Anne K. Chipman

University of Washington

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Elizabeth D. Rosenman

University of Washington

Rosemarie Fernandez

University of Florida

Marie C. Vrablik

University of Washington

Sarah Brolliar

University of Washington

James A. Grand

University of Maryland, College Park

Jonathan S. Ilgen

University of Washington

Brian Chinnock

California State University, Fresno

Nicholas M. Mohr

University of Iowa

Adam Janicki

University of Pittsburgh

Frank LoVecchio

Arizona State University

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University of Washington

University of Iowa

Centers for Disease Control and Prevention

Emory University

Johns Hopkins University

University of Pittsburgh

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University of California, Los Angeles

Brigham and Women's Hospital

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Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting

JAMA Network Open (2023)

Lyndsey S. Benson Sarah K. Holt John L. Gore Lisa S. Callegari Anne K. Chipman

Importance Early pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ. Objective To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. Design, Setting, and Participants This retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022. Exposures The primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities. Main Outcomes and Measures The primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis. Results A total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service. Conclusions and Relevance In this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Outpatient clinic

Early Pregnancy Loss

10.1001/jamanetworkopen.2023.2639

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Citations (17)

Ischemic ECG Pattern Recognition to Facilitate Interpretation While Task Switching: A Parallel Curriculum

MedEdPORTAL (2021)

Caitlin Schrepel Ashley E. Amick Madeline Sayed Anne K. Chipman

OPEN ACCESSSeptember 7, 2021Ischemic ECG Pattern Recognition to Facilitate Interpretation While Task Switching: A Parallel Curriculum Caitlin Schrepel, MD, Ashley E. Amick, MD, MS, Madeline Sayed, Anne K. Chipman, MD, MS Caitlin Schrepel, MD https://orcid.org/0000-0003-0204-7657 Acting Instructor, Department of Emergency Medicine, University of Washington School of Medicine E-mail Address: [email protected] Google Scholar More articles by this author , Ashley E. Amick, MD, MS Acting Instructor, Department of Emergency Medicine and Internal Medicine, University of Washington School of Medicine Google Scholar More articles by this author , Madeline Sayed Residency Education Manager, Department of Emergency Medicine, University of Washington School of Medicine Google Scholar More articles by this author , Anne K. Chipman, MD, MS Assistant Professor and Assistant Program Director, Department of Emergency Medicine, University of Washington School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.11182 SectionsAboutPDF ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: Interruptions are an inevitable part of working as an emergency physician, yet these can increase cognitive load and precipitate medical error. Emergency physicians learn to balance these responsibilities using a process called task switching. Yet residents have little exposure to exercises that purposefully integrate task switching during their training. We addressed this gap by exposing emergency medicine (EM) trainees to task-switching events in the form of critical ECG interpretation while they were engaged in concurrent, parallel activities. Methods: The curriculum was carried out in three phases. First, 12 PGY 2 residents engaged in a small-group session testing their baseline confidence and ECG interpretation skills. The second phase was longitudinal: During concurrent educational activities, investigators interrupted tasks and asked trainees to interpret ECGs in 10 seconds or less. The curriculum's final phase was used to review the ECGs and answer any questions. Results: Confidence and percentage of correct interpretations were compared from phase 1 to phase 2. Participants showed improved confidence (M = 2.5, SD = 0.6, to M = 2.9, SD = 0.6; p = .02; 5-point Likert scale) and increased mean percent correct (M = 0.7, SD = 0.1, to M = 0.8, SD = 0.1; p = .01) following the curriculum. Discussion: Our curriculum provides a pragmatic, reproducible approach to enhancing critical ECG interpretation with task switching in a way that mirrors the EM practice environment, promoting a reduction of cognitive load and highlighting the skills learners will need as they develop expertise. Educational Objectives By the end of this course, learners will be able to: 1.Recognize which ECGs require immediate cardiac catheterization (cath) lab activation in less than 10 seconds.2.Recognize which ECGs require immediate cath lab activation in less than 10 seconds while task switching from a parallel activity.3.Report increased confidence in interpretation of ECGs in less than 10 seconds while task switching from a parallel task. Introduction Interruptions are a common1 reality for emergency physicians and can lead to cognitive and medical errors.2,3 Learning to deal with these interruptions is a necessary skill for emergency medicine (EM) trainees to master since accurately interpreting critical information in a time-sensitive manner while still attending to the current task at hand is crucial to providing patient care. For example, guidelines recommend that any patient who presents to the emergency department (ED) with chest pain must have a screening ECG performed and interpreted by a physician within 10 minutes of arrival to prevent delays in diagnosis of critical ischemia and associated mortality and morbidity.4,5 As a consequence, physicians in the ED are interrupted multiple times a shift for ECG interpretation. Rather than simply multitasking, these interruptions are managed with a process known as task switching.6,7 When task switching, the physician shifts attention from their current task to address the interruption. Only when the interrupting task is dealt with do they return their attention to the primary task. The process of task switching is complex and contributes to overall cognitive load. Cognitive load theory8 suggests that these types of interruptions place increased stress on working memory, increasing the possibility of error. The principles of cognitive load theory and task switching are important concepts for medical educators to understand as they work to find innovative ways to reduce cognitive load. In fact, there is a push for educators to create educational experiences that help learners integrate the skills and knowledge necessary for effective task switching.9 While this approach to education has been done previously with high-fidelity simulation,10–12 there is a continued need for pragmatic, easy-to-implement curricular innovations to address this challenge. Additionally, while previous medical educators have recognized the importance of teaching the skills needed for rapid and accurate interpretation of ECGs, their curricula have focused primarily on teaching ECG basics to novices13,14 or finding innovative online formats to supplement the core curriculum.15–17 While one curriculum currently available in MedEdPORTAL16 presents a creative way to use online modules to increase accuracy of ECG interpretation in an emergency setting, the focus is on pediatric emergency patterns rather than the ischemic patterns often seen in adult patients. Additionally, its ECGs are presented as part of online modules, rather than interruptions requiring task switching for interpretation. Our curriculum adds to this body of work by demonstrating that core content, such as ischemic ECG interpretation, can effectively be taught in a manner that mirrors the EM practice environment and promotes skills needed for task switching without requiring extensive resources or high-fidelity simulation. Methods All EM residents at our institution participate in a 4-day boot camp prior to their PGY 2 year. This 4-day session involves lectures, small-group discussions, simulation, and procedure lab. All sessions are meant to prepare students for their new role as a senior resident. We implemented our ECG curriculum over the course of this boot camp, but it was designed to be used as a parallel activity to any aspect of the curriculum over any time frame. Our target audience included PGY 2 EM residents as they transitioned to a senior resident role. However, the curriculum could also be used with PGY 1 EM residents or residents in other fields who are required to interpret ECGs while task switching, including residents working in the ICU. The only materials needed were an audiovisual setup, a computer that could run PowerPoint, pen/pencils, and printed ECGs. The study of this curriculum was deemed exempt by the University of Washington Institutional Review Board (STUDY00009976). All ECGs were obtained from the open-access website Life in the Fast Lane and its ECG library.18 We selected which ECG patterns to include based on previous core content at our institution, our institutional protocols, and our expertise in ECG interpretation. ECGs were typical representations of the pattern with minimal ambiguity. All authors had to agree on the diagnosis for the ECG to be included. The same set of ECGs was used for all aspects of this curriculum in order to minimize the ambiguity of the diagnosis and maximize our ability to compare pre- and posttests in this study setting. The curriculum consisted of three components. First, residents engaged in an interactive, 1-hour, small-group session using PowerPoint, which focused on pattern recognition for ECGs requiring emergent cardiac catheterization (cath) and common ST-segment elevation myocardial infarction (STEMI) mimics (Appendix A). During this part of the course, we presented the ECGs on slides and residents had 10 seconds to decide if an ECG required (1) cath lab activation, (2) a call to cardiology for possible cath lab activation, or (3) no activation. They recorded their answer on the provided answer sheet (Appendix B). Of note, the choice of “a call to cardiology for possible cath lab activation” was added as an option given that there were patterns that were not universally part of institutional STEMI protocols (e.g., isolated elevation in aortic valve replacement) in order to allow flexibility when used at other institutions. As each institution has different guidelines on when to activate the cath lab for critical ischemia, these materials may need to be modified in some instances to reflect those differences. Only 10 seconds were given for interpretation as the goal was to emphasize those patterns that need to be distinguished quickly, while understanding that more subtle findings would require more time to interpret. The group then discussed the ECG and the important aspects of the pattern. Residents each had an opportunity to participate in the discussion of the ECG patterns. To maximize participation, we asked all residents to tell the group how they had answered by raising their hand. We then asked for volunteers to explain their reasoning. This interactive gamification approach made use of small-group learning techniques to both engage learners and promote debate and critical reasoning. The second part of the curriculum was longitudinal in nature. As residents completed the various activities of the boot camp (e.g., lectures, simulation, and procedure lab), we randomly handed them ECGs to interpret (Appendices C and D). For example, a resident might have been participating in a trauma simulation as part of the structured boot camp activities. We interrupted them during their resuscitation of a simulated patient to ask them to interpret an unrelated ECG. These interruptions did not always occur during simultaneous simulations, but also could take place during procedure lab, small groups, and lectures. In each case, the learner had to switch attention away from the primary task to interpret the ECG. When handed the ECG, they had 10 seconds to make the decision regarding cath lab activation. They circled their choice with a pen. All residents received all 20 ECGs in a random and distinct order. This pragmatic simulation was chosen as an instructional technique to promote the skills needed for rapid ECG interpretation while managing other tasks, as is common in the ED. The final component of the curriculum was a 1-hour review session using PowerPoint to discuss the answers for the ECGs handed out during the longitudinal phase. We included notes for the instructors to emphasize important points (Appendix E). We then evaluated the curriculum with pre- and posttests of confidence (Appendices F and G) and accuracy of ECG interpretation during the pretest (Appendix B) and task-switching activity (Appendix C). The pretest was given prior to any instruction, while the task-switching exercise was used as the posttest to assess whether learners could apply the information they had learned in the classroom while being interrupted. The impact of task switching on accuracy was not directly measured. We created the survey by adapting one used by prior educators when evaluating confidence following an educational intervention.19 All residents completed our standard course evaluation (Appendix H). Finally, we sent learners a follow-up quiz 1 month later to assess for retention (Appendix I). Data was collected in Microsoft Excel. Mean percent correct and confidence were compared before and after the curriculum using a paired t test. A Pearson correlation coefficient was used to explore the relationship between confidence and accuracy on the knowledge assessment. Results This curriculum was first implemented in 2018, with three iterations thus far, each with 12 residents. While it has been highly rated on past institutional course evaluations, 2020 was the first year that data regarding accuracy and confidence in interpretation of ECGs were collected. The exercise was completed by all 12 PGY 2 residents in June 2020. Following the introduction session on pattern recognition, participants demonstrated an increased mean percent correct (M = 0.7, SD = 0.1, to M = 0.8, SD = 0.1; p = .01) despite the addition of task switching during the posttest. Participants also reported improved overall confidence (M = 2.5, SD = 0.6, to M = 2.9, SD = 0.6; p = .02; 5-point Likert scale) following the curriculum. Pretest results demonstrated a lack of correlation between confidence and accuracy (r = .04, R2 = .001, p = .92). Following the curriculum, there was improvement in the correlation between confidence and accuracy, although it was not statistically significant (r = .53, R2 = .28, p = .07). Unfortunately, the response rate for the 1-month follow-up course was only 16% (two of 12) and therefore could not be used to meaningfully contribute to our results. However, course evaluations for the 2020 class remained extremely positive, with comments from learners such as “This is how all programs should teach ECG” and “This is how we should teach all core content.” Discussion Our curriculum is among the first demonstrating that core content can be taught in a manner that mirrors the practice environment, promotes the skills necessary for task switching, and can be easily embedded parallel to existing didactic and simulation curricula, with very little additional resource cost. While we were encouraged by the finding that our learners improved in both accuracy and confidence, this experience also served as an important exercise wherein residents came to understand the unique challenge of performing critical high-stakes tasks while under time and cognitive constraints. In order to promote the integration of information and reduce cognitive error, it is our role as educators to help learners manage cognitive load while working in the interruption-heavy learning environment of the ED. Our curriculum provides an example of how core content can be taught in a manner that promotes task switching. While not directly measured by our results, the design of our curriculum addresses both intrinsic and extraneous components of cognitive load. The intrinsic load of a task depends on the complexity of the task and the proficiency of the individuaI.8 We addressed the intrinsic load of ECG interpretation by harnessing the power of repetition to increase proficiency and by focusing on ischemic pattern recognition to simplify the task and increase automaticity. Extraneous load, on the other hand, which refers to the load imposed on a learner's working memory that is not necessary for the task at hand,8 was introduced into the curriculum in the form of distractions. By interrupting residents who were engaged in parallel activities, we were purposefully increasing the extraneous load to emphasize to the learner the skills needed for effective task switching. As trainees develop expertise, they also need to learn the skill of “knowing when to slow down,” as described by Moulton, Regehr, Mylopoulos, and MacRae.20 In their work, they argue that expertise should be judged by an individual's ability to respond effectively in the moment using automatic resources and also by their ability to transition to effortful processes when needed. While this ability to switch to effortful processing may take time to develop, our curriculum represents a practical way for educators to begin teaching this crucial skill by forcing trainees to practice task switching. Additionally, as emphasized by researchers such as Ratwani, Fong, Puthumana, and Hettinger,21 interruption-management skills can be used to prioritize tasks and improve patient safety. As Ratwani and colleagues argue, physicians should be taught the skills needed to effectively resume tasks following an interruption and to delay or avoid interruptions when appropriate. Curricula such as ours could be used to teach learners these techniques while simultaneously emphasizing core content. In addition to emphasizing the role of cognitive load and task switching on decision-making, our curriculum can provide an opportunity for an important reality check for trainees. While confidence improved following the completion of the sessions overall, it is important to note that confidence was not correlated with accuracy. The lack of correlation was most striking prior to instruction. This may not be surprising to educators who understand that many learners suffer from an illusion of competence.22 However, it can be surprising to the learners. In fact, several of the learners who struggled the most reached out to leadership for further help after realizing that their confidence did not correlate with their skills. Finally, given the ever-expanding amount of material that is being integrated into resident curricula, it is crucial to continue to explore innovative and practical methods to teach core content. We accomplished this goal in creating a curriculum that requires very few material and personnel resources and can also be modified easily to fit in with existing course structure. In implementing this course, we learned several lessons. First, we were surprised by the results of the knowledge pretest, which demonstrated a surprising lack of accuracy in recognizing ECGs requiring cath lab activation. This finding suggests that perhaps we need to emphasize this crucial skill more thoroughly during the PGY 1 year. Our learners also experienced some confusion over the option of “a call to cardiology for possible cath lab activation.” Because we think it is important to have this option available given the reality of clinical uncertainty and variability of institutional guidelines in some cases, we will need to spend more time explaining the option to ensure understanding. While we were encouraged by the improvement of trainee accuracy seen during this course, we must note some important limitations. First, while we intended to use interruptions to mimic the workplace environment and add extraneous load, the simulation of this process was distinct from the interruptions seen in the ED. In the simulated environment, there are fewer competing interruptions, and the stakes linked to the decision are much lower. Additionally, the ECGs selected for this course did not involve ambiguity, and the same set was used for all sessions. These ECGs were selected from Life in the Fast Lane18 to provide other educators with a starter pack of ECGs; however, this limited our ability to determine how learners would do with more nuanced findings on ECGs. We also do not have any data to determine whether the encouraging results of this curriculum are lasting. We did send out a 1-month follow-up quiz to answer this question, but despite multiple reminders, we did not receive enough completed quizzes to comment on durability of the results. We suspect that our low response rate stemmed from the fact that we utilized an online platform not frequently used by residents for other activities. Additionally, the follow-up quiz was not a required event and had no incentive given for completion. In order to increase the response rate, we would recommend using an in-person format for a follow-up quiz or providing learners with an incentive for completion. Finally, our pre- and postcourse confidence surveys (Appendices F and G) were adapted from a similar survey in the literature, but we did not independently explore its validity in this educational context. Regardless, we believe that curricula such as this are beneficial as we strive to both teach core content and encourage residents to develop the skills they will need to develop into experts. Future research could include adding more nuanced ECG findings to the course or performing the task-switching task while learners work a real clinical shift. This technique could be expanded to other diagnoses that require a rapid triage evaluation by a provider, such as stroke or arrhythmia. Finally, curricula such as this could be used to teach learners the skills they might need to manage interruptions as they occur. References1. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?Acad Emerg Med. 2000;7(11):1239–1243. https://doi.org/10.1111/j.1553-2712.2000.tb00469.xMedline, Google Scholar2. Johnson M, Sanchez P, Langdon R, et al. The impact of interruptions on medication errors in hospitals: an observational study of nurses. J Nurs Manag. 2017;25(7):498–507. https://doi.org/10.1111/jonm.12486Medline, Google Scholar3. Institute of Medicine. To Err Is Human: Building a Safer Health System. National Academies Press; 2000.Google Scholar4. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163–1170. https://doi.org/10.1056/NEJM200004203421603Medline, Google Scholar5. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Catheter Cardiovasc Interv. 2013;82(1):E1–E27. https://doi.org/10.1002/ccd.24776Medline, Google Scholar6. Benda NC, Meadors ML, Hettinger AZ, Ratwani RM. Emergency physician task switching increases with the introduction of a commercial electronic health record. Ann Emerg Med. 2016;67(6):741–746. https://doi.org/10.1016/j.annemergmed.2015.07.514Medline, Google Scholar7. Walter SR, Raban MZ, Dunsmuir WTM, Douglas HE, Westbrook JI. Emergency doctors’ strategies to manage competing workload demands in an interruptive environment: an observational workflow time study. Appl Ergon. 2017;58:454–460. https://doi.org/10.1016/j.apergo.2016.07.020Medline, Google Scholar8. Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive load theory: implications for medical education: AMEE Guide no. 86. Med Teach. 2014;36(5):371–384. https://doi.org/10.3109/0142159X.2014.889290Medline, Google Scholar9. Weidman J, Baker K. The cognitive science of learning: concepts and strategies for the educator and learner. Anesth Analg. 2015;121(6):1586–1599. https://doi.org/10.1213/ANE.0000000000000890Medline, Google Scholar10. Soares WE, Price LL, Prast B, Tarbox E, Mader TJ, Blanchard R. Accuracy screening for ST elevation myocardial infarction in a task-switching simulation. West J Emerg Med. 2019;20(1):177–184. https://doi.org/10.5811/westjem.2018.10.39962Medline, Google Scholar11. Turner J, Drew J, Mugele J, Duncan T, Blickendorf R, Cooper D. R2 emergency medicine multipatient simulation. MedEdPORTAL. 2015;11:10321. https://doi.org/10.15766/mep_2374-8265.10321Google Scholar12. Turner J, Wilbur L, Kirschner J, Knopp J, Rodgers K, Cooper D. Third-year emergency medicine multiple-patient simulation. MedEdPORTAL. 2014;10:9948. https://doi.org/10.15766/mep_2374-8265.9948Google Scholar13. Zachow R, Coromilas J, Sadley C. Introduction to electrocardiography diagnostic skills. MedEdPORTAL. 2012;8:9159. https://doi.org/10.15766/mep_2374-8265.9159Google Scholar14. Roberts J. It's all connected: coronary anatomy, EKG interpretation, and acute myocardial infarction. MedEdPORTAL. 2015;11:10202. https://doi.org/10.15766/mep_2374-8265.10202Google Scholar15. Klein AJ, Berlacher M, Doran JA, Corbelli J, Rothenberger SD, Berlacher K. A resident-authored, case-based electrocardiogram email curriculum for internal medicine residents. MedEdPORTAL. 2020;16:10927. https://doi.org/10.15766/mep_2374-8265.10927Medline, Google Scholar16. Gopwani P, Patel S, Greene EA, Chapman J. A module-based pediatric ECG curriculum to improving accuracy of ECG interpretation by pediatric emergency medicine providers. MedEdPORTAL. 2014;10:9779. https://doi.org/10.15766/mep_2374-8265.9779Google Scholar17. Weinberg J, Ottolini M, Sestokas J, Greene EA. Using a case scenario-based self-teaching module to increase overall skill in ECG interpretation for pediatric residents. MedEdPORTAL. 2013;9:9648. https://doi.org/10.15766/mep_2374-8265.9648Google Scholar18. ECG library. Life in the Fast Lane. Accessed August 22, 2019. https://litfl.com/ecg-library/Google Scholar19. Triantafylidis LK, Phillips SC, Hawley CE, Schwartz AW. Finding the Sweet Spot: an interactive workshop on diabetes management in older adults. MedEdPORTAL. 2019;15:10845. https://doi.org/10.15766/mep_2374-8265.10845Medline, Google Scholar20. Moulton CAE, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10)(suppl):S109–S116. https://doi.org/10.1097/ACM.0b013e3181405a76Medline, Google Scholar21. Ratwani RM, Fong A, Puthumana JS, Hettinger AZ. Emergency physician use of cognitive strategies to manage interruptions. Ann Emerg Med. 2017;70(5):683–687. https://doi.org/10.1016/j.annemergmed.2017.04.036Medline, Google Scholar22. Koriat A, Bjork RA. Illusions of competence in monitoring one's knowledge during study. J Exp Psychol Learn Mem Cogn. 2005;31(2):187–194. https://doi.org/10.1037/0278-7393.31.2.187Medline, Google Scholar Sign up for the latest publications from MedEdPORTAL Add your email below APPENDICESReferencesRelatedDetailsAppendices Introduction Lecture.pptx Knowledge Pretest Answer Sheet.docx ECG Handout.docx ECG Handout Answers.docx Review Lecture.pptx Presurvey of Confidence.docx Postsurvey of Confidence.docx Course Evaluation.docx Delayed Knowledge Posttest.docx All appendices are peer reviewed as integral parts of the Original Publication. Download Copyright & Permissions© 2021 Schrepel et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution license.KeywordsProcedural Skills TrainingClinical TrainingECG InterpretationEmergency MedicineTask SwitchingCognitive LoadDisclosures None to report. Funding/Support None to report. Ethical Approval The University of Washington Institutional Review Board deemed further review of this project not necessary. Loading ...

Task force

10.15766/mep_2374-8265.11182

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Oh, the places you'll go! A qualitative study of resident career decisions in emergency medicine

AEM Education and Training (2024)

Jaime Jordan Jack Buckanavage Jonathan S. Ilgen Michael Gottlieb Laura R. Hopson

Postresidency career choices are complex decisions that involve personal, professional, and financial preferences and may be influenced by training programs. It is unknown how residents navigate these decisions during emergency medicine (EM) residency. We explored EM residents' perspectives on career decision making and how residency programs can support career planning.

Mentorship

Thematic Analysis

Preparedness

10.1002/aet2.10956

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Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay

BMJ Quality & Safety (2017)

Jeremy Branzetti Adeyinka Adedipe Matthew Gittinger Elizabeth D. Rosenman Sarah Brolliar

Background

A subset of high-risk procedures present significant safety threats due to their (1) infrequent occurrence, (2) execution under time constraints and (3) immediate necessity for patient survival. A Just-in-Time (JIT) intervention could provide real-time bedside guidance to improve high-risk procedural performance and address procedural deficits associated with skill decay.

Objective

To evaluate the impact of a novel JIT intervention on transvenous pacemaker (TVP) placement during a simulated patient event.

Methods

This was a prospective, randomised controlled study to determine the effect of a JIT intervention on performance of TVP placement. Subjects included board-certified emergency medicine physicians from two hospitals. The JIT intervention consisted of a portable, bedside computer-based procedural adjunct. The primary outcome was performance during a simulated patient encounter requiring TVP placement, as assessed by trained raters using a technical skills checklist. Secondary outcomes included global performance ratings, time to TVP placement, number of critical omissions and System Usability Scale scores (intervention only).

Results

Groups were similar at baseline across all outcomes. Compared with the control group, the intervention group demonstrated statistically significant improvement in the technical checklist score (11.45 vs 23.44, p<0.001, Cohen’s d effect size 4.64), the global rating scale (2.27 vs 4.54, p<0.001, Cohen’s d effect size 3.76), and a statistically significant reduction in critical omissions (2.23 vs 0.68, p<0.001, Cohen’s d effect size −1.86). The difference in time to procedural completion was not statistically significant between conditions (11.15 min vs 12.80 min, p=0.12, Cohen’s d effect size 0.65). System Usability Scale scores demonstrated excellent usability.

Conclusion

A JIT intervention improved procedure perfromance, suggesting a role for JIT interventions in rarely performed procedures.

10.1136/bmjqs-2017-006656

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Academic springboard: The chief resident position correlates with career path in emergency medicine

AEM Education and Training (2021)

Jaime Jordan Laura R. Hopson Samuel Clarke Adam Frisch Anne K. Chipman

The chief resident role often includes additional administrative and educational experiences beyond those of nonchief senior residents. It is unclear to what extent these experiences influence the postresidency career path of those selected as chief residents. The objective of this study was to evaluate the association of chief resident status on immediate postresidency career characteristics relative to nonchief residents in emergency medicine (EM).

Graduation (instrument)

Career path

Graduate medical education

Program director

Academic year

10.1002/aet2.10639

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3317 Translating simulation-based team leadership training into patient-centered outcomes

Journal of Clinical and Translational Science (2019)

Rosemarie Fernandez Elizabeth D. Rosenman Anne K. Chipman Sarah Brolliar Marie C. Vrablik

OBJECTIVES/SPECIFIC AIMS: The objective of this research was to assess the clinical impact of simulation-based team leadership training on team leadership effectiveness and patient care during actual trauma resuscitations. This translational work addresses an important gap in simulation research and medical education research. METHODS/STUDY POPULATION: Eligible trauma team leaders were randomized to the intervention (4-hour simulation-based leadership training) or control (standard training) condition. Subject-led actual trauma patient resuscitations were video recorded and coded for leadership behaviors (primary outcome) and patient care (secondary outcome) using novel leadership and trauma patient care metrics. Patient outcomes for trauma resuscitations were obtained through the Harborview Medical Center Trauma Registry and analyzed descriptively. A one-way ANCOVA analysis was conducted to test the effectiveness of our training intervention versus a control group for each outcome (leadership effectiveness and patient care) while accounting for pre-training performance, injury severity score, postgraduate training year, and days since training occurred. Association between leadership effectiveness and patient care was evaluated using random coefficient modeling. RESULTS/ANTICIPATED RESULTS: Sixty team leaders, 30 in each condition, completed the study. There was a significant difference in post-training leadership effectiveness [F(1,54)=30.19, p<.001, η2=.36] between the experimental and control conditions. There was no direct impact of training on patient care [F(1,54)=1.0, p=0.33, η2=.02]; however, leadership effectiveness mediated an indirect effect of training on patient care. Across all trauma resuscitations team leader effectiveness correlated with patient care (p<0.05) as predicted by team leadership conceptual models. DISCUSSION/SIGNIFICANCE OF IMPACT: This work represents a critical step in advancing translational simulation-based research (TSR). While there are several examples of high quality translational research programs, they primarily focus on procedural tasks and do not evaluate highly complex skills such as leadership. Complex skills present significant measurement challenges because individuals and processes are interrelated, with multiple components and emergent nature of tasks and related behaviors. We provide evidence that simulation-based training of a complex skill (team leadership behavior) transfers to a complex clinical setting (emergency department) with highly variable clinical tasks (trauma resuscitations). Our novel team leadership training significantly improved overall leadership performance and partially mediated the positive effect between leadership and patient care. This represents the first rigorous, randomized, controlled trial of a leadership or teamwork-focused training that systematically evaluates the impact on process (leadership) and performance (patient care).

Trauma Center

10.1017/cts.2019.136

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Simulation-Based Team Leadership Training Improves Team Leadership During Actual Trauma Resuscitations: A Randomized Controlled Trial

Critical Care Medicine (2019)

Rosemarie Fernandez Elizabeth D. Rosenman Jeffrey Olenick Anthony Misisco Sarah Brolliar

Trauma resuscitations are complex critical care events that present patient safety-related risk. Simulation-based leadership training is thought to improve trauma care; however, there is no robust evidence supporting the impact of leadership training on clinical performance. The objective of this study was to assess the clinical impact of simulation-based leadership training on team leadership and patient care during actual trauma resuscitations.Randomized controlled trial.Harborview Medical Center (level 1 trauma center).Seventy-nine second- and third-year residents were randomized and 360 resuscitations were analyzed.Subjects were randomized to a 4-hour simulation-based leadership training (intervention) or standard orientation (control) condition.Participant-led actual trauma resuscitations were video recorded and coded for leadership behaviors and patient care. We used random coefficient modeling to account for the nesting effect of multiple observations within residents and to test for post-training group differences in leadership behaviors while controlling for pre-training behaviors, Injury Severity Score, postgraduate training year, and days since training occurred. Sixty participants completed the study. There was a significant difference in post-training leadership behaviors between the intervention and control conditions (b1 = 4.06, t (55) = 6.11, p < 0.001; intervention M = 11.29, SE = 0.66, 95% CI, 9.99-12.59 vs control M = 7.23, SE = 0.46, 95% CI, 6.33-8.13, d = 0.92). Although patient care was similar between conditions (b = 2.00, t (55) = 0.99, p = 0.325; predicted means intervention M = 62.38, SE = 2.01, 95% CI, 58.43-66.33 vs control M = 60.38, SE = 1.37, 95% CI, 57.69-63.07, d = 0.15), a test of the mediation effect between training and patient care suggests leadership behaviors mediate an effect of training on patient care with a significant indirect effect (b = 3.44, 95% CI, 1.43-5.80). Across all trauma resuscitations leadership was significantly related to patient care (b1 = 0.61, SE = 0.15, t (273) = 3.64, p < 0.001).Leadership training resulted in the transfer of complex skills to the clinical environment and may have an indirect effect on patient care through better team leadership.

Trauma Center

Simulation training

10.1097/ccm.0000000000004077

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Citations (57)

An Innovative Approach to Quality Improvement and Patient Safety: A Resident-initiated and Administered Quality Improvement Committee

Western Journal of Emergency Medicine (2014)

Nikki R. Adler Anne K. Chipman Charlotte P. Wills H. Gene Hern

Source

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“Not just a checkbox”: A qualitative study of the resident scholarly experience

AEM Education and Training (2022)

Jaime Jordan Max Berger Mark Curato Jonathan S. Ilgen Laura R. Hopson

Scholarship is a requirement of residency training; however, the scholarly productivity of trainees is highly variable. The purpose of this study was to explore the perspectives of residents who have been highly productive in scholarship.

Mentorship

Thematic Analysis

Graduate medical education

Mindset

10.1002/aet2.10824

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IS A MISCARRIAGE AN EMERGENCY? A QUALITATIVE STUDY ASSESSING EMERGENCY MEDICINE PHYSICIANS’ VIEWS TOWARD APPROPRIATE CARE FOR EARLY PREGNANCY LOSS IN THE EMERGENCY DEPARTMENT

Contraception (2024)

Emma Lantos E.E. McCoy Anne K. Chipman BT Nguyen LS Benson

Emergency Contraception

10.1016/j.contraception.2024.110627

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