A survey of handoff practices in emergency medicine.

This study aimed to assess practices in emergency department (ED) handoffs as perceived by emergency medicine (EM) residency program directors and other senior-level faculty and to determine if there are deficits in resident handoff training. This cross-sectional survey study was guided by the Kern model for medical curriculum development. A 12-member Council of Emergency Medicine Residency Directors (CORD) Transitions in Care task force of EM physicians performed these steps and constructed a survey. The survey was distributed to the CORD listserv. There were 147 responses to the anonymous survey, which were collected using an online tool. At least 41% of the 158 American College of Graduate Medical Education EM residency programs were represented. More than half (56.6%) of responding EM physicians reported that their ED did not use a standardized handoff. There also exists a dearth of formal handoff training and handoff proficiency assessments for EM residents.

An algorithm for transition of care in the emergency department.

OBJECTIVES: The objective of this study is to present an algorithm for improving the safety and effectiveness of transitions of care (ToC) in the emergency department (ED). METHODS: This project was undertaken by the Council of Emergency Medicine Residency Directors (CORD) Transitions of Care Task Force and guided by the six-step Kern model for curriculum development. A targeted needs assessment in survey form was designed using a modified Delphi method among the CORD ToC Task Force. The survey was designed for four subgroups within the ED: emergency medicine (EM) residency program directors, EM academic chairpersons, EM residents, and EM nurses. Members from nationally recognized EM organizations assisted in the development of each respective survey, including the Academic Affairs Committee of the American College of Emergency Physicians, the leadership of the Emergency Medicine Residents' Association (EMRA), and the leadership of Emergency Nurses Association (ENA). The surveys contained questions about current handoff practices and asked participants to rate the importance of key logistical and informational parameters within a ToC. Survey validity was achieved through content validity, item analysis, format familiarity, and electronic scoring. The surveys of program directors and academic chairpersons were distributed through the CORD listserv, the resident survey was distributed via EMRA correspondents, and the nurse survey was distributed through the ENA listserv. Following survey collection, the ToC Task Force convened and used the data to assess handoff practices and deficiencies. The Task Force developed recommendations for a ToC algorithm that was then piloted by medical educators in their institutions. These educators shared their experiences with senior department members in a phone interview. This informant feedback was used to address deficiencies in the algorithm and finalize the recommendations from the CORD Task Force. RESULTS: The surveys for program directors (n = 147), academic chairpersons (n = 99), residents (n = 194), and nurses (n = 902) were electronically scored. Handoff education in the form of structured workshops or classes was typically not offered, with only 10.9% of residents and 9.0% of nurses reporting that they received such training. The majority (93.9%) of EM academic chairpersons stated that assessments of handoff proficiency were not conducted within their programs. Computerized handoff was the most popular assistive tool among all surveyed groups. Handoff parameters that were rated as "important" and "extremely important" included uninterrupted time and space to perform the handoff, identification of "high-risk" handoffs, and the opportunity for questions and clarification from the handoff recipient. The developed handoff algorithm consisted of five steps: 1) setting the stage, 2) assembling the team, 3) identification of high-risk patients, 4) shift sign-out, and 5) closing the loop. CONCLUSIONS: The authors present specific guidelines for an algorithm-based approach to transitioning care within the ED. This algorithm is based on surveys of perceived deficiencies and emphasizes informational and logistical parameters within a ToC. Standardizing the process of the ToC may allow for future research on the link between effective ToC and patient outcomes.

No diversion in Western Massachusetts.

BACKGROUND: Massachusetts (MA) instituted a moratorium on ambulance diversion ("No Diversion") on January 1, 2009. STUDY OBJECTIVES: Determine whether No Diversion was associated with changes in Emergency Department (ED) throughput measures. DESIGN: Comparison of three 3-month periods. Period 1: 1 year prior (January-March 2008); Period 2: 3 months prior (October-December 2008); Period 3: 3 months after (January-March 2009). SETTING: Seven EDs in Western MA; two - including the only Level I Trauma Center - were "high" diversion (≥562 h/year) and 5 were "low" diversion (≤260 h/year). For "all," "high" diversion and "low" diversion ED groups, we compared mean monthly throughput measures, including: 1) total volume, 2) number of admissions, 3) number of elopements, 4) length of stay for all, admitted and discharged patients. Mean absolute and percent changes were estimated using mixed-effects regression analysis. Linear mixed models were run for "all," "high" and "low" diversion EDs comparing means of changes between periods. Results are presented as mean change per month in number and percent, and 95% confidence intervals were calculated. We specified that a clinically significant effect of No Diversion had to meet two criteria: 1) there was a consistent difference in the means for both the Period 1 vs. Period 3 comparison and the Period 2 vs. Period 3 comparison, and 2) both comparisons had to achieve statistical significance at p ≤ 0.01. RESULTS: According to pre-determined criteria, no clinically significant changes were found in any ED group in mean monthly volume, admissions, elopements, or length-of-stay for any patient disposition group. CONCLUSION: No Diversion was not associated with significant changes in throughput measures in "all," "high" diversion and "low" diversion EDs.

A rapid upward shift of a forest ecotone during 40 years of warming in the Green Mountains of Vermont.

Detecting latitudinal range shifts of forest trees in response to recent climate change is difficult because of slow demographic rates and limited dispersal but may be facilitated by spatially compressed climatic zones along elevation gradients in montane environments. We resurveyed forest plots established in 1964 along elevation transects in the Green Mountains (Vermont) to examine whether a shift had occurred in the location of the northern hardwood-boreal forest ecotone (NBE) from 1964 to 2004. We found a 19% increase in dominance of northern hardwoods from 70% in 1964 to 89% in 2004 in the lower half of the NBE. This shift was driven by a decrease (up to 76%) in boreal and increase (up to 16%) in northern hardwood basal area within the lower portions of the ecotone. We used aerial photographs and satellite imagery to estimate a 91- to 119-m upslope shift in the upper limits of the NBE from 1962 to 2005. The upward shift is consistent with regional climatic change during the same period; interpolating climate data to the NBE showed a 1.1 degrees C increase in annual temperature, which would predict a 208-m upslope movement of the ecotone, along with a 34% increase in precipitation. The rapid upward movement of the NBE indicates little inertia to climatically induced range shifts in montane forests; the upslope shift may have been accelerated by high turnover in canopy trees that provided opportunities for ingrowth of lower elevation species. Our results indicate that high-elevation forests may be jeopardized by climate change sooner than anticipated.