Implementation of an Education Value Unit (EVU) System to Recognize Faculty Contributions

Introduction: Faculty educational contributions are hard to quantify, but in an era of limited resources it is essential to link funding with effort. The purpose of this study was to determine the feasibility of an educational value unit (EVU) system in an academic emergency department and to examine its effect on faculty behavior, particularly on conference attendance and completion of trainee evaluations.Methods: A taskforce representing education, research, and clinical missions was convened to develop a method of incentivizing productivity for an academic emergency medicine faculty. Domains of educational contributions were defined and assigned a value based on time expended. A 30-hour EVU threshold for achievement was aligned with departmental goals. Targets included educational presentations, completion of trainee evaluations and attendance at didactic conferences. We analyzed comparisons of performance during the year preceding and after implementation.Results: Faculty (N=50) attended significantly more didactic conferences (22.7 hours v. 34.5 hours, p<0.005) and completed more trainee evaluations (5.9 v. 8.8 months, p<0.005). During the pre-implementation year, 84% (42/50) met the 30-hour threshold with 94% (47/50) meeting post-implementation (p=0.11). Mean total EVUs increased significantly (94.4 hours v. 109.8 hours, p=0.04) resulting from increased conference attendance and evaluation completion without a change in other categories.Conclusion: In a busy academic department there are many work allocation pressures. An EVU system integrated with an incentive structure to recognize faculty contributions increases the importance of educational responsibilities. We propose an EVU model that could be implemented and adjusted for differing departmental priorities at other academic departments

Implementation of an Education Value Unit (EVU) System to Recognize Faculty Contributions

Introduction: Faculty educational contributions are hard to quantify, but in an era of limited resources it is essential to link funding with effort. The purpose of this study was to determine the feasibility of an educational value unit (EVU) system in an academic emergency department and to examine its effect on faculty behavior, particularly on conference attendance and completion of trainee evaluations. Methods: A taskforce representing education, research, and clinical missions was convened to develop a method of incentivizing productivity for an academic emergency medicine faculty. Domains of educational contributions were defined and assigned a value based on time expended. A 30-hour EVU threshold for achievement was aligned with departmental goals. Targets included educational presentations, completion of trainee evaluations and attendance at didactic conferences. We analyzed comparisons of performance during the year preceding and after implementation. Results: Faculty (N=50) attended significantly more didactic conferences (22.7 hours v. 34.5 hours, p<0.005) and completed more trainee evaluations (5.9 v. 8.8 months, p<0.005). During the pre-implementation year, 84% (42/50) met the 30-hour threshold with 94% (47/50) meeting post-implementation (p=0.11). Mean total EVUs increased significantly (94.4 hours v. 109.8 hours, p=0.04) resulting from increased conference attendance and evaluation completion without a change in other categories. Conclusion: In a busy academic department there are many work allocation pressures. An EVU system integrated with an incentive structure to recognize faculty contributions increases the importance of educational responsibilities. We propose an EVU model that could be implemented and adjusted for differing departmental priorities at other academic departments

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

Introduction: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.Methods: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.Results: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.Conclusion: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations

Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?

Introduction: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions. Methods: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins. Results: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality. Conclusion: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations

Reducing Computed Tomography Scan Utilization for Pediatric Minor Head Injury in the Emergency Department: A Quality Improvement Initiative

BackgroundThe validated Pediatric Emergency Care Applied Research Network (PECARN) prediction rules are meant to aid clinicians in safely reducing unwarranted imaging in children with minor head injuries (MHI). Even so, computed tomography (CT) scan utilization remains high, especially in intermediate‐risk (per PECARN) MHI patients. The primary objective of this quality improvement initiative was to reduce CT utilization rates in the intermediate‐risk MHI patients.MethodsThis project was conducted in a Level I trauma pediatric emergency department (ED). Children < 18 years evaluated for intermediate‐risk MHI from June 2016 through July 2019 were included. Our key drivers were provider education, decision support, and performance feedback. Our primary outcome was change in head CT utilization rate (%). Balancing measures included return visit within 72 hours of the index visit, ED length of stay (LOS), and clinically important traumatic brain injury (ciTBI) on the revisit. We used statistical process control methodology to assess head CT rates over time.ResultsA total of 1,535 eligible intermediate‐risk MHI patients were analyzed. Our intervention bundle was associated with a decrease in CT use from 18.5% (95% confidence interval [CI] = 14.5% to 22.5%) in the preintervention period to 13.9% (95% CI = 13.8% to 14.1%) in the postintervention period, an absolute reduction of 4.6% (p = 0.015). Over time, no difference was noted in either ED LOS or return visit rate. There was only one revisit with a ciTBI to our institution during the study period.ConclusionsOur multifaceted quality improvement initiative was both safe and effective in reducing our CT utilization rates in children with intermediate‐risk MHI.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/1/acem14177_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/2/acem14177-sup-0002-checklist.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/3/acem14177.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/4/acem14177-sup-0001-DataSupplementS1.pd

Reducing Computed Tomography Scan Utilization for Pediatric Minor Head Injury in the Emergency Department: A Quality Improvement Initiative

BackgroundThe validated Pediatric Emergency Care Applied Research Network (PECARN) prediction rules are meant to aid clinicians in safely reducing unwarranted imaging in children with minor head injuries (MHI). Even so, computed tomography (CT) scan utilization remains high, especially in intermediate‐risk (per PECARN) MHI patients. The primary objective of this quality improvement initiative was to reduce CT utilization rates in the intermediate‐risk MHI patients.MethodsThis project was conducted in a Level I trauma pediatric emergency department (ED). Children < 18 years evaluated for intermediate‐risk MHI from June 2016 through July 2019 were included. Our key drivers were provider education, decision support, and performance feedback. Our primary outcome was change in head CT utilization rate (%). Balancing measures included return visit within 72 hours of the index visit, ED length of stay (LOS), and clinically important traumatic brain injury (ciTBI) on the revisit. We used statistical process control methodology to assess head CT rates over time.ResultsA total of 1,535 eligible intermediate‐risk MHI patients were analyzed. Our intervention bundle was associated with a decrease in CT use from 18.5% (95% confidence interval [CI] = 14.5% to 22.5%) in the preintervention period to 13.9% (95% CI = 13.8% to 14.1%) in the postintervention period, an absolute reduction of 4.6% (p = 0.015). Over time, no difference was noted in either ED LOS or return visit rate. There was only one revisit with a ciTBI to our institution during the study period.ConclusionsOur multifaceted quality improvement initiative was both safe and effective in reducing our CT utilization rates in children with intermediate‐risk MHI.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/1/acem14177_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/2/acem14177-sup-0002-checklist.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/3/acem14177.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168525/4/acem14177-sup-0001-DataSupplementS1.pd

Assessing the Validity Evidence of an Objective Structured Assessment Tool of Technical Skills for Neonatal Lumbar Punctures

Background The lumbar puncture ( LP ) is a procedural competency deemed necessary by the Accreditation Council for Graduate Medical Education and the Emergency Medicine and Pediatric Residency Review Committees. The emergency department ( ED ) is a primary site for residents to be evaluated performing neonatal LP s. Current evaluation methods lack validity evidence as assessment tools. Objectives This was a pilot study to develop an objective structured assessment of technical skills for neonatal LP ( OSATS ‐ LP ) and to document validity evidence for the instrument in regard to five sources of test validity: content, response process, relation to other variables, inter‐rater reliability, and consequences of testing. Methods Pediatric residents were videotaped in the fall of 2011 for comparison of faculty evaluation of resident performance during a neonatal LP using a video‐delayed format. Residents completed a demographic experience survey evaluating relations to other variables. Content and response process validity was obtained through expert panel meetings and resulted in the following seven domains of performance for the OSATS ‐ LP : preparation, positioning, analgesia, needle insertion, cerebrospinal fluid ( CSF ) collection, management of laboratory studies, and sterility. t‐tests assessed significance between level of training, previous intensive care unit experience, and residents' self‐assessed confidence in comparison with their total performance score. The inter‐rater agreement of the OSATS ‐ LP was obtained using the Fleiss' kappa for each domain. Results Sixteen pediatric residents completed the simulation with six raters evaluating each resident (96 ratings). The domains of sterility and CSF collection had moderate statistical reliability (κ = 0.41 and 0.51, respectively). The domains of preparation, analgesia, and management of laboratories had substantial reliability (κ = 0.60, 0.62, and 0.62, respectively). The domains of positioning and needle insertion were less reliable (κ = 0.16 and 0.16, respectively). Individuals who had completed one or more rotations in the neonatal intensive care unit ( NICU ) had a higher total score (12.5 vs. 16.9; p < 0.01). The residents' own perception of ability to perform an LP unsupervised did not result in a higher total score. Conclusions The OSATS ‐ LP has reasonable evidence in four of the five sources for test validity. This study serves as a launching point for using this tool in clinical environments such as the ED and, therefore, has the potential to provide real‐time formative and summative feedback to improve resident skills and ultimately lead to improvements in patient care. Resumen Comprobación de la Validez de una Herramienta de Evaluación Estructurada Objetiva de Habilidades Técnicas para las Punciones Lumbares Neonatales Introducción La punción lumbar ( PL ) es un procedimiento cuya competencia se considera necesaria por el Accreditation Council for Graduate Medical Education y los Emergency Medicine and Pediatric Residency Review Committees . El servicio de urgencias ( SU ) es un lugar primario para evaluar a los residentes en la realización de la PL neonatal. Los métodos de evaluación actuales carecen de evidencia válida como herramientas de evaluación. Objetivos Éste fue un estudio piloto para desarrollar una evaluación estructurada objetiva de las habilidades técnicas para la PL neonatal ( OSATS ‐ LP ) y para documentar la validez para el instrumento respecto a cinco fuentes de la validez de un test: el contenido, el proceso respuesta, la relación a otras variables, la fiabilidad interobservador y las consecuencias del test. Metodología Los residentes de pediatría fueron grabados en otoño de 2011 para la comparación de la evaluación docente del rendimiento del residente durante una PL neonatal usando un formato de video diferido. Los residentes completaron una encuesta de experiencia demográfica mediante la evaluación de las relaciones con otras variables. La validez del contenido y del proceso de respuesta se obtuvo a través de las reuniones de un panel de expertos y resultó en los siguientes siete dominios de la realización para el OSATS ‐ LP : la preparación, la posición, la analgesia, la inserción de la aguja, la recogida del líquido cefalorraquídeo ( LCR ), el manejo de los estudios de laboratorio y la esterilidad. La significación entre el nivel de entrenamiento, la experiencia previa en una unidad de cuidados intensivos y la confianza autoevaluada del residente en comparación con su puntuación de rendimiento total se analizó con el test de la t de Student. La concordancia interobservador del OSATS ‐ LP se obtuvo con el índice kappa de Fleiss para cada dominio. Resultados Dieciséis residentes de pediatría completaron la simulación con seis evaluadores que examinaron a cada residente (96 clasificaciones). Los dominios de esterilidad y recogida de LCR tuvieron una fiabilidad moderada (k = 0,41 y 0,51, respectivamente). Los dominios de preparación, analgesia y manejo de laboratorio tuvieron una fiabilidad sustancial (k = 0,60, 0,62, y 0,62, respectivamente). Los dominios de la posición e inserción de la aguja fueron menos fiables (k = 0,16 y 0,16, respectivamente). Los residentes que habían realizado más PL se correlacionaron con una puntuación total mayor (coeficiente de correlación de Pearson = 0,5, p < 0,05). Los sujetos que habían completado una o más rotaciones en la unidad de cuidados intensivos neonatal tuvieron una puntuación total más alta (12,5 vs. 16,9; p < 0,01). La autopercepción de los residentes de la capacidad para realizar una PL no supervisada no resultó en una puntuación total más alta. Conclusiones La OSATS ‐ LP tiene una evidencia razonable en cuatro de las cinco fuentes para la validez del test. Este estudio sirve como un punto de partida para usar esta herramienta en los ambientes clínicos como el SU , y por ello, tiene la potencialidad para proporcionar una formación a tiempo real y una retroalimentación sumativa para mejorar las habilidades de los residentes, y conducir finalmente a mejoras en la atención del paciente.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97233/1/acem12093.pd

Assessing the Validity Evidence of an Objective Structured Assessment Tool of Technical Skills for Neonatal Lumbar Punctures

Background The lumbar puncture ( LP ) is a procedural competency deemed necessary by the Accreditation Council for Graduate Medical Education and the Emergency Medicine and Pediatric Residency Review Committees. The emergency department ( ED ) is a primary site for residents to be evaluated performing neonatal LP s. Current evaluation methods lack validity evidence as assessment tools. Objectives This was a pilot study to develop an objective structured assessment of technical skills for neonatal LP ( OSATS ‐ LP ) and to document validity evidence for the instrument in regard to five sources of test validity: content, response process, relation to other variables, inter‐rater reliability, and consequences of testing. Methods Pediatric residents were videotaped in the fall of 2011 for comparison of faculty evaluation of resident performance during a neonatal LP using a video‐delayed format. Residents completed a demographic experience survey evaluating relations to other variables. Content and response process validity was obtained through expert panel meetings and resulted in the following seven domains of performance for the OSATS ‐ LP : preparation, positioning, analgesia, needle insertion, cerebrospinal fluid ( CSF ) collection, management of laboratory studies, and sterility. t‐tests assessed significance between level of training, previous intensive care unit experience, and residents' self‐assessed confidence in comparison with their total performance score. The inter‐rater agreement of the OSATS ‐ LP was obtained using the Fleiss' kappa for each domain. Results Sixteen pediatric residents completed the simulation with six raters evaluating each resident (96 ratings). The domains of sterility and CSF collection had moderate statistical reliability (κ = 0.41 and 0.51, respectively). The domains of preparation, analgesia, and management of laboratories had substantial reliability (κ = 0.60, 0.62, and 0.62, respectively). The domains of positioning and needle insertion were less reliable (κ = 0.16 and 0.16, respectively). Individuals who had completed one or more rotations in the neonatal intensive care unit ( NICU ) had a higher total score (12.5 vs. 16.9; p < 0.01). The residents' own perception of ability to perform an LP unsupervised did not result in a higher total score. Conclusions The OSATS ‐ LP has reasonable evidence in four of the five sources for test validity. This study serves as a launching point for using this tool in clinical environments such as the ED and, therefore, has the potential to provide real‐time formative and summative feedback to improve resident skills and ultimately lead to improvements in patient care. Resumen Comprobación de la Validez de una Herramienta de Evaluación Estructurada Objetiva de Habilidades Técnicas para las Punciones Lumbares Neonatales Introducción La punción lumbar ( PL ) es un procedimiento cuya competencia se considera necesaria por el Accreditation Council for Graduate Medical Education y los Emergency Medicine and Pediatric Residency Review Committees . El servicio de urgencias ( SU ) es un lugar primario para evaluar a los residentes en la realización de la PL neonatal. Los métodos de evaluación actuales carecen de evidencia válida como herramientas de evaluación. Objetivos Éste fue un estudio piloto para desarrollar una evaluación estructurada objetiva de las habilidades técnicas para la PL neonatal ( OSATS ‐ LP ) y para documentar la validez para el instrumento respecto a cinco fuentes de la validez de un test: el contenido, el proceso respuesta, la relación a otras variables, la fiabilidad interobservador y las consecuencias del test. Metodología Los residentes de pediatría fueron grabados en otoño de 2011 para la comparación de la evaluación docente del rendimiento del residente durante una PL neonatal usando un formato de video diferido. Los residentes completaron una encuesta de experiencia demográfica mediante la evaluación de las relaciones con otras variables. La validez del contenido y del proceso de respuesta se obtuvo a través de las reuniones de un panel de expertos y resultó en los siguientes siete dominios de la realización para el OSATS ‐ LP : la preparación, la posición, la analgesia, la inserción de la aguja, la recogida del líquido cefalorraquídeo ( LCR ), el manejo de los estudios de laboratorio y la esterilidad. La significación entre el nivel de entrenamiento, la experiencia previa en una unidad de cuidados intensivos y la confianza autoevaluada del residente en comparación con su puntuación de rendimiento total se analizó con el test de la t de Student. La concordancia interobservador del OSATS ‐ LP se obtuvo con el índice kappa de Fleiss para cada dominio. Resultados Dieciséis residentes de pediatría completaron la simulación con seis evaluadores que examinaron a cada residente (96 clasificaciones). Los dominios de esterilidad y recogida de LCR tuvieron una fiabilidad moderada (k = 0,41 y 0,51, respectivamente). Los dominios de preparación, analgesia y manejo de laboratorio tuvieron una fiabilidad sustancial (k = 0,60, 0,62, y 0,62, respectivamente). Los dominios de la posición e inserción de la aguja fueron menos fiables (k = 0,16 y 0,16, respectivamente). Los residentes que habían realizado más PL se correlacionaron con una puntuación total mayor (coeficiente de correlación de Pearson = 0,5, p < 0,05). Los sujetos que habían completado una o más rotaciones en la unidad de cuidados intensivos neonatal tuvieron una puntuación total más alta (12,5 vs. 16,9; p < 0,01). La autopercepción de los residentes de la capacidad para realizar una PL no supervisada no resultó en una puntuación total más alta. Conclusiones La OSATS ‐ LP tiene una evidencia razonable en cuatro de las cinco fuentes para la validez del test. Este estudio sirve como un punto de partida para usar esta herramienta en los ambientes clínicos como el SU , y por ello, tiene la potencialidad para proporcionar una formación a tiempo real y una retroalimentación sumativa para mejorar las habilidades de los residentes, y conducir finalmente a mejoras en la atención del paciente.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97233/1/acem12093.pd

Model for Developing Educational Research Productivity: The Medical Education Research Group

Introduction: Education research and scholarship are essential for promotion of faculty as well as dissemination of new educational practices. Educational faculty frequently spend the majority of their time on administrative and educational commitments and as a result educators often fall behind on scholarship and research. The objective of this educational advance is to promote scholarly productivity as a template for others to follow. Methods: We formed the Medical Education Research Group (MERG) of education leaders from our emergency medicine residency, fellowship, and clerkship programs, as well as residents with a focus on education. First, we incorporated scholarship into the required activities of our education missions by evaluating the impact of programmatic changes and then submitting the curricula or process as peer-reviewed work. Second, we worked as a team, sharing projects that led to improved motivation, accountability, and work completion. Third, our monthly meetings served as brainstorming sessions for new projects, research skill building, and tracking work completion. Lastly, we incorporated a work-study graduate student to assist with basic but time-consuming tasks of completing manuscripts.Results: The MERG group has been highly productive, achieving the following scholarship over a three-year period: 102 abstract presentations, 46 journal article publications, 13 MedEd Portal publications, 35 national didactic presentations and five faculty promotions to the next academic level.Conclusion: An intentional focus on scholarship has led to a collaborative group of educators successfully improving their scholarship through team productivity, which ultimately leads to faculty promotions and dissemination of innovations in education

A global survey of emergency department responses to the COVID-19 pandemic

Publisher Copyright: © 2021 Mahajan et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License.Introduction: Emergency departments (ED) globally are addressing the coronavirus disease 2019 (COVID-19) pandemic with varying degrees of success. We leveraged the 17-country, Emergency Medicine Education & Research by Global Experts (EMERGE) network and non-EMERGE ED contacts to understand ED emergency preparedness and practices globally when combating the COVID-19 pandemic. Methods: We electronically surveyed EMERGE and non-EMERGE EDs from April 3-June 1, 2020 on ED capacity, pandemic preparedness plans, triage methods, staffing, supplies, and communication practices. The survey was available in English, Mandarin Chinese, and Spanish to optimize participation. We analyzed survey responses using descriptive statistics. Results: 74/129 (57%) EDs from 28 countries in all six World Health Organization global regions responded. Most EDs were in Asia (49%), followed by North America (28%), and Europe (14%). Nearly all EDs (97%) developed and implemented protocols for screening, testing, and treating patients with suspected COVID-19 infections. Sixty percent responded that provider staffing/back-up plans were ineffective. Many sites (47/74, 64%) reported staff missing work due to possible illness with the highest provider proportion of COVID-19 exposures and infections among nurses. Conclusion: Despite having disaster plans in place, ED pandemic preparedness and response continue to be a challenge. Global emergency research networks are vital for generating and disseminating large-scale event data, which is particularly important during a pandemic.Peer reviewe