Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department

Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study

BACKGROUND

Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety.

METHODS

Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews.

RESULTS

The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused.

CONCLUSION

Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.

Improving Wait Times for Children with Caregivers with Limited English Proficiency in the Emergency Department

Introduction

In our pediatric emergency department (ED), children triaged as low acuity who presented with Spanish-speaking caregivers with limited English proficiency (SSLEP) experienced disparately longer wait times than similarly triaged children with English-proficient caretakers. Although inequities in ED care based on language preference exist, little is known about effective interventions to eliminate the disparity. This quality improvement study aimed to eliminate the disparity in wait times and share effective interventions.

Methods

A multidisciplinary team incorporating clinicians, professional interpreters, and data analysts utilized quality improvement methodology to introduce early identification of SSLEP children, standardize physician workflow, and optimize the interpreter process. The primary outcome was the length of stay. The secondary outcome was time to the provider. The balancing measures were revisits and non-LEP length of stay and time to the provider. Secondary analyses distinguished between the effect of our QI intervention and secular trends.

Results

The mean length of stay for SSLEP children decreased from a mean of 178 to 142 minutes, a 36-minute (20%) decrease. Mean time to provider for SSLEP decreased from 92.8 to 55.5 minutes, a 37-minute improvement (40%). The 72-hour-revisit rates did not increase for SSLEP children throughout the project.

Conclusions

We identified feasible interventions to improve wait times for children with SSLEP. Future directions include addressing components of the entire ED visit to decrease the length of stay discrepancies between populations. We hope to extend our findings to benefit all LEP communities.

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED.

Using 360-degree video for teaching emergency medicine during and beyond the COVID-19 pandemic

OBJECTIVE

During the COVID-19 pandemic, emergency medicine (EM) teachers had to employ innovative methods to ensure the continuity of the education process. The purpose of this study was to explore the adequacy of the 360-degree video (video 360) technology in EM education in the context of: (a) students' attitudes towards the video 360; (b) students' academic performance in their required examination at the end of the EM course compared to the assessment results of students from the previous academic year.

METHODS

A mixed-method research project enrolled the fourth-year medical students who attended the required EM course during the first semester of the academic year 2020-2021 when all activities with undergraduate students went online and teaching scenarios recorded in the video 360 format were employed. Data collection was two-fold: (a) anonymous questionnaires, complemented with basic YouTube analytics; (b) multiple-choice questionnaires (MCQ) and oral examination, contrasting the results with those in 2019-2020. Data analysis used descriptive statistics and non-parametric methods.

RESULTS

Seventy-nine students (53 females and 26 males) participated in the project and all completed the EM course. Students' interest in and their acceptance of the video 360 technology were high (total scoring in the upper 20% of the respective scales), with consistently good performance in two parallel, independent, interview-based oral/practical evaluations (Spearman correlation coefficient R = 0.665, p < .001). The majority scored over 90% in the summative MCQ, with higher values compared to their colleagues' during the previous academic year (with on-site teaching): scoring percentages with mean ± standard deviation of 92.52 ± 4.57 and 76.67 ± 18.77, respectively.

CONCLUSION

Our project showed that the video 360 scenarios were effective in teaching EM. In the long term, employing this accessible and inexpensive educational approach would add value to on-site training by enriching the exposure to a specific ED environment.KEY MESSAGESMedical students valued the 360-degree video scenarios as contributing substantially to their EM knowledge and preparedness.Examination results confirmed the 360-degree video scenarios as viable in EM teaching.The 360-degree video technology would be a sustainable solution for hybrid medical teaching in the long term.

Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department

Objectives

Academic emergency physicians must find ways to teach residents, medical students, and advanced practice providers amidst the myriad demands on their time during clinical shifts. In this study, we sought to characterize in detail what types of teaching occurred, how often they occurred, and how attending teaching styles differed at one academic emergency department (ED).

Methods

We conducted this observational study in a large, urban, quaternary care, academic Level I trauma center with an emergency medicine (EM) residency. The on-shift activities of EM attending physicians (attendings) were observed and recorded over 42 hours by a fourth-year EM resident with co-observations by an EM education fellow. Teaching categories were identified, developed iteratively, and validated by the study team. We then characterized the distribution of teaching activities during shifts through the coding of attending activities every 30 seconds during observations. Teaching archetypes were then developed through the synthesis of notes taken during observations.

Results

Attendings spent a mean of 25% (standard deviation 7%) of their time engaging in teaching activities during shifts. Of this teaching time 36% consisted of explicit instruction, while the remaining 64% of teaching occurred implicitly through the discussion of cases with learners. The time distribution of on-shift activities varied greatly between attendings, but three archetypes emerged for how attendings coupled patient care and teaching: “in-series”; “in-parallel modeling”; and “in-parallel supervision.”

Conclusions

Teaching in this academic ED took many forms, most of which arose organically from patient care. The majority of on-shift teaching occurred through implicit means, rather than explicit instruction. Attendings also spent their time in markedly different ways and embodied distinct teaching archetypes. The impact of this variability on both educational and patient care outcomes warrants further study.

The Parallel Encounter: An Alternative to the Traditional Serial Trainee-Attending Patient Evaluation Model

BACKGROUND

The emergency department environment requires the clinician-educator to use adaptive teaching strategies to balance education with efficiency and patient care. Recently, alternative approaches to the traditional serial trainee-attending patient evaluation model have emerged in the literature.

METHODS

The parallel encounter involves the attending physician and resident seeing the patient independently. Instead of the trainee delivering a traditional oral case presentation, the trainee does not present the history and examination to the attending physician. Rather, the attending and trainee come together following their independent evaluations to jointly discuss and formulate the assessment and plan.

RESULTS

The parallel encounter has the potential to enhance the teaching encounter by emphasizing clinical reasoning, reduce cognitive bias by integrating two independent assessments of the same patient, increase attending workflow flexibility and efficiency, and improve patient satisfaction and outcomes by reducing time to initial provider contact. The attending must be mindful of protecting resident autonomy. This model tends to work better for more senior learners.

CONCLUSIONS

The parallel encounter represents a novel approach to the traditional serial trainee-attending patient evaluation model that may enhance the teaching encounter and improve patient care.

Institution of an emergency department "swarming" care model and sepsis door-to-antibiotic time: A quasi-experimental retrospective analysis

Background

Prompt sepsis treatment is associated with improved outcomes but requires a complex series of actions by multiple clinicians. We investigated whether simply reorganizing emergency department (ED) care to expedite patients’ initial evaluation was associated with shorter sepsis door-to-antibiotic times.

Methods

Patients eligible for this retrospective study received IV antibiotics and demonstrated acute organ failure after presenting to one of three EDs in Utah. On May 1, 2016, the intervention ED instituted “swarming” as the default model for initial evaluation of all mid- and low-acuity patients. Swarming involved simultaneous patient evaluation by the ED physician, nurse, and technician followed by a team discussion of the initial care plan. Care was unchanged at the two control EDs. A 30-day wash-in period separated the baseline (May 16, 2015 to April 15, 2016) and post-intervention (May 16, 2016 to November 15, 2016) analysis periods. We conducted a quasi-experimental analysis comparing door-to-antibiotic time for sepsis patients at the intervention ED after versus before care reorganization, applying difference-in-differences methods to control for trends in door-to-antibiotic time unrelated to the studied intervention and multivariable regression to adjust for patient characteristics.

Results

The analysis included 3,230 ED sepsis patients, including 1,406 from the intervention ED. Adjusted analyses using difference-in-differences methods to control for temporal trends unrelated to the studied intervention revealed no significant change in door-to-antibiotic time after care reorganization (-7 minutes, 95% CI -20 to 6 minutes, p = 0.29). Multivariable pre/post analyses using data only from the intervention ED overestimated the magnitude and statistical significance of outcome changes associated with ED care reorganization.

Conclusions

Implementation of an ED care model involving parallel multidisciplinary assessment and early team discussion of the care plan was not associated with improvements in mid- and low-acuity sepsis patients’ door-to-antibiotic time after accounting for changes in the outcome unrelated to the studied intervention.