"I don't want to be the squeaky wheel": Addressing bias as a leader in emergency medicine.

BACKGROUND: Implicit bias poses a barrier to inclusivity in the health care workforce and is detrimental to patient care. While previous studies have investigated knowledge and training gaps related to implicit bias, emergency medicine (EM) leaders' self-awareness and perspectives on bias have not been studied. Using art to prompt reflections on implicit bias, this qualitative study explores (1) the attitudes of leaders in EM toward implicit bias and (2) individual or structural barriers to navigating and addressing bias in the workplace. METHODS: Investigators facilitated an hour-long workshop in May 2022 for those with leadership positions in the Society for Academic Emergency Medicine (SAEM), a leading national EM organization, including 62 attending physicians, eight residents/fellows, and four medical students. The workshop utilized arts-based methods to generate a psychologically supportive space to lead conversations around implicit bias in EM. The session included time for individual reflection, where participants used an electronic platform to respond anonymously to questions regarding susceptibility, fears, barriers, and experiences surrounding bias. Two independent coders compiled, coded, and reviewed the responses using an exploratory constructivist approach. RESULTS: A total of 125 responses were analyzed. Four major themes emerged: (1) acceptance that bias exists; (2) individual barriers, including fear of negative reactions, often due to power dynamics between respondents and other members of the ED; (3) institutional barriers, such as insufficient funding and unprotected time committed to addressing bias; and (4) ambiguity about defining and prioritizing bias. CONCLUSIONS: This qualitative analysis of reflections from an arts-based workshop highlights perceived fears and barriers that may impact EM physicians' motivation and comfort in addressing bias. These results may help guide interventions to address individual and structural barriers to mitigating bias in the workplace.

Novel cricothyrotomy assessment tool for attending physicians: A multicenter study of an error avoidance checklist.

BACKGROUND: This study used existing literature and expert feedback to develop and pilot a novel error-avoidance checklist tool for cricothyrotomy in attending physicians. Prior literature has not focused on expert cricothyrotomy performance. While published checklists teach a specific procedural method, ideal for novice learners, this may hinder expert learners. OBJECTIVES: We endeavored to create a succinct error-avoidance checklist for cricothyrotomy. We hypothesized that such a checklist would prove feasible and acceptable to attending physicians. METHODS: This is a multicenter prospective checklist creation, evaluation, and feasibility study. Multiple experts pursued an iterative process to reach consensus on a 7-item error-avoidance checklist. The checklist was trialed for feasibility in pilot sessions at two sites by 45 attending emergency physicians who used the checklist for peer performance assessment and provided feedback. RESULTS: During the pilot implementation, 94% of respondents completed the procedure within the allotted 120 s. Greater than 85% of respondents agreed that four of the five procedural errors on the checklist were very or somewhat critical to avoid, including cutting >2 cm from midline, creating a false passage, failing to continuously maintain an object in the trachea, and injuring oneself during the procedure. Only 66% of participants felt severing the cricoid cartilage was critical. Successful breath administration and time under 120 s were critical for 100% and 95% of participants, respectively. The checklist was rated "easy" or "very easy" to use by 93% of participants, and 95% found this checklist reasonable for evaluating attending physicians. CONCLUSIONS: We present the multicenter development and implementation of a novel error-avoidance checklist tool for use in expert cricothyrotomy performance. Attending emergency medicine (EM) physicians rated our tool easy to use and agreed that most of the proposed errors were critical. Participants overwhelmingly agreed this tool would be reasonable for evaluation of cricothyrotomy performance among attending EM physicians.

When the Learner Is the Expert: A Simulation-Based Curriculum for Emergency Medicine Faculty.

Emergency physicians supervise residents performing rare clinical procedures, but they infrequently perform those procedures independently. Simulation offers a forum to practice procedural skills, but simulation labs often target resident learners, and barriers exist to faculty as learners in simulation-based training. Simulation-based curricula focused on improving emergency medicine (EM) faculty's rare procedure skills were not discovered on review of published literature. Our objective was to create a sustainable, simulation-based faculty education curriculum for rare procedural skills in EM. Between 2012 and 2019, most EM teaching faculty at a single, urban, Level 1 trauma center completed an annual two-hour simulation-based rare procedure lab with small-group learning and guided hands-on instruction, covering 30 different procedural education sessions for faculty learners. A questionnaire administered before and after each session assessed EM faculty physicians' self-perceived ability to perform these rare procedures. Participants' self-reported confidence in their performance improved for all procedures, regardless of prior procedural experience. Faculty participation was initially mandatory, but is now voluntary. Diverse strategies were used to address barriers in this learner group including eliciting learner feedback, offering continuing medical education credits, gradual roll-out of checklist assessments, and welcoming expertise of faculty leaders from EM and other specialties and professions. Participants perceived training to be most helpful for the most rarely-encountered clinical procedures. Similar curricula could be implemented with minimal risk at other institutions.

Alternative Markers of Performance in Simulation: Where We Are and Where We Need To Go.

This article on alternative markers of performance in simulation is the product of a session held during the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." There is a dearth of research on the use of performance markers other than checklists, holistic ratings, and behaviorally anchored rating scales in the simulation environment. Through literature review, group discussion, and consultation with experts prior to the conference, the working group defined five topics for discussion: 1) establishing a working definition for alternative markers of performance, 2) defining goals for using alternative performance markers, 3) implications for measurement when using alternative markers, identifying practical concerns related to the use of alternative performance markers, and 5) identifying potential for alternative markers of performance to validate simulation scenarios. Five research propositions also emerged and are summarized.

Assessing the Informed Consent Skills of Emergency Medicine Resident Physicians.

BACKGROUND: Informed consent (IC) is an essential component of shared medical decision making between patients and providers in emergency medicine (EM). The basic components required for adequate consent are well described, yet little is published investigating whether EM residents demonstrate adequate IC skills. OBJECTIVE: The objectives were to assess the ability of EM residents to obtain IC for an invasive emergency procedure using a novel assessment tool and to assess reliability and validity of the tool. METHODS: This was an observational study in which participants were initially blinded to the primary objectives of the study. Each participant conducted a video-recorded history and physical examination with a standardized patient, requiring tube thoracostomy due to spontaneous pneumothorax. Two faculty EM physicians independently reviewed the videos and evaluated the participants' IC skills. First, they gave an overall impression of whether IC was obtained; they then evaluated the participants using a 30-point scoring tool based on the five elements of IC (decision-making capacity, disclosure, voluntariness, understanding, and physician recommendation). Upon all participants' case completion, we revealed the primary objectives and gave participants the option to withdraw from the study. Descriptive statistics and kappa coefficient were generated from the data collected. RESULTS: Twenty-two residents completed the study. None withdrew from the study after the primary objectives were revealed. Twenty residents (91%) obtained adequate IC based on both reviewers' overall impression. One disagreement occurred between reviewers (κ = 0.64). The mean IC score on a 30-point scale was 18.5 ± 0.5. CONCLUSIONS: In a simulated setting, most EM residents at this training program possess the knowledge and skills necessary to obtain IC prior to an invasive procedure. The assessment tool appears reliable and demonstrates construct validity.

The use of simulation in the development of individual cognitive expertise in emergency medicine.

This consensus group from the 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise," held in Washington, DC, May 28, 2008, focused on the use of simulation for the development of individual expertise in emergency medicine (EM). Methodologically sound qualitative and quantitative research will be needed to illuminate, refine, and test hypotheses in this area. The discussion focused around six primary topics: the use of simulation to study the behavior of experts, improving the overall competence of clinicians in the shortest time possible, optimizing teaching strategies within the simulation environment, using simulation to diagnose and remediate performance problems, and transferring learning to the real-world environment. Continued collaboration between academic communities that include medicine, cognitive psychology, and education will be required to answer these questions.

Simulator training improves fiber-optic intubation proficiency among emergency medicine residents.

OBJECTIVES: The objective was to observe how a workshop using a virtual reality bronchoscopy simulator and computer-based tutorial affects emergency medicine (EM) resident skill in fiber-optic intubation. METHODS: In this observational before-and-after study, EM resident performance on three simulated pediatric difficult airway cases was observed before and after a short computer-based tutorial and 10 minutes of self-directed practice. The primary outcome was the total time required to place the endotracheal tube (ETT), secondary outcomes included the number of endoscope collisions with mucosa, and a calculated efficiency score measuring the proportion of time participants spent looking at correct central airway structures. Nonparametric Wilcoxon signed rank tests compared performance on the first versus the repeat attempt for each of the three simulated cases. Participants were surveyed regarding their assessments of the experience. RESULTS: Significant decreases in median procedure times and number of scope collisions and increases in median efficiency scores were seen for Cases 1 and 2. Case 3 showed no significant changes in outcomes between first and repeat attempts. Participants positively assessed the training and felt that its use would improve clinical practice. CONCLUSIONS: Participation in a simulation-based fiber-optic intubation skill workshop can improve fiber-optic intubation performance rapidly among EM residents. Future research should evaluate if this enhanced performance translates to improved clinical performance in the emergency department (ED).

Initial test of emergency procedure performance in temporary negative pressure isolation by using simulation technologies.

STUDY OBJECTIVE: The potential of infectious disease spread in diseases such as tuberculosis, infectious disease epidemic such as avian flu and the threat of terrorism with agents capable of airborne transmission have focused attention on the need for increased surge capacity for patient isolation. Total negative pressure isolation using portable bioisolation tents may provide a solution. The study assesses the ability of health care workers to perform emergency procedures in this environment. METHODS: Physician performance in completing predetermined critical actions in 5 emergency care scenarios inside and outside of a bioisolation tent ("setting") was studied in an advanced medical simulation laboratory. By design, no pretraining of subjects about total negative pressure isolation use occurred. Impact of setting on time to completion of predetermined critical actions was the primary outcome measured. Secondary variables studied included impact of study groups, scenarios, and run order (inside or outside of the tent first). Subjective assessments were obtained through questionnaires. RESULTS: Four teams of 3 physicians completed 5 emergency patient care scenarios during 2 4-hour sessions. Mean time to completion of critical actions was for tent/no tent 298 seconds/284 seconds (P=.69, one way ANOVA), respectively. Mean time to completion for first versus second performance of a scenario in the crossover design was 338 versus 243 (P=.01). The mean score for self-assessed performance did not differ according to setting. CONCLUSION: The ability of physicians naive to the total negative pressure isolation environment to perform emergency medical critical actions was not significantly degraded by a simulated bioisolation tent patient care environment.

Characteristics and temporal trends of "left before being seen" visits in US emergency departments, 1995-2002.

The purpose of this study was to describe nationally representative characteristics and temporal trends in "left before being seen" (LBBS) visits in US emergency departments (EDs). The ED portion of the federal National Hospital Ambulatory Medical Care Survey, 1995-2002, was analyzed. Of the 810.6 million ED visits during the 8-year study period, an estimated 11.4 million (1.41%, 95% confidence interval [CI] 1.30-1.52) had an LBBS disposition. The number and proportion of LBBS visits have increased over time, from 1.1 million visits in 1995 (1.15%, 95% CI 0.95-1.35) to 2.1 million visits in 2002 (1.92%, 95% CI 1.67-2.17). LBBS patients were more likely to be younger, non-White, Hispanic, urban, and uninsured compared to non-LBBS patients. The number and proportion of LBBS visits have increased over time. LBBS visits disproportionately affect vulnerable populations. These findings suggest that recent strains on the US ED system are adversely affecting healthcare quality and access.

A comprehensive medical simulation education curriculum for emergency medicine residents.

Medical simulation allows trainees to experience realistic patient situations without exposing patients to the risks inherent in trainee learning and is adaptable to situations involving widely varying clinical content. Although medical simulation is becoming more widely used in medical education, it is typically used as a complement to existing educational strategies. Our approach, which involved a complete curriculum redesign to create a fully integrated medical simulation model with an "all at once" implementation, represents a significant departure from conventional graduate medical education models. We applied adult learning principles, medical simulation learning theory, and standardized national curriculum requirements to create an innovative set of simulation-based modules for integration into our emergency medicine residency curriculum. Here we describe the development of our simulation modules using various simulation technologies, their implementation, and our experiences during the first year of integration.