared with residents who were absent and not receiving supplemental Web-based learning. Neither the self-perceived level of mastery with the lecture topic nor the amount of reported reading was found to be a predictor of test scores. CONCLUSIONS: In an EM residency program, asynchronous Web-based learning may result in medical knowledge acquisition similar to or better than attending traditional core content lectures. The percentage of curriculum delivery by asynchronous learning that may be used to achieve overall terminal learning objectives in medical knowledge acquisition requires further study.

Serious injuries related to the Segway® personal transporter: a case series.

STUDY OBJECTIVE: We describe a case series of emergency department (ED) visits for injuries related to the Segway® personal transporter. METHODS: This was a retrospective case review using a free-text search feature of an electronic ED medical record to identify patients arriving April 2005 through November 2008. Data were hand extracted from the record, and further information on admitted patients was obtained from the hospital trauma registry. RESULTS: Forty-one cases were included. The median age was 50 years, and 30 patients (73.2%) were women. Twenty-nine (70.7%) of the patients resided outside the District of Columbia, Maryland, and Virginia, and 32 (78.1%) arrived between June and September. Seven (17.1%) patients had documented helmet use. Ten (24.4%) were admitted. Four patients (40% of admitted patients) required admission to the ICU. CONCLUSION: The severity of trauma in this case series of patients injured by the use of the self-balancing personal transporter is significant. Further investigation into the risks of use, as well as the optimal length and type of training or practice, is warranted. A distinct E-code and Consumer Product Safety Commission's product code is needed to enable further investigation of injury risks for this mode of transportation.

Occupational asthma in the commercial fishing industry: a case series and review of the literature.

We present a case series of snow crab-induced occupational asthma (OA) from a fishing and processing vessel, followed by a review of OA in the commercial fishing industry. OA is typically caused from an IgE-mediated hypersensitivity reaction after respiratory exposure to aerosolized fish and shellfish proteins. It more commonly occurs due to crustaceans, but molluscs and fin fish are implicated as well. Standard medical therapy for asthma may be used acutely; however, steps to reduce atmospheric allergen concentrations in the workplace have proven to be preventive for this disease.

Incorporating evidence-based medicine into resident education: a CORD survey of faculty and resident expectations.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) invokes evidence-based medicine (EBM) principles through the practice-based learning core competency. The authors hypothesized that among a representative sample of emergency medicine (EM) residency programs, a wide variability in EBM resident training priorities, faculty expertise expectations, and curricula exists. OBJECTIVES: The primary objective was to obtain descriptive data regarding EBM practices and expectations from EM physician educators. Our secondary objective was to assess differences in EBM educational priorities among journal club directors compared with non-journal club directors. METHODS: A 19-question survey was developed by a group of recognized EBM curriculum innovators and then disseminated to Council of Emergency Medicine Residency Directors (CORD) conference participants, assessing their opinions regarding essential EBM skill sets and EBM curricular expectations for residents and faculty at their home institutions. The survey instrument also identified the degree of interest respondents had in receiving a free monthly EBM journal club curriculum. RESULTS: A total of 157 individuals registered for the conference, and 98 completed the survey. Seventy-seven (77% of respondents) were either residency program directors or assistant/associate program directors. The majority of participants were from university-based programs and in practice at least 5 years. Respondents reported the ability to identify flawed research (45%), apply research findings to patient care (43%), and comprehend research methodology (33%) as the most important resident skill sets. The majority of respondents reported no formal journal club or EBM curricula (75%) and do not utilize structured critical appraisal instruments (71%) when reviewing the literature. While journal club directors believed that resident learners' most important EBM skill is to identify secondary peer-reviewed resources, non-journal club directors identified residents' ability to distinguish significantly flawed research as the key skill to develop. Interest in receiving a free monthly EBM journal club curriculum was widely accepted (89%). CONCLUSIONS: Attaining EBM proficiency is an expected outcome of graduate medical education (GME) training, although the specific domains of anticipated expertise differ between faculty and residents. Few respondents currently use a formalized curriculum to guide the development of EBM skill sets. There appears to be a high level of interest in obtaining EBM journal club educational content in a structured format. Measuring the effects of providing journal club curriculum content in conjunction with other EBM interventions may warrant further investigation.

Measuring the opportunity loss of time spent boarding admitted patients in the emergency department: a multihospital analysis.

Emergency department (ED) crowding is an international crisis affecting the timeliness and quality of patient care. Boarding of admitted patients in the ED is recognized as a major contributor to ED crowding. The opportunity loss of this time is the benefit or value it could produce if it were used for something else. In crowded EDs, the typical alternative use of this time is to treat patients waiting to be seen. Various ED performance benchmarks related to inpatient boarding have been proposed, but they are not commonly reported and have yet to be evaluated to determine whether they correlate with the opportunity loss of time used for boarding. This study quantified several measures of ED boarding in a variety of hospital settings and looked for correlations between them and the opportunity loss of the time spent on boarding. In particular, average boarding time per admission was found to be easy to measure. Results revealed that it had a near-perfect linear correlation with opportunity loss. The opportunity loss of every 30 minutes of average boarding time equaled the time required to see 3.5 percent of the ED's daily census. For busy hospitals, the opportunity loss allowed sufficient time for staff to be able to see up to 36 additional patients per day. This correlation suggests that average boarding time per admission may be useful in evaluating efforts to reduce ED crowding and improve patient care.

Suspected methicillin-resistant Staphylococcus aureus infections at sea.

BACKGROUND: Methicillin-resistant Staphylococcus aureues (MRSA) has been increasingly reported as the cause of community acquired skin infections in individuals without established risk factors. MRSA infections have been reported in multiple settings, but not yet in the commercial maritime industry. OBJECTIVE: To evaluate the incidence of skin and soft tissue infections at sea over the past 5 years, and to see if there are trends in reported clinical features that suggest MRSA as the pathogen. METHOD: A retrospective chart review was undertaken of all cases reported from 2002 until 2006 to a single tele-medical advice service for ships at sea. Since microbiologic diagnosis is not feasible at sea, cases were evaluated for the following features which may suggest MRSA: the presence of pus, small abscess or furuncle, or suspected spider bite. RESULTS: From 2002 to 2006 the percentage of cases that were skin infections rose from 5.5 to 8.8%. In 2002, 36% had features consistent with MRSA infection and 74 % had them in 2006 ( p <.05). Across all years approximately 25% of cases required an I&D procedure at sea or upon arrival in port. CONCLUSIONS: The number of skin infections reported to a single tele-medical advice service has increased in the past five years. Furthermore, the proportion of cases with features common to MRSA infections doubled. Planners for health care at sea should consider stocking appropriate antibiotics for suspected MRSA and ensure medical officers are trained to perform I&D (incision and drainage) in order to treat this increasingly common skin infection.