“Breaking” the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

Introduction: Our goal was to critically examine emergency physician’s (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative.Methods: We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a “cut-and-sort” process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation.Results: We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care.Conclusion: The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care

#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.

Utilization of Wellness Practices For Burnout and Stress During COVID-19 Among an Interdisciplinary Cohort of Emergency Healthcare Workers

Introduction: The Coronavirus Disease (COVID-19) introduced additional stress to the baseline occupational stressors of emergency care workers. The objectives of this study were to evaluate perceived stress and burnout and the utilization and perceived benefit of wellness practices among emergency healthcare workers (EHCWs), including: emergency physicians, advanced practice providers (APPs), nurses, and departmental administrative staff during the COVID-19 pandemic. Methods: A cross-sectional 28-item electronic survey of EHCWs at three hospitals in a major United States city was used to measure participants’ utilization and perceived benefit of wellness practices, burnout (2-item measure), overall stress (perceived stress scale), and stress related to COVID-19. Results: The sample consisted of 260 respondents (response rate 44.6%, 583 eligible). Over one-half (56.5%) reported burnout from their job and a majority (58.5%) reported moderate to high stress. Wellness activities including regular exercise and engaging in hobbies were associated with lower reports of burnout. Higher stress levels were reported by participants who had tested positive for COVID-19. Nurses reported the highest rates of burnout overall (80.6%). Females reported higher rates of burnout than males across the cohort (64.5 vs 41.9%, p = 0.001), and female APPs reported significantly higher burnout than did male APPs (69.2 vs 38.5%, p = 0.048). Participants reported donated personal protective equipment (PPE) and meals on shift were extremely helpful. Conclusion: The COVID-19 pandemic was a significant contributor to the stress of EHCWs. Regular engagement in wellness activities was associated with lower rates of burnout. The benefit of engagement in wellness practices, both individual practices and organizational interventions are paramount to mitigate stress and burnout in EHCWs

A Comprehensive Residency Wellness Curriculum

Introduction: Resident physician burnout is an epidemic in medical education. There are several wellness curricula published, but few describe a comprehensive program to address wellness. Our objectives were to develop and pilot a longitudinal resident wellness curriculum and assess for feasibility and sustainability. Methods: We surveyed emergency medicine (EM) residents from two residency programs in the United States to assess a baseline level of burnout using the Maslach Burnout Inventory. We developed a comprehensive and longitudinal wellness curriculum for EM residents that incorporated all domains identified by the American College of Emergency Physicians Wellness Wheel. Mindfulness practice was incorporated throughout the curriculum. Results: A convenience sample of 106 EM residents were sent the baseline survey. A response rate of 69% was achieved, the median age of the respondents was 29 years, and 44.5% were female. Overall, 67.5% (95% CI: 50.5; 80.8%) reported burnout in at least one of the three domains of the Maslach Burnout inventory. 34.8% reported burnout in the personal accomplishment domain, 40.8% reported depersonalization, and 44.3% reported emotional exhaustion. The wellness curriculum was successfully implemented at the Georgia-based residency program. The curriculum has proven to be sustainable since it began in 2016. Quantitative statistical testing for the post-intervention survey was not possible due to a low response rate. However, subjective receivability was high, with participants describing these sessions as high-yield, informative and practical. Conclusions: Burnout is highly prevalent among EM residents. We provide a curriculum developed for an EM residency program that is multifaceted and comprehensive, including basic wellness topics, mindfulness, financial and medicolegal issues, as well as topics that address the stresses specific to clinical emergency medicine. The curriculum has been in place in its current form since 2016 and has proven to be sustainable

Racial and Ethnic Diversity in Academic Emergency Medicine: How Far Have We Come? Next Steps for the Future

Although the U.S. population continues to become more diverse, black, Hispanic, and Native American doctors remain underrepresented in emergency medicine (EM). The benefits of a diverse medical workforce have been well described, but the percentage of EM residents from underrepresented groups is small and has not significantly increased over the past 20 years. A group of experts in the field of diversity and inclusion convened a work group during the Council of Emergency Medicine Residency Program Directors (CORD) and Society for Academic Emergency Medicine (SAEM) national meetings. The objective of the discussion was to develop strategies to help EM residency programs examine and improve racial and ethnic diversity in their institutions. Specific recommendations included strategies to recruit racially and ethnically diverse residency candidates and strategies to mentor, develop, retain, and promote minority faculty.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147225/1/aet210204.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/147225/2/aet210204_am.pd

The Prevalence of Lesbian, Gay, Bisexual, and Transgender Health Education and Training in Emergency Medicine Residency Programs: What Do We Know?

Background The Institute of Medicine, The Joint Commission, and the U.S. Department of Health and Human Services all have recently highlighted the need for cultural competency and provider education on lesbian, gay, bisexual, and transgender ( LGBT ) health. Forty percent of LGBT patients cite lack of provider education as a barrier to care. Only a few hours of medical school curriculum are devoted to LGBT education, and little is known about LGBT graduate medical education. Objectives The objective of this study was to perform a needs assessment to determine to what degree LGBT health is taught in emergency medicine ( EM ) residency programs and to determine whether program demographics affect inclusion of LGBT health topics. Methods An anonymous survey link was sent to EM residency program directors ( PD s) via the Council of Emergency Medicine Residency Directors listserv. The 12‐item descriptive survey asked the number of actual and desired hours of instruction on LGBT health in the past year. Perceived barriers to LGBT health education and program demographics were also sought. Results There were 124 responses to the survey out of a potential response from 160 programs (response rate of 78%). Twenty‐six percent of the respondents reported that they have ever presented a specific LGBT lecture, and 33% have incorporated topics affecting LGBT health in the didactic curriculum. EM programs presented anywhere from 0 to 8 hours on LGBT health, averaging 45 minutes of instruction in the past year (median = 0 minutes, interquartile range [ IQR ] = 0 to 60 minutes), and PD s support inclusion of anywhere from 0 to 10 hours of dedicated time to LGBT health, with an average of 2.2 hours (median = 2 hours, IQR  = 1 to 3.5 hours) recommended. The majority of respondents have LGBT faculty (64.2%) and residents (56.2%) in their programs. The presence of LGBT faculty and previous LGBT education were associated with a greater number of desired hours on LGBT health. Conclusions The majority of EM residency programs have not presented curricula specific to LGBT health, although PD s desire inclusion of these topics. Further curriculum development is needed to better serve LGBT patients. Resumen Introducción El Institute of Medicine, la Joint Commission y el Department of Health and Human Services han subrayado recientemente la necesidad en la competencia cultural y la educación sanitaria de los profesionales sanitarios sobre lesbianas, gays, bisexuales y transexuales ( LGBT ). El 40% de los pacientes LGBT reconoce una falta de formación de los sanitarios como una barrera en la atención médica. Sólo unas pocas horas del programa universitario de medicina está dedicada a la formación en LGBT , y se sabe poco sobre la formación médica de postgrado sobre LGBT . Objetivos El objetivo de este estudio fue evaluar qué grado de formación sanitaria sobre LGBT se enseña en los programas de residencia de Medicina de Urgencias y Emergencias ( MUE ) y determinar si las características de las personas que realizan el programa afectan a la inclusión de temas sanitarios sobre LGBT . Metodología Se envió un enlace de encuesta anónima a los directores del programa de residencia de la MUE a través de la lista del servidor del Council of Emergency Medicine Residency Directors. La encuesta descriptiva de 12 ítems preguntó el número de horas reales y deseadas de formación saniataria sobre LGBT en el pasado año. También se buscaron las barreras percibidas para la educación sanitaria sobre LGBT y la demografía del programa. Resultados Hubo 124 respuestas a la encuesta de una respuesta potencial de 160 programas (porcentaje de respuesta del 78%). Un 26% de los encuestados contest que nunca había presentado una clase específica sobre LGBT , y un 33% ha incorporado temas que afectan a la salud de LGBT en el plan de estudios. Los programas de MUE presentaron en cualquier lugar de 0–8 horas de formación sanitaria sobre LGBT , con un promedio de 45 minutos de formación en el pasado año (mediana de 0 minutos, RIC 0 a 60 minutos), y los directores del programa apoyan la inclusión en cualquier lugar de 0 a 10 horas de tiempo dedicado a la formacion sanitaria sobre LGBT , con un promedio recomendado de 2,2 horas (mediana 2, RIC de 1 a 3,5 horas). La mayoría de los encuestados tienen profesores (64,2%) y residentes (56,2%) LGBT en sus programas. La presencia de profesores LGBT y la formación sanitaria previa sobre LGBT se asociaron con un mayor número de horas deseadas sobre formación sanitaria sobre LGBT . Conclusiones La mayoría de los programas de residencia en MUE no ha presentado un plan de estudios específico para formación sanitaria sobre LGBT , aunque los directores del programa desean la inclusión de estos temas. Es necesario el desarrollo de un programa futuro para atender mejor a los pacientes LGBT .Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106813/1/acem12368.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/106813/2/acem12368-sup-0001-DataSupplementS1.pd

Redefining Our Understanding of The Impact of Firearm-Related Injury in the State of Georgia: A White Paper by the Violence Prevention Task Force of IPRCE

Abstract: Background: Firearm-related injury is a crisis that afflicts vulnerable populations of all ages, ethnicities, races and gender. The purpose of this white paper is to delineate the impact of firearm-related violence on the health and well-being of citizens and communities across Georgia based on the available literature and data. The aim of this white paper is to examine and characterize the currently available data on the impact of firearm violence and injury from a statewide perspective, principally as it relates to the National Violent Death Reporting System (NVDRS) report for Georgia. Materials and method: We performed a literature review to analyze data obtained through the the Web-based Injury Statistics Query and Reporting System (WISQARS™) and NVDRS. We used the data to characterize the types and extent of firearm injuries and deaths in the U.S. and Georgia. Results: We identified an overall mortality rate of 27% for all-types of firearm injuries. The estimated average annual age-adjusted firearm injury rate was 31.5 per 100,000 people. The case fatality rate for suicide due to firearm injury notably had the highest gun-related mortality rate by greater than 6-fold. Furthermore, from 2015 to 2016, the national mean annual case fatality rate was 84% for firearm-related suicide according to 2017 CDC report. Conclusion: Greater investment into research, education and prevention of gun-related violence among citizens in the state of Georgia is necessary. Although firearm-related aggravated assault due to interpersonal violence is common, the case fatality rate due to suicide has a greater than 6-fold higher rate of death

Basic science232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function

Background: Cardiovascular disease is a major comorbidity of rheumatoid arthritis (RA) and a leading cause of death. Chronic systemic inflammation involving tumour necrosis factor alpha (TNF) could contribute to endothelial activation and atherogenesis. A number of anti-TNF therapies are in current use for the treatment of RA, including certolizumab pegol (CZP), (Cimzia ®; UCB, Belgium). Anti-TNF therapy has been associated with reduced clinical cardiovascular disease risk and ameliorated vascular function in RA patients. However, the specific effects of TNF inhibitors on endothelial cell function are largely unknown. Our aim was to investigate the mechanisms underpinning CZP effects on TNF-activated human endothelial cells. Methods: Human aortic endothelial cells (HAoECs) were cultured in vitro and exposed to a) TNF alone, b) TNF plus CZP, or c) neither agent. Microarray analysis was used to examine the transcriptional profile of cells treated for 6 hrs and quantitative polymerase chain reaction (qPCR) analysed gene expression at 1, 3, 6 and 24 hrs. NF-κB localization and IκB degradation were investigated using immunocytochemistry, high content analysis and western blotting. Flow cytometry was conducted to detect microparticle release from HAoECs. Results: Transcriptional profiling revealed that while TNF alone had strong effects on endothelial gene expression, TNF and CZP in combination produced a global gene expression pattern similar to untreated control. The two most highly up-regulated genes in response to TNF treatment were adhesion molecules E-selectin and VCAM-1 (q 0.2 compared to control; p > 0.05 compared to TNF alone). The NF-κB pathway was confirmed as a downstream target of TNF-induced HAoEC activation, via nuclear translocation of NF-κB and degradation of IκB, effects which were abolished by treatment with CZP. In addition, flow cytometry detected an increased production of endothelial microparticles in TNF-activated HAoECs, which was prevented by treatment with CZP. Conclusions: We have found at a cellular level that a clinically available TNF inhibitor, CZP reduces the expression of adhesion molecule expression, and prevents TNF-induced activation of the NF-κB pathway. Furthermore, CZP prevents the production of microparticles by activated endothelial cells. This could be central to the prevention of inflammatory environments underlying these conditions and measurement of microparticles has potential as a novel prognostic marker for future cardiovascular events in this patient group. Disclosure statement: Y.A. received a research grant from UCB. I.B. received a research grant from UCB. S.H. received a research grant from UCB. All other authors have declared no conflicts of interes