Focused Teaching Improves Medical Student Professionalism and Data Gathering Skills in the Emergency Department.

INTRODUCTION:  Leaders in medical education have developed milestones and core competencies in an attempt to ensure that relational skills, such as communication and professionalism, are emphasized in addition to the usual skills of medical knowledge, data gathering, and emergency stabilization during students' emergency medicine (EM) medical education. Providers facile in each of these areas have better patient outcomes, patient experiences, and decreased incidence of malpractice cases. The authors attempted to demonstrate that by deliberate teaching of these skills during an EM medical student clerkship, students could significantly improve their clinical performance. METHODS:  This prospective, randomized, single-blinded cohort study was performed at an academic, tertiary, urban ED to investigate the effects of a one-on-one preceptor shift on the clinical performance of fourth-year medical students. Students were randomized into two groups and assessed by pre- and post-intervention objective structured clinical encounters (OSCEs) with standardized patients (SPs) at weeks one and three. A crossover design was employed so that students in the control group participated in a preceptor shift after their second OSCE. Measurements were based on a five-point Likert scale assessment linked to early EM milestones as defined by the Accreditation Council on Graduate Medical Education (ACGME).  Results: The mean improvement in total overall score was significantly greater in the intervention group: 4.31 versus 2.57 (Cohen's d = 0.57, p = 0.029). When each milestone was assessed individually, students in the intervention group improved significantly in data gathering (Cohen's d = 0.47, p = 0.048) and professionalism (Cohen's d = 0.66, p = 0.011). There was a nonstatistically significant improvement for the intervention compared to control group in emergency management and communication skills. There was no improvement for either group in medical knowledge. CONCLUSION:  A one-on-one preceptor shift can result in a statistically significant improvement in data gathering and professionalism skills as measured by OSCEs.

The effect of adding a second helicopter on trauma-related mortality in a county-based trauma system.

OBJECTIVES: Despite conflicting evidence regarding its efficacy, helicopter transportation of trauma victims is widespread. We determined the effect of adding a second helicopter to a countywide emergency medicine system on trauma-related mortality. METHODS: A before-and-after trial design was used to compare hospital mortality before and after introducing a second helicopter to the eastern end of Suffolk County, New York, in 2001 aimed at reducing transport times to the regional trauma center. Outcomes before and after introducing the second helicopter were compared with parametric or nonparametric tests as appropriate. RESULTS: A total of 1,551 trauma patients were included in this study from June 1996 to May 2006, with 705 in the single-helicopter period and 846 in the two-helicopter period. Mean ages, gender distributions, and mean Injury Severity Scores (ISSs) were similar between groups. Total mortality significantly decreased after the addition of the second helicopter (16.2% before vs. 11.9% after; p = 0.02). CONCLUSIONS: Introduction of a second helicopter to the east end of Long Island was associated with a significant reduction in the total trauma mortality.

Emergency department activation of an interventional cardiology team reduces door-to-balloon times in ST-segment-elevation myocardial infarction.

STUDY OBJECTIVE: American Heart Association/American College of Cardiology guidelines recommend door-to-balloon times of fewer than 90 minutes in patients with acute ST-segment-elevation myocardial infarction. We hypothesized that immediate activation of an interventional cardiology team (code H) would reduce the time to percutaneous coronary intervention by 1 hour and increase the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival. METHODS: Study design was a before-and-after trial in an academic suburban emergency department (ED) with a certified cardiac catheterization laboratory. Subjects were a consecutive sample of patients presenting to the ED with ST-segment-elevation myocardial infarction evident on the initial ECG. Patients without chest pain and refusing catheterization were excluded. The intervention was the use of a central paging system for activation of the interventional cardiology team (attending physician, fellow, nurse, technician) by emergency physicians in patients presenting to the ED with ST-segment-elevation myocardial infarction. Measures were demographic and clinical information collected with standardized data collection forms. Outcomes were door-to-balloon times and the proportion of patients undergoing percutaneous coronary intervention within 90 minutes of arrival. Groups were compared with chi2 and t tests. RESULTS: There were 97 patients included in the study; 43 were treated in the 2 years before implementation of the code H and 54 patients were treated the subsequent 2 years. Mean age (SD) was 56.9 years (13.7), 27% were women, and 86% were white. Groups were similar in age, sex, and race. Implementation of a code H reduced the median door-to-balloon time by 68 minutes (from 176 to 108 minutes; P<.001) and increased the proportion of patients undergoing percutaneous coronary intervention within 90 minutes from 2.8% to 29.0% (mean difference 26.5; 95% confidence interval 15.0 to 36.9). To determine whether further improvements occurred, 48 patients treated in 2006 showed a 20-minute further reduction in door-to-balloon time; 52% underwent angioplasty within 90 minutes of ED presentation. CONCLUSION: Institutional implementation of a protocol that requires emergency physicians to activate an interventional cardiology team response in ED patients with ST-segment-elevation myocardial infarction reduces the door-to-balloon time and increases the proportion of patients undergoing percutaneous coronary intervention within 90 minutes.