Introduction: Burnout is a major threat to patient care quality and physician career longevity in emergency medicine. We sought to develop and implement a quality improvement process to engage emergency department (ED) faculty in identifying sources of burnout and generating interventions targeted at improving the work environment.

Methods: In this prospective interventional study conducted at a large, urban, academic medical center, we surveyed a 60-person faculty group using the Professional Fulfilment Index (PFI), as well as burnout-relevant questions from the American Medical Association’s Mini-Z survey and the Maslach-Leiter framework for organizational burnout, in order to identify organizational sources of burnout. We assessed the relationship between burnout scores and responses to the Maslach-Leiter framework using univariate regression analysis. In a two-hour facilitated session, we shared survey results and led the group in a process using the six Maslach-Leiter domains to develop a rank-ordered list of interventions to reduce burnout in each domain.

Results: In total, 47 of 60 faculty (78.3%) completed the survey and 45 faculty (75%) attended the discussion session. Of the 47 survey respondents, 14 (30%) met criteria for moderate to severe burnout. The respondents’ answers to the Maslach-Leiter organizational burnout domain questions were significantly correlated with their burnout scores (P <0.001). Session attendees generated 31 potential interventions for process improvement, which were analyzed and thematically organized. Common intervention themes included reducing documentation burden, receiving more positive feedback on patient care, improving ease of obtaining consults, decreasing ED crowding, and increasing intrafaculty social connection. Interventions were subsequently reviewed and scored based on relative importance and feasibility to create a departmental action plan for process improvement.

Conclusion: Using the Maslach-Leiter organizational burnout framework, in conjunction with a facilitated solution-oriented faculty discussion, led to the creation of a departmental agenda focused on organizational solutions for augmenting professional fulfillment and reducing burnout. We propose that this process can be used by healthcare organizations to engage physicians and others in efforts to improve their work experiences, which in turn is likely also to support the provision of higher quality of care.

Introduction: Nothing has been published to describe the practices of medical societies in choosing abstracts for presentations at their annual meetings. We surveyed medical societies to determine their practices, and also present a theoretical analysis of the topic.

Methods: We contacted a convenience sample of large U.S. medical conferences, and determined their approach to choosing abstracts. We obtained information from web sites, telephone, and email. Our theoretical analysis compares values-based and empirical approaches for scoring system development.

Results: We contacted 32 societies and obtained data on 28 (response rate 88%). We excluded one upon learning that research was not presented at its annual meeting, leaving 27 for analysis. Only 2 (7%) made their abstract scoring process available to submitters. Reviews were blinded in most societies (21; 78%), and all but one asked reviewers to recuse themselves for conflict of interest (96%). All required ≥3 reviewers. Of the 24 providing information on how scores were generated, 21 (88%) reported using a single gestalt score, and three used a combined score created from pooled domain-specific sub-scores. We present a framework for societies to use in choosing abstracts, and demonstrate its application in the development of a new scoring system.

Conclusions: Most medical societies use subjective, gestalt methods to select research for presentation at their annual meetings and do not disclose to submitters the details of how abstracts are chosen. We present a new scoring system that is transparent to submitters and reviewers alike with an accompanying statement of values and ground rules. We discuss the challenges faced in selecting abstracts for a large scientific meeting and share the values and practical considerations that undergird the new system.

Introduction: Despite prior efforts to improve well-being in emergency medicine, clinician burnout in the specialty is rising. In this study we examined the acceptability and feasibility of using a method called “experience sampling” to explore factors important to clinician experience in emergency departments (ED). Experience sampling enables the measuring of work experience in real time, with more granular detail than in usual burnout surveys. The approach may reveal new opportunities for improving work experience in emergency medicine at a critical time.

Methods: We conducted this pilot study in a large, urban, academic, quaternary care ED. Iterative multidisciplinary focus groups were used to generate a brief, experience-sampling tool that was comprised of three different surveys to assess emergency clinician experience before, during, and after shifts. These were deployed using a smartphone application to a convenience sample of 11 clinicians (three attending physicians, two residents, five physician assistants, and one registered nurse) during four shifts each. A post-pilot survey was also sent to all participants to evaluate their experience of using the tool. Our primary outcome measures were feasibility, assessed by the survey response rates during the pilot, and acceptability, assessed by participant sentiment as expressed in the post-pilot surveys. Secondary outcomes were quantitative- and qualitative- experience data collected using the tool.

Results: The overall response rates for pre-shift, on-shift, and post-shift surveys were 79%, 73%, and 91%, respectively. All participants responded to the post-pilot survey and indicated they would be willing to use the experience-sampling tool again in the future. Many participants noted that the simple and open-ended on-shift questions were relatively easy to complete; some also said on-shift survey questions could present added difficulty during busy shifts. Four participants said the exercise of completing surveys itself improved on-shift experience by prompting reflection. Common themes associated with positive experiences included manageable patient volumes, excellent teamwork, interesting cases, adequate staffing, and feeling able to provide adequate care. Common themes associated with negative experiences included crowding, inadequate staffing, feeling overwhelmed, complex patient cases, difficult disposition plans, and feeling unable to provide adequate care.

Conclusion: Experience sampling is an acceptable and feasible method for measuring clinician experience in a busy academic ED. Further studies could potentially use this approach to identify targets for reducing burnout in emergency medicine. 

Introduction: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic.

Methods: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales.

Results: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were “to enhance my sense of community and connection” (81%) followed by “to support colleagues” (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/- 17.6) interquartile range: 73-89), NPPs were less comfortable speaking up (58.5 +/- 23.6) than attending physicians (77.8 +/- 25.0) (p = < 0.008).

Conclusion: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce.

Introduction: Emergency physicians have the highest rates of burnout among our physician peers, with prior literature suggesting clinician schedules can play a significant role in burnout. We assessed our transition from a tenure- and age-based paradigm to an egalitarian, night shift buy-out program that allows schedule flexibility for physicians at all stages of their careers.

Methods: The night shift buy-out program was implemented in the emergency department (ED) of an academic, quaternary-care center that treats approximately 100,000 adult patients annually with 56 faculty emergency physicians. We sought to create a cost-neutral program, carefully balancing incentives between nocturnists and those wanting to reduce allotted night shifts. Ultimately, the program was designed to allow all faculty to buy out of any number of nights for $500 per night shift, with the funds generated used to increase nocturnist salaries. We analyzed two years of the program (July 2022–June 2024) to assess trends in night shift buy-outs, the primary outcome. We also conducted an all-faculty survey after the program’s first year to gauge sentiments about the program.

Results: Over two years, 22 faculty (42%) fully bought out of nights; an additional 10 (15%) bought out of some nights. By year two, the program could grant all faculty their preferred night-shift allotment. Faculty who bought out fully had worked longer in EM on average, worked fewer clinical hours per year, were more likely to be associate/full professors, and were less likely to be women. Nocturnists had the highest mean clinical hours of the four groups, had the lowest average tenure, and were least likely to be associate/full professors. A total of 86% of faculty responded to the survey, to which more than 80% of those buying out reported that reducing the night-shift burden was either “very important” or “critical for continuing in this job.”

Conclusion: Our academic ED transitioned from a tenure- and age-based, overnight shift paradigm to an egalitarian buy-out program that allows physicians flexibility at all career stages. This approach could improve career satisfaction and reduce burnout among emergency physicians.

Introduction: Growing evidence supports emergency physician (EP)-performed point-of-care ultrasound (PoC US). However, there is a utilization gap between academic emergency departments (ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample of predominantly non-academic EDs to inform future strategies to increase PoC US utilization, particularly in non-academic centers.

Methods: In 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota, Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and whether EPs can bill for PoC US.

Results: Response rates were >80% in each state. Overall, 47% of EDs reported PoC US availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability was associated with higher ED visit volume, and percent of EPs who were board certified/board eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense (39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC US. Only 12% of EPs used it ≥80% of the time when placing central venous lines.

Conclusion: Only 47% of EDs in our five-state sample of predominantly non-academic EDs had PoC US immediately available. When available, the greatest barriers to use were limited training, expense, and limited need. Recent educational and technical advancements may help overcome these barriers.

INTRODUCTION

While only 15-20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR) as well as use and yield of foot and ankle radiographs in patients with acute ankle injury.

METHODS

Institutional Review Board approval was obtained for this randomized controlled study performed April 18, 2012 through December 15, 2013.  All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. Patients with foot and ankle complaints were identified via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups.

RESULTS

Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01) while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04).

CONCLUSION

Clinical Decision Support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increase imaging yield.

INTRODUCTION

Emergency Department (ED) crowding is prevalent and can result in care delays, medical errors, increased costs and mortality. Simultaneously, capacity constraints on EDs are worsening, yet patient arrival rates and inpatient bed capacity are often outside the influence of ED administrators. Therefore systems engineering to improve throughput and reduce waste and waits holds the most readily available promise. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays, and determine the most effective techniques.

METHODS

This prospective, before and after analysis of radiology process flow improvements in a academic hospital ED was exempt from Institutional Review Board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely utilizing Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013-3/2016 and requiring plain film imaging were included. Electronic medical record data were analyzed using Microsoft Excel and SAS version 9.4.

RESULTS

Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.1 ± 4.2 minutes during the 3 months pre-intervention. It was reduced by 13% in the first three months (3.8 minutes; to 24.3 ± 3.3 min, P=0.021), 17% in the following six months (4.8 minutes; to 23.3 ± 3.5 min, P=0.003), and 24% one year following the intervention (6.8 minutes; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in Emergency Department (ED) radiology processes.

CONCLUSION

In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use.

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.