Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures.

PURPOSE: Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures. METHODS: We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment. RESULTS: MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures. CONCLUSIONS: MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

Cell-targeted PD-1 agonists that mimic PD-L1 are potent T cell inhibitors.

The PD-1/PD-L1 pathway is a key immune checkpoint that regulates T cell activation. There is strong rationale to develop PD-1 agonists as therapeutics against autoimmunity, but progress in this area has been limited. Here, we generated T cell receptor (TCR) targeting, PD-1 agonist bispecifics called ImmTAAI molecules that mimic the ability of PD-L1 to facilitate the colocalization of PD-1 with the TCR complex at the target cell-T cell interface. PD-1 agonist ImmTAAI molecules specifically bound to target cells and were highly effective in activating the PD-1 receptor on interacting T cells to achieve immune suppression. Potent PD-1 antibody ImmTAAI molecules closely mimicked the mechanism of action of endogenously expressed PD-L1 in their localization to the target cell-T cell interface, inhibition of proximal TCR signaling events, and suppression of T cell function. At picomolar concentrations, these bispecifics suppressed cytokine production and inhibited CD8+ T cell-mediated cytotoxicity in vitro. Crucially, in soluble form, the PD-1 ImmTAAI molecules were inactive and, hence, could avoid systemic immunosuppression. This study outlines a promising new route to generate more effective, potent, tissue-targeted PD-1 agonists that can inhibit T cell function locally with the potential to treat autoimmune and chronic inflammatory diseases of high unmet need.

Tension Hemopneumothorax in the Setting of Mechanical CPR during Prehospital Cardiac Arrest.

INTRODUCTION: There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

An Innovative Inexpensive Portable Pulmonary Edema Intubation Simulator.

Audience: This pulmonary edema intubation simulator is designed to instruct paramedics, medical students, emergency medicine residents, emergency medical services fellows, and attending physicians. Introduction: Acute pulmonary edema results in respiratory distress and may require endotracheal intubation. On occasion, pulmonary edema can result in copious amounts of pink, frothy sputum in the airway, complicating intubation by hindering the intubator's view. Although airway management skills are frequently taught in a simulation setting, the frothy sputum seen in acute pulmonary edema is not easily replicated. Several articles have been published in reference to simulation model development for difficult airway management due to emesis obscuring the view of the glottic opening.1,2 There is, however, a scarcity of literature describing pulmonary edema airway management simulator construction, with only one other model identified on our review of the literature, which utilized cadavers, baking soda, vinegar, and red food coloring.3In our simulation center, we teach a variety of learners who may be called upon to care for patients in acute pulmonary edema in their clinical practice, including medical students, residents from various specialties, practicing physicians and pre-hospital personnel. We wished to familiarize these trainees with the challenges associated with intubating patients with significant frothy secretions within the hypopharynx by developing a dynamic, realistic, portable and inexpensive model to simulate the airway manifestations associated with acute pulmonary edema. Educational Objectives: By the end of the session, learners will be able to: 1. Discuss the pathophysiology of, and immediate stabilization management steps for, acute cardiogenic pulmonary edema. 2. List the indications, contraindications, and risks associated with intubating a patient with acute cardiogenic pulmonary edema. 3. Demonstrate effective communication and teamwork skills to manage the airway of a simulated patient in respiratory distress due to acute cardiogenic pulmonary edema. 4. Successfully and safely intubate a simulated patient with a difficult airway due to visual obstruction from frothy pulmonary edema secretions. Educational Methods: We adapted a previously owned commercial airway task trainer simulator using an aquarium pump, tubing, an air stone, and an endotracheal tube. Pulmonary edema solution was created with glycerin, dish soap, (distilled) water and simulated blood. The solution and air stone are placed in one of the simulator's lungs. Subsequently, turning on the aquarium air pump generates simulated pulmonary edema within the lung itself, which froths up and out of the trachea and into the hypopharynx, mimicking the gross pathophysiological process.Learners complete pre-reading assignments prior to attending a small group didactic-practical session. Following a brief case discussion, led by the instructor, about the management of a patient in respiratory distress due to acute pulmonary edema, learners transition to a hands-on experience intubating the pulmonary edema manikin with the use of direct and video laryngoscopy, aided by a large bore Yankauer for suction and a bougie. Depending on the training level of the learners, the instructor will use judgment and may elect to demonstrate intubating the manikin using video laryngoscopy before the learners attempt the procedure. The authors recommend that the instructor use video laryngoscopy for teaching purposes so that all learners can visualize the intubation techniques (Yankauer, bougie) in the context of copious pulmonary edema fluid obscuring the glottis and surrounding airway structures.The practical portion is dedicated solely to intubation, with one learner assuming the role of the intubator and another assuming the role of a respiratory therapist, while the other leaners observe and/or provide real-time feedback. Learners rotate through these aforementioned roles. To maintain efficiency of the simulation session and maximize the number of intubation attempts each learner receives, the session is designed to begin with a case discussion about the management of a patient with acute pulmonary edema up through the timepoint of successful intubation, followed by a practical portion where the learners perform multiple intubations on the innovative pulmonary edema airway management task trainer. During the practical portion, real-time constructive feedback is given to each learner. At the end of the simulation session, a debriefing is completed.This model can be used to address several ACGME Emergency Medicine Milestones,4 specifically Milestone 9 (General Approach to Procedures - PC9), Level 4 (Performs indicated procedures on any patients with challenging features [eg, poorly identifiable landmarks, at extremes of age or with comorbid conditions], and also Milestone 10 (Airway Management - PC10), Level 4 (Performs airway management in any circumstance taking steps to avoid potential complications). This model can also be used to address ACGME Emergency Medical Services Milestones,5 specifically "Procedures Performed in the Pre-hospital Environment - Patient Care," Level 4 (Performs indicated procedures on any patients, including those with challenging features (eg, poorly identifiable landmarks, at extremes of age or with co-morbid conditions). Research Methods: At the conclusion of the session, verbal feedback is sought from each participant by the instructor: How helpful did you find this simulation experience for learning about airway management in patients with acute pulmonary edema? Did you find the pulmonary edema intubation model to be realistic? Following this simulation experience, how would you rate your personal confidence in terms of managing an airway complicated by acute pulmonary edema? Results: For under fifty dollars, we have been able to adapt one of our previously owned airway management task trainers to build a pulmonary edema intubation simulator. It has been used in a wide variety of settings for different learners, including medical students, residents, fellows and pre-hospital providers. Since the 2016-2017 academic year, two hundred and twenty-six emergency medicine residents (PGY1, PGY2, and PGY3) have successfully used our innovative pulmonary edema airway management task trainer. Qualitatively it has been well-received and felt to be realistic by both our learners and instructors based on verbal feedback received following the simulation sessions. Discussion: We are aware of only one prior report attempting to simulate the frothy sputum seen in acute pulmonary edema. Lipe, et al., described mixing baking soda, vinegar and red food coloring in a cadaver hypopharynx just prior to an intubation attempt.3 This combination creates a fizzy frothy solution that fills the hypopharynx and pushes proximally into the mouth. This model is limited by design, however, in that it was unable to mimic a true in vivo appearance of a continuous flow of pulmonary edema-like fluid from the glottic opening. We feel we were able to overcome this limitation and also believe it is important for the leaner to experience the challenges of intubation when faced with copious secretions originating from within the lower airways. Our model generates the froth from within the lung itself, and it migrates proximally, similar to the dynamic pathophysiological process that occurs in vivo. Since we did not compare these two techniques, it is unknown which is more realistic. Neither the Lipe cadaver model nor our manikin model has been validated in terms of the realistic nature of the simulated pulmonary edema fluid. This would be ripe for future investigation. Nonetheless, informal qualitative feedback from our learners and instructors has been positive.Resident use of our innovative dynamic pulmonary edema airway management task trainer has been incorporated into our Emergency Medicine residency and Emergency Medical Services fellowship Clinical Competency Committee discussions with respect to ACGME Milestone satisfaction. Our model addresses level 4 of Emergency Medicine Milestone 9 (General Approach to Procedures) and Milestone 10 (Airway Management). Additionally, level 4 of Emergency Medical Services Milestone 2 (Procedures Performed in the Pre-hospital Environment - Patient Care) is addressed. Incorporating successful intubation of the dynamic pulmonary edema airway management task trainer has provided the EM and EMS faculty with a more objective measure by which to score the aforementioned milestones during the mid-year and year-end Clinical Competency Committee meetings.Overall, this innovation has met our objectives well. We have added this model to our library of more complicated airway management scenarios, such as vomitus and aspiration. Our emergency medicine residency program hosts a version of the difficult airway course and includes this pulmonary edema simulation station as part of that course. The model is very portable, allowing us to transport it to different sites for use. It is inexpensive, costing less than $50 to construct. Finally, the design is readily adaptable to any standard airway training manikin that has a simulated hollow lung with a detachable connection to a conduit representing a bronchus, which has a direct connection with a simulated trachea into which an endotracheal tube can physically be passed. Topics: Airway management, difficult airway, intubation, obstructed airway, pulmonary edema, video laryngoscopy, visual obstruction.

A survey of simulation fellowship programs.

BACKGROUND: A number of specialized educational programs (i.e., simulation fellowships) have been developed, but their characteristics are not well known. OBJECTIVE: We studied the characteristics of existing simulation fellowship programs. METHODS: Fellowships were identified and characteristics determined from public sources and direct survey. RESULTS: Seventeen fellowships were identified. The sponsoring academic unit was emergency medicine in 53%, pediatric emergency medicine in 7%, urology in 7%, emergency medicine/anesthesiology in 13%, and interdisciplinary units in 20%. Fifty-nine percent were open to emergency medicine residency graduates, and 12% were open to either anesthesia or emergency medicine graduates, or 12% to physician graduates of any specialty. One fellowship was open to pediatric emergency medicine graduates only and another specifically to surgically trained physicians. Seventy-eight percent indicated that fellows were required to work clinically as part of the fellowship, averaging 19 hours per week. Twenty-seven percent of fellowships were 1 year in length and 13% were 2 years. Common (47%) was the option of a 1- or 2-year fellowship, with those in the 2-year track earning a graduate degree or certificate. Most programs accepted a single fellow each year, and some accepted either one or two. Fellowships reported a high fill rate. CONCLUSIONS: The 17 identified fellowship programs differed greatly in length, sponsoring academic unit, and prerequisites. The majority require their fellows to provide clinical service. Fellowships reported a high fill rate, suggesting substantial interest in simulation among current residents.

A multicenter study of the family educational rights and privacy act and the standardized letter of recommendation: impact on emergency medicine residency applicant and faculty behaviors.

BACKGROUND: Residency applicants have the right to see letters of recommendation written on their behalf. It is not known whether applicants are affected by waiving this right. OBJECTIVES: Our multicenter study assessed how frequently residency applicants waived their FERPA rights to view their letters of recommendation, and whether this affected the ratings they were given by faculty. METHODS: We reviewed all ERAS-submitted letters of recommendation to 14 ACGME-accredited programs in 2006-2007. We collected ERAS ID, program name, FERPA declaration, standardized letter of recommendation (SLOR) use, and SLOR Global Assessment ranking. The percentage of applicants who waived their FERPA rights was determined. Chi-square tests of independence assessed whether applicants' decision to waive their FERPA rights was associated with their SLOR Global Assessment. RESULTS: We examined 1776 applications containing 6424 letters of recommendations. Of 2736 letters that specified a Global Assessment, 2550 (93%) applicants waived their FERPA rights, while 186 did not. Of the applicants who chose not to waive their rights, 45.6% received a ranking of Outstanding, 35.5% Excellent, 18.3% Very Good, and 1.6% Good. Of applicants who waived their FERPA rights, 35.1% received a ranking of Outstanding, 49.6% Excellent, 13.7% Very Good, and 1.6% Good. Applicants who did not waive their FERPA rights were more likely to receive an Outstanding Assessment (P  =  .003). CONCLUSIONS: The majority (93%) of residency applicants waived their FERPA rights. Those who did not waive their rights had a statistically higher chance of receiving an Outstanding Assessment than those who did.

The Family Education Rights and Privacy Act's impact on residency applicant behavior and recommendations: a pilot study.

BACKGROUND: The Family Education Rights and Privacy Act (FERPA) provides residency applicants the right to view letters of recommendation. Applicants must indicate whether they waive this right. OBJECTIVES: We determined how frequently applicants to an emergency medicine residency program waived the right to view letters of recommendation and whether such decisions impacted the letters' contents. METHODS: A retrospective, observational review of all letters of recommendation submitted to an emergency medicine residency program in 2005-2006 determined applicants' FERPA declaration, use of the Standardized Letter of Recommendation (SLOR), and the SLOR Global Assessment ranking. The percentage of applicants waiving FERPA rights was determined. Chi-squared tests of independence assessed whether applicants' decisions influenced the SLOR Global Assessment. All statistical analysis used a 5% level of significance. RESULTS: There were 367 applications received; 1120 letters of recommendation accompanied 264 US medical school applications, 449 (40%) using the SLOR format. Of the SLORs, only 6% stated that the applicant did not waive his FERPA right; 426 SLORs included a Global Assessment. Of those waiving FERPA rights, 30% were ranked "Outstanding," 50% "Excellent," 17% "Very Good," and 3% "Good." For those not waiving FERPA rights, 35% were ranked as "Outstanding," 46% "Excellent," 15% "Very Good," and 4% "Good." There was no statistical difference in Global Assessment ranking between applicants who waived FERPA rights and those who did not (p = 0.934). CONCLUSIONS: In this pilot study, the vast majority of applicants waived FERPA rights to view letters of recommendation. The applicants' decisions did not influence their SLOR Global Assessment ranking.

Evaluation of prehospital use of furosemide in patients with respiratory distress.

OBJECTIVE: To evaluate the appropriateness of prehospital use of furosemide. METHODS: All patients over 18 years old receiving prehopsital furosemide were retrospectively identified, and cases were matched to subsequent hospital records. Data collected included ED and hospital primary and secondary diagnoses, brain-type natriuretic peptide (BNP) levels and final disposition. Furosemide was considered appropriate when the primary or secondary ED or hospital diagnoses included congestive heart failure (CHF) or pulmonary edema, or the BNP was > 400. Furosemide was considered inappropriate when none of the diagnoses included CHF, when the BNP was < 200, or when an order for IV fluid hydration was given. Furosemide was considered potentially harmful when the diagnoses included sepsis, dehydration or pneumonia, without a diagnosis of CHF or BNP > 400. RESULTS: Of the 144 included patients, a primary or secondary diagnosis of CHF was reported in 42% and 17% patients, respectively. The initial BNP was > 400 in 44% of the 120 patients in which this lab test was obtained. Sixty patients (42%) did not receive a diagnosis of CHF, 30 (25%) patients had a BNP < 200, and 33 (23%) had an order for IV fluid hydration. A diagnosis of sepsis, dehydration or pneumonia without a diagnosis of CHF or a BNP > 400 occurred in 17% of patients. Seven of the 9 deaths did not receive a diagnosis of CHF. Furosemide was considered appropriate in 58%, inappropriate in 42% and potentially harmful in 17% of patients. CONCLUSIONS: In this EMS system, prehospital furosemide was frequently administered to patients in whom its use was considered inappropriate, and not uncommonly to patients when it was considered potentially harmful. EMS systems should reconsider the appropriateness of prehospital diuretic use.

General competencies are intrinsic to emergency medicine training: a multicenter study.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS: This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS: Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS: EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.

The effect of a new emergency medicine residency program on patient length of stay in a community hospital emergency department.

OBJECTIVES: It is not clear how emergency medicine residents affect emergency department (ED) efficiency. The objective of this study was to determine whether a new emergency medicine residency program affected the length of stay (LOS) of patients in a community hospital ED. METHODS: A before-and-after observational study was conducted during a one-year period prior to, and for three years after, the start of a new residency. An additional year's worth of data were collected during the fifth year after the residency started. Patients were excluded if their LOS was less than 30 minutes and they were admitted directly to the hospital. Explanatory variables included scheduled resident and student hours/day; scheduled faculty hours/day; nursing plus clerk hours/day; patients/day; ambulances/day; and admissions/day. The data were analyzed using descriptive and correlation statistics and regression analysis. RESULTS: Average patient LOS prior to the residency was 122.9 minutes. During the first year of residency, it was 126.6 minutes; second year, 129.9 minutes; third year, 158.9 minutes; and fifth year, 162.4 minutes. There was a positive correlation between LOS and third-postgraduate-year resident (PGY-3) hours (rho = 0.43), and between LOS and PGY-3 hours/patients/day (rho = 0.42). All other correlations were poor (rho < 0.4). CONCLUSIONS: In this ED, there was a weak, positive correlation between ED patient length of stay and the presence of PGY-3 emergency medicine residents.