How Competent Are Emergency Medicine Interns for Level 1 Milestones: Who Is Responsible?

Objectives The Next Accreditation System ( NAS ) of the Accreditation Council for Graduate Medical Education ( ACGME ) includes the implementation of developmental milestones for each specialty. The milestones include five progressively advancing skill levels, with Level 1 defining the skill level of a medical student graduate, and Level 5, that of an attending physician. The goal of this study was to query interns on how well they thought their medical school had prepared them to meet the proposed emergency medicine ( EM ) Level 1 milestones. Methods In July 2012, an electronic survey was distributed to the interns of 13 EM residency programs, asking interns whether they were taught and assessed on the proposed Level 1 milestones. Results Of possible participants, 113 of 161 interns responded (70% response rate). The interns represented all four regions of the country. The interns responded that the rates of Level 1 milestones they had been taught ranged from 61% for ultrasound to 98% for performance of focused history and physical examination. A substantial number of interns (up to 39%) reported no instruction on milestones such as patient disposition, pain management, and vascular access. Graduating medical students were less commonly assessed than taught the milestones. Skills with technology, including “explain the role of the electronic health record and computerized physician order entry,” were assessed for only 39% of interns, and knowledge ( USMLE ) and history and physical were assessed in nearly all interns. Disposition, ultrasound, multitasking, and wound management were assessed less than half of the time. Conclusions Many entering EM interns may not have had either teaching or assessment on the knowledge, skills, and behaviors making up the Level 1 milestones expected for graduating medical students. Thus, there is a potential gap in the teaching and assessment of EM interns. Based on these findings, it is unclear who will be responsible (medical schools, EM clerkships, or residency programs) for ensuring that medical students entering residency have achieved Level 1 milestones. Resumen Competencia de los Residentes de Medicina de Urgencias y Emergencias para el Nivel 1: ¿Quién es el Responsable? El próximo sistema de acreditación ( NAS , Next Accreditation System ) del Accreditation Council for Graduate Medical Education ( ACGME ) incluye la implementación de objetivos por área de desarrollo para cada especialidad. Los objetivos por área incluyen cinco niveles de habilidades progresivamente avanzadas, con un nivel 1 definido por el nivel de habilidad de un estudiante licenciado de medicina, y un nivel definido por el nivel, de un médico adjunto. El objetivo de este estudio fue preguntar a los residentes cómo pensaban que sus universidades les habían preparado para alcanzar los objetivos por área de nivel 1 propuestos en medicina de urgencias y emergencias ( MUE ). Metodología En julio de 2012, se distribuyó una encuesta electrónica a los residentes de 13 programas de residencia de MUE , preguntándoles si estaban formados y evaluados en los objetivos por área de nivel 1 propuestos. Resultados De los posibles participantes, 113 de 161 residentes (70%) respondieron. Los residentes representaban las cuatro regiones del país. Los residentes respondieron que los porcentajes de objetivos por área de nivel 1 en los que se habían formado variaron del 61% para la ecografía al 98% para la realización de la historia clínica y la exploración física. Un número importante de residentes (hasta un 39%) respondieron no formarse en objetivos por áreas tales como la ubicación del paciente, el manejo del dolor y el acceso vascular. Los estudiantes licenciados de medicina fueron menos frecuentemente evaluados que formados en los objetivos por área. Las habilidades con la tecnología, incluyendo la explicación del rol de la historia clínica electrónica y la solicitud de órdenes médicas computarizadas, se evaluaron sólo en el 39% de los residentes y el conocimiento ( USMLE , United States Medical Licensing Examination ) y la historia clínica y exploración física se evaluaron en casi todos los residentes. Es más, la ubicación, la ecografía, la multitarea y el manejo de heridas se evaluaron en menos de la mitad de las ocasiones. Conclusiones Muchos de los residentes que se inician en MUE pueden no haber tenido formación o evaluación en el conocimiento, las habilidades y los comportamientos preparatorios para los objetivos por área de nivel 1 esperados para los estudiantes licenciados de medicina. Además, hay una brecha potencial en la formación y la evaluación de los residentes de MUE . En base a estos hallazgos, no está claro quién será el responsable, las facultades de medicina, la administración de la MUE o los programas de residencia, para asegurar que los estudiantes de medicina que entren en la residencia hayan alcanzado los objetivos por área de nivel 1.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99036/1/acem12162.pd

Geochemical approaches to the quantification of dispersed volcanic ash in marine sediment

Volcanic ash has long been recognized in marine sediment, and given the prevalence of oceanic and continental arc volcanism around the globe in regard to widespread transport of ash, its presence is nearly ubiquitous. However, the presence/absence of very fine-grained ash material, and identification of its composition in particular, is challenging given its broad classification as an “aluminosilicate” component in sediment. Given this challenge, many studies of ash have focused on discrete layers (that is, layers of ash that are of millimeter-to-centimeter or greater thickness, and their respective glass shards) found in sequences at a variety of locations and timescales and how to link their presence with a number of Earth processes. The ash that has been mixed into the bulk sediment, known as dispersed ash, has been relatively unstudied, yet represents a large fraction of the total ash in a given sequence. The application of a combined geochemical and statistical technique has allowed identification of this dispersed ash as part of the original ash contribution to the sediment. In this paper, we summarize the development of these geochemical/statistical techniques and provide case studies from the quantification of dispersed ash in the Caribbean Sea, equatorial Pacific Ocean, and northwest Pacific Ocean. These geochemical studies (and their sedimentological precursors of smear slides) collectively demonstrate that local and regional arc-related ash can be an important component of sedimentary sequences throughout large regions of the ocean

Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers

Introduction: Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers.Methods: Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test.Results: There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts.Conclusion: This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence. [West J Emerg Med. 2012;13(5):429-433.

Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers

Introduction: Healthcare and social workers have the highest incidence of workplace violence ofany industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries fromoccupational violence. Our goal was to develop and evaluate an instrument for prospective collectionof data relevant to emergency department (ED) violence against healthcare workers.Methods: Participants at a high-volume tertiary care center were shown 11 vignettes portrayingverbal and physical assaults and responded to a survey developed by the research team andpiloted by ED personnel addressing the type and severity of violence portrayed. Demographic andemployment groups were compared using the independent-samples Mann-Whitney U Test.Results: There were 193 participants (91 male). We found few statistical differences whencomparing occupational and gender groups. Males assigned higher severity scores to acts ofverbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statisticalsignificance, subgroup analysis revealed that attending physicians rated acts of verbal violencehigher than resident physicians, and nurses assigned higher severity scores to acts of sexual,verbal, and physical violence versus their physician counterparts.Conclusion: This survey instrument is the first tool shown to be accurate and reliable in characterizingacts of violence in the ED across all demographic and employment groups using filmed vignettesof violent acts. Gender and occupation of ED workers does not appear to play a significant role inperception of severity workplace violenc

Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers

Introduction: Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers.Methods: Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test.Results: There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p&lt;0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts.Conclusion: This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence. [West J Emerg Med. 2012;13(5):429-433.

Programmatic Assessment of Level 1 Milestones in Incoming Interns

Objectives With the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System, emergency medicine (EM) residency programs will be required to report residents' progress through the EM milestones. The milestones include five progressively advancing skill levels, with Level 1 defining the skill set of a medical school graduate and Level 5, that of an attending physician. The ACGME stresses that multiple forms of assessment should be used to ensure capture of the multifaceted competencies. The objective of this study was to determine the feasibility and results of programmatic assessment of Level 1 milestones using multisource assessments for incoming EM interns in July. Methods The study population was interns starting in 2012 and 2013. Interns' Level 1 milestone assessment was done with four distinct methods: 1) the postgraduate orientation assessment (POA) by the Graduate Medical Education Office for all incoming interns (this multistation examination covers nine of the EM milestones and includes standardized patient cases, task completion, and computer‐based stations); 2) direct observation of patient encounters by core faculty using a milestones‐based clinical skills competency checklist; 3) the global monthly assessment at the end of the intern orientation month that was updated to reflect the EM milestones; and 4) faculty assessment during procedural labs. These occurred during the July orientation month that included the POA, clinical shifts, didactic sessions, and procedure labs. Results In the POA, interns were competent in 48% to 93% of the milestones assessed. Overall, competency was 70% to 80%, with low scores noted in aseptic technique (patient care Milestone 13 [PC13]) and written and verbal hand‐off (interpersonal communications skills [ICS]2). In overall communication, 70% of interns demonstrated competency. In excess of 80% demonstrated competency in critical values interpretation (PC3), informed consent (PC9), pain assessment (PC11), and geriatric functional assessment (PC3). On direct observation, almost all Level 1 milestones were achieved (93% to 100%); however, only 78% of interns achieved competency in pharmacotherapy (PC5). On global monthly evaluations, all interns met Level 1 milestones. Conclusions A multisource assessment of EM milestones is feasible and useful to determine Level 1 milestones achievement for incoming interns. A structured assessment program, used in conjunction with more traditional forms of evaluation such as global monthly evaluations and direct observation, is useful for identifying deficits in new trainees and may be able inform the creation of early intervention programs. Resumen Objetivos Con el próximo sistema de acreditación (PSA) del Accreditation Council for Graduate Medical Education desde, se exigirá a los programas de residencia que documenten los progresos de los residentes a través de hitos. Los hitos incluyen cinco niveles de habilidad que aumentan progresivamente, con el nivel 1 que define el conjunto de habilidades de un licenciado en medicina, hasta el nivel 5 de un médico asistencial. La ACGME subraya que deberían ser utilizadas múltiples formas de evaluación para asegurar la captura de las competencias polifacéticas. El objetivo de este estudio fue determinar la viabilidad y los resultados de la evaluación programática de los hitos de nivel 1 usando evaluaciones de múltiples fuentes para los residentes entrantes de Medicina de Urgencias y Emergencias (MUE) en julio. Metodología La población de estudio fueron residentes que comenzaron en 2012 y 2013. La evaluación de los hitos de nivel 1 de los residentes se llevó a cabo con cuatro métodos distintos: 1) la evaluación de orientación posgrado (EOP) por la oficina Graduate Medical Education para todos los residentes entrantes. Este examen multiestación abarca nueve de los hitos de la MUE e incluye casos clínicos de pacientes estandarizados, realización de tareas y estaciones basadas en informática; 2) la observación directa de los encuentros con los pacientes por núcleo de profesores utilizando una lista de comprobación de competencia de habilidades clínicas basadas en hitos; 3) la evaluación mensual global al final del mes de orientación del residente que se actualiza para reflejar los hitos de la MUE; y 4) la evaluación del profesorado en los laboratorios de procedimientos. Éstos ocurrieron durante el mes de orientación de julio e incluyeron la EOP, las guardias, las sesiones clínicas y los laboratorios de procedimiento. Resultados En la EOP, los residentes fueron competentes en un 48–93% de los hitos evaluados. La competencia global fue de un 70% a un 80%, con puntuaciones bajas observadas en técnicas asépticas (PC13) así como las transferencias verbal y escrita (ICS2). En la comunicación total, un 70% de los residentes demostraron competencia. Se demostró más de un 80% de competencia en interpretación de valores críticos (PC3), consentimiento informado (PC9), valoración del dolor (PC11) y valoración funcional geriátrica (PC3). En la observación directa, se lograron casi todos los hitos de nivel 1 (93% a 100%), sin embargo sólo el 78% de los residentes adquirieron la competencia en farmacoterapia (PC5). En las evaluaciones mensuales globales, todos los residentes alcanzaron los hitos de nivel 1. Conclusiones Una evaluación multifuente de los hitos de la MUE es viable y útil para determinar los hitos de nivel 1 para residentes entrantes. Un programa de evaluación estructurado, usado en conjunción con las formas más tradicionales de evaluación como las evaluaciones mensuales globales y la observación directa, es útil para identificar los déficits en los nuevos residentes y puede ser capaz de informar para la creación de programas de intervención temprana.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108037/1/acem12393-sup-0001-DataSupplementS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/108037/2/acem12393.pd

Preoperative topical antimicrobial decolonization in head and neck surgery

Objectives/Hypothesis: Surgical site infections (SSIs) are an important cause of morbidity and mortality after head and neck surgery. Our primary objective was to determine the efficacy of preoperative topical antimicrobial decolonization before head and neck surgery. Study Design: Prospective, randomized controlled trial. Methods: This study was conducted among 84 patients presenting for head and neck surgery requiring admission to an academic medical center. Preoperative cultures were performed to identify Staphylococcus aureus carriers. Patients were randomized to preoperative topical antimicrobial decolonization with a 5‐day regimen of chlorhexidine skin rinses and intranasal mupirocin coupled with standard perioperative systemic antimicrobial prophylaxis, versus standard prophylaxis alone. The main outcome was the incidence of SSIs. Results: Despite a trend suggesting a decrease in SSIs with perioperative topical antimicrobial decolonization (24% vs. 10%), there was no significant difference (odds ratio, 0.34; 95% confidence interval, 0.10–1.18; P = .079). Patients with a higher American Society of Anesthesiologists score (3 vs. 1; P = .02), with more operative blood loss ( P = .05), and who required operative takeback ( P = .04) had a higher rate of SSIs; there was a trend suggesting a higher rate of SSIs among patients undergoing clean‐contaminated surgery compared to clean cases ( P = .08) and among those having received prior radiation ( P = .07) or chemotherapy ( P = .06). Conclusions: Preoperative antimicrobial decolonization did not significantly decrease the incidence of SSIs after head and neck surgery, but might be considered for high‐risk groups despite the lack of conclusive evidence confirming efficacy. Risk factors for SSIs after head and neck surgery are identified for the first time in a prospective study. Laryngoscope, 2012Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/94244/1/23487_ftp.pd

Reporting achievement of medical student milestones to residency program directors: An educational handover

Copyright © by the Association of American Medical Colleges. Problem Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear - as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. Approach A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. Outcomes In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. Next Steps An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions