A pre-clinical medical student was trained as a reviewer by an emergency medicine attending who was a QI officer with experience in chart review.We reviewed each patient’s index ED note for the following: age at time of ED visit; gender; migraine history; known history of significant intracranial pathology; whether brain imaging was performed during the index ED visit; and findings from the brain imaging if performed. We reviewed all ED, neurology, neurosurgery, and primary care clinic notes as well as any HCT or brain magnetic resonance imaging results occurring in the 22.5-month period following each index ED visit. This length of time was selected because it was the maximum window available from the last visit in the dataset at the time that data collection began. Follow-up data included the following: whether a follow up visit took place for a similar headache; diagnoses assigned at follow-up visits; date of follow-up visit; the service providing follow-up care; whether death was recorded in our EMR; whether brain imaging was performed in the follow up period; and findings from brain imaging if performed. We distinguished between follow-up for any reason and those related to the ED visit as a marker for sample retention during the follow-up window. Data were entered into a standardized data collection spreadsheet. Prior to data collection we defined all terms in the spreadsheet in a data dictionary. No adjustment was made for trainee involvement or subsequent shift changes at the time of the index ED visit. A priori we defined potential missed diagnosis as the presence of any of the following conditions being found after the index ED visit: aneurysm involving the intracranial or cervical vessels; hydrocephalus; intracranial hypertension; stroke ; intracranial mass; subarachnoid hemorrhage; subdural hemorrhage; epidural hemorrhage; intraparenchymal hemorrhage; or dural sinus thrombosis.

To determine which subsequently-identified intracranial conditions should be counted as missed diagnoses we employed a board-certified EP to perform an independent review of all records where subsequent intracranial conditions were identified. This reviewer was blinded to the study hypothesis and had not been involved in or measured by the initial QI project. For each potential missed diagnosis, the independent reviewer reviewed the index ED visit note,indoor garden table follow-up visit notes and radiology reports before assigning a determination of whether the subsequently-diagnosed cranial condition could have potentially been diagnosed at the index visit. We labeled these as missed intracranial diagnoses.During our QI effort we did not observe a decrease in HCT after a year of educational interventions, but we observed a 9.6% decrease after providers reviewed their own data. This accords with the Institute of Medicine suggestion that feeding providers’ data back to them may be an important part of effectively changing physician behavior.It is worth noting that during our QI effort we never explicitly instructed providers to decrease HCT ordering. This was motivated by the assumption that our doctors were already trying to do the right thing and avoid unnecessary testing, but that doctors might be capable of being more diligent in diagnosis assignment. The decrease in HCT ordering that we observed came after providers reviewed their own data. So this decrease appears to have resulted from a change that providers took upon themselves after being given the opportunity to look at objective data of their practice patterns and to reflect on what this data told them about their own practice. Happily, this would seem to support our initial assumption that doctors are generally trying to do the right thing. Previous studies have found that CT pulmonary angiography for evaluation of pulmonary embolism could be safely decreased, thereby decreasing resource utilization without causing harm to patients.20,21 These studies used probabilistic decision models or looked at inpatient charges, limiting their generalizability to ED patients.

The most compelling evidence supporting the safety and cost effectiveness of decreasing CTPA in ED patients had median hospital stays of 7.7 days and medical charges of $6,281.This was in contrast to the typical patient presenting to the ED with headache, where reduced testing may mean no testing. We found that a reduction in HCT use for the evaluation of ED patients with headache was not followed by increased death or missed diagnoses. However, the observations that those patients who returned for reevaluation of the same complaint and those who subsequently received brain imaging were more likely to have not had HCT during index visit calls the true impact of decreasing ED-based testing on overall resource utilization into question.It may be the case that many patients simply feel that they need some sort of test to have had a thorough evaluation. This is supported by studies finding that ED patients who do not receive CT imaging for headache or for abdominal pain were more likely to return within 30 days.A previous study has observed up to three-fold variability in the proportion of HCT use for the evaluation of atraumatic headache in the ED.In our study we observed a convergence between EPs’ HCT-ordering proportions when we compared the pre-intervention to the post-data review phases; however, because our study was not designed or powered to investigate this, our observation is only suggestive. This study has several limitations. As a retrospective chart review, we only had access to information contained in the EMR. Patients who did not follow up with us may have had death or missed diagnoses that we did not observe. In the pre post study design, however, these factors are likely distributed across time periods, so we do not expect that this study type biased our findings. Approximately 86% of the sample had a subsequent visit within our EMR, suggesting that access to care was good and that the probability of patients seeking care outside our health system was low. Though we cannot exclude other causes of HCT reduction over time, there were no co existing initiatives in place in the study institution to change HCT ordering practices.

Since we do not practice in a closed medical system, patients could have presented to other systems for care or could have died without presenting to our hospital. To address this issue, we limited the outcomes assessment to patients who received primary care within our university health system by excluding patients who were transferred in,microgreens grow rack improving the probability that we would capture events. Because of neurosurgical coverage in our predominantly rural state, nearly all patients in our region with significant intracranial pathology would be transferred to our institution for care; therefore, it is unlikely that such outcomes were not captured. This is supported by the observation that over 85% of patients in this study had another encounter in our health system within 22.5 months of the index visit. The use of an outcome that did not account for the clinical conditions, comorbidities, or appropriateness of initial CT ordering limits the applicability of our findings. However, this type of metric was drafted as part of the proposed quality measure; so interpreting our CT ordering practices in this context parallels the outcomes that might be expected if this metric were more widely adopted. In this way, our study is pragmatic and reflects the limitations of case identification and administrative data use. CMS OP-15 was found to be unreliable, in part because it relied upon administrative data.We addressed this issue by relying on chart review, the gold standard against which the aforementioned study compared OP-15. This resulted in a more reliable measure but at the cost of a highly labor intensive technique.Burnout, depression, and suicidality among residents across all specialties have become a critical focus of attention for the medical education community. Prevalence studies have revealed rates of burnout among residents to be as high as 76%, as measured by the Maslach Burnout Inventory.1 Residents suffering from burnout have a higher risk than their peers of developing depression, anxiety, and substance-abuse problems.Even more alarmingly, up to 9.4% of fourth-year medical students and interns reported having suicidal thoughts.These numbers are borne out in the estimated 400 physicians who commit suicide each year.In response to these findings, the Accreditation Council for Graduate Medical Education approved major changes to the Common Program Requirements to begin in July 2017. In section VI.C, residency programs are mandated to educate residents and faculty members in the identification of burnout, depression, and substance abuse and to implement curricula that encourage their optimal well being.However, the ACGME has yet to provide residency programs with concrete guidelines for the creation of wellness curricula to adequately address this mandate. Many residency programs have already implemented some form of wellness training for their residents. Unfortunately, evidence supporting the efficacy of these interventions is sparse and often limited to single institutions and small sample sizes.

Nor has the medical education community reached an agreement on the best method of identifying relevant and high-impact wellness topics for residents, or understanding the optimal method for delivery and dissemination of information. From October 3, 2016, to May 14, 2017, members of the Wellness Think Tank communicated through a shared online platform to discuss the strengths and weaknesses of the wellness programs at their respective training sites. The Think Tank is a virtual community of practice, hosted by a medical education organization Academic Life in Emergency Medicine, which is comprised of 142 emergency medicine residents from 100 different training programs in North America. Multiple residents noted a haphazard and ineffective approach to teaching wellness topics, which they attributed primarily to a lack of shared knowledge between residency programs. Residents voiced a clear need for more widely shared lesson plans that focus on the development of practical skills fostering personal wellness. In preparation for the 2017 Resident Wellness Consensus Summit in-person event on May 15, 2017, an Educator Toolkit working group was created. Using a group consensus process, the residents of the Wellness Think Tank selected and agreed upon three high-yield topics that would benefit educators as an evidence-based, robust resource: second victim syndrome , mindfulness and meditation, and positive psychology. Each toolkit was designed using Kern’s six-step model of curriculum design, active teaching techniques, and accountability to increase engagement. Representing 20 different programs, 8, 16, and 17 residents participated in the development of the SVS, mindfulness and meditation, and positive psychology educator tool kits, respectively. Two faculty members trained in educational theory, one with a master’s degree in medical education, provided oversight. Twenty-two resident members of the Wellness Think Tank and 22 additional residents attended the live RWCS event. These residents represented 31 EM residency programs located in three different countries. Five faculty members facilitated the event. Members of the Educator Toolkit working group presented their drafts to the RWCS consensus group for review. There, participants discussed the proposed topics, learning objectives, and teaching techniques for each of the three topics. Following the RWCS, each educator toolkit was further refined based on the feedback, which resulted in the final versions presented here. A phenomenon growing in national awareness,8–10 SVS is commonly defined as feelings of guilt, inadequacy, or incompetence following an unexpected, negative patient outcome. Commonly manifesting as anxiety, depression or shame, it often goes unrecognized. It is likely that most healthcare providers experience symptoms of SVS at least once in their careers and the emotional “wear-and-tear” may contribute to burnout, the decision to depart from clinical medicine, or even suicide.Victims of SVS may require assistance from mentors, colleagues, or mental health professionals to cope with the frequently intense, negative personal and professional ramifications of the experience.Awareness of the existence of SVS is critical for residents and faculty so that they may develop strategies to mitigate the negative effects in both themselves and their colleagues. Despite its relevance across specialties, and especially EM, no published residency curricula discuss SVS. Our toolkit aims to fill that education gap to ensure that residents are prepared for the emotional and professional toll from inevitable negative patient outcomes that will occur during their careers. To maximize learner engagement and provide flexibility for residency programs, this toolkit includes four “mini modules” using a flipped-classroom approach. Each module consists of a pre-reading assignment followed by a 20-minute group discussion.