Impact of night shifts on emergency medicine resident resuscitation performance

Effect of serial night shifts on the cognitive, psychomotor, and moral performance of residents in the department of Emergency Medicine

OBJECTIVES

The objective was to study the effect of serial night shifts on the cognitive, psychomotor, and moral performance of emergency medicine residents of an academic Emergency Medicine Department.

METHODS

This prospective case-crossover study compared emergency medicine residents' sleep time, subjective sleepiness, cognitive function, moral judgment, and psychomotor skills after 5 consecutive days versus night shifts using sleep diaries, activity monitors, and multiple performance tests. Paired t-tests and Wilcoxon signed-rank tests were used to analyze data based on normality. Correlation analysis was done using Spearman's correlation test. Subgroup analysis was also performed to find any difference based on gender and year of residency.

RESULTS

Twenty-seven emergency medicine residents participated (13 males, 48.1%). The distribution across residency years was as follows: 44.4% in their first year, 25.9% in their second year, and 29.6% in their third year. Following five consecutive night shifts, total sleep duration decreased significantly from 338.1 ± 67.8 to 307.4 ± 71.0 min (p < 0.001), while subjective sleepiness scores increased from 9.6 ± 3.3 to 13.6 ± 4.6. Psychomotor performance and reaction times did not significantly differ between night and day shifts. However, working memory declined, assessed by self-paced three-back test scores (median [IQR] 517.1 [471.9-546.7] vs. 457.6 [334.4-508.8]; p = 0.034) and interference test scores (445.5 ± 59.9 vs. 407.2 ± 56.8; p < 0.001), along with moral judgment (median [IQR] 19 [18-28] vs. 15 [11-21]; p = 0.010) after serial night shifts. No correlations existed between performance measures nor differences based on gender or residency year.

CONCLUSIONS

Residents sleep less following night versus day shifts, reporting the highest sleepiness levels after 5 consecutive nights. Despite this, psychomotor performance and reaction times did not significantly differ. However, considerable reductions occurred in moral judgment, working memory, and interference test performance after serial night shifts.

Medico-legal risk and use of medical directives in the emergency department

PURPOSE

The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED.

METHODS

We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including "standing order", "nursing initiated", "nurse initiated", "nursing order", "triage initiated", "triage ordered", "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

RESULTS

From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated.

CONCLUSION

Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.

Direct Observation Tools in Emergency Medicine: A Systematic Review of the Literature

OBJECTIVES

Direct observation is important for assessing the competency of medical learners. Multiple tools have been described in other fields, although the degree of emergency medicine-specific literature is unclear. This review sought to summarize the current literature on direct observation tools in the emergency department (ED) setting.

METHODS

We searched PubMed, Scopus, CINAHL, the Cochrane Central Register of Clinical Trials, the Cochrane Database of Systematic Reviews, ERIC, PsycINFO, and Google Scholar from 2012 to 2020 for publications on direct observation tools in the ED setting. Data were dual extracted into a predefined worksheet, and quality analysis was performed using the Medical Education Research Study Quality Instrument.

RESULTS

We identified 38 publications, comprising 2,977 learners. Fifteen different tools were described. The most commonly assessed tools included the Milestones (nine studies), Observed Structured Clinical Exercises (seven studies), the McMaster Modular Assessment Program (six studies), Queen's Simulation Assessment Test (five studies), and the mini-Clinical Evaluation Exercise (four studies). Most of the studies were performed in a single institution, and there were limited validity or reliability assessments reported.

CONCLUSIONS

The number of publications on direct observation tools for the ED setting has markedly increased. However, there remains a need for stronger internal and external validity data.

Correlation of student performance on clerkship with quality of medical chart documentation in a simulation setting

BACKGROUND

Medical chart documentation is an essential skill acquired in a clinical clerkship (CC). However, the utility of medical chart writing simulations as a component of the objective structured clinical examination (OSCE) has not been sufficiently evaluated. In this study, medical chart documentation in several clinical simulation settings was performed as part of the OSCE, and its correlation with CC performance was evaluated.

METHODS

We created a clinical situation video and images involving the acquisition of informed consent, cardiopulmonary resuscitation, and diagnostic imaging in the emergency department, and assessed medical chart documentation performance by medical students as part of the OSCE. Evaluations were conducted utilizing original checklist (0-10 point). We also analyzed the correlation between medical chart documentation OSCE scores and CC performance of 120 medical students who performed their CC in 2019 as 5th year students and took the Post-CC OSCE in 2020 as 6th year students.

RESULTS

Of the OSCE components, scores for the acquisition of informed consent and resuscitation showed significant correlations with CC performance (P<0.001 for each). In contrast, scores for diagnostic imaging showed a slightly positive, but non-significant, correlation with CC performance (P = 0.107). Overall scores for OSCE showed a significant correlation with CC performance (P<0.001).

CONCLUSION

We conducted a correlation analysis of CC performance and the quality of medical chart documentation in a simulation setting. Our results suggest that medical chart documentation can be one possible alternative component in the OSCE.

Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study

Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED). Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison. Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37-4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42-8.26), p < 0.001). Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.