- Email: [email protected]
EMF-10: Emergency Physician Leadership In Acute Stroke Care
Research Forum Abstracts new EM residency graduates choose to practice in rural emergency departments (EDs), and the barriers to recruitment to rural EDs. Methods: Using the American Medical Association Physician Masterfile to identify 2006-2008 EM residency graduates, we surveyed everyone currently practicing in rural EDs, and a random sample of emergency physicians practicing in urban EDs. We asked all emergency physicians about the importance of 13 factors (previously reported as potentially important in the EM and primary care literature) that may have affected their decision to practice in their current rural/urban location. We asked urban emergency physicians to characterize which factors, if changed, would influence their decision toward practicing in a rural community. We also asked emergency physicians about participation in a rural ED rotation/experience during residency and time spent in a rural area during childhood years (0-18 years). We also obtained additional demographic characteristics from the Masterfile data. We compared responses from rural and urban emergency physicians using differences in proportions with 95% confidence intervals (CIs). Results: We received responses from 197 (67%) of the 296 eligible emergency physicians (110 rural [73% of eligible] and 87 urban [60% of eligible]). The factors most often rated as “somewhat” or “very” important in choice of practice location were: lifestyle (98%), access to amenities/recreation (95%), ED volume/acuity (93%), and family/spouse connection (90%). Access to specialists was rated as the biggest difference in rating of very important (20% for rural versus 44% for urban emergency physicians; difference ⫹24% [95%CI, ⫹37 to ⫹11]). More rural emergency physicians spent their entire childhood (IE, 18 years) in rural areas than urban emergency physicians (42% versus 24%; difference ⫹18% [95%CI, 5 to 31]). The changes that would have most influenced urban emergency physicians to practice in rural communities were family/spouse connection (92%), higher salary/signing bonus (90%), and increased access to specialists (90%). Overall, 22 (25%) of the 87 urban emergency physicians stated that they considered practicing in a rural area immediately following graduation. Of urban emergency physicians that did not participate in a rural rotation during residency, 44% said they would have, if it were available. Conclusions: The ongoing shortage of EM residency-trained emergency physicians in rural areas supports the importance of developing new and effective interventions for improving emergency physician recruitment and retention to rural areas. Of factors that are amenable to change, higher salaries are most likely to influence new EM residency graduates to practice in rural EDs. Additionally, EM residency recruitment of individuals with a rural upbringing may be a promising strategy to increase rural recruitment (family connection). Concerns about limited rural access to specialists appeared to be an important barrier to rural practice. Increasing the availability of rural rotations during EM residency may not only motivate some new graduates to choose a career in a rural area, but it also might better prepare EM residency graduates for the unique challenges and opportunities of rural emergency care.
EMF-9
Implementation of the Central Venous Catheter Observer and Checklist Bundle In Emergency Departments: A Qualitative Study
LeMaster C, Hoffart N, Benzer T, Chafe T, Pallin D, Schreiber H, Wang R, Schuur J/Brigham and Women’s Hospital, Boston, MA; Bouve College of Health Sciences, Northeastern University, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard University, Cambridge, MA
Study Objectives: Based on research from intensive care units (ICUs), in 2010 the Joint Commission mandated the use of a central venous catheter (CVC) checklist during CVC placement in all areas of the hospital, including the emergency department (ED). The ED faces unique barriers to implementation of this safety goal because of human factors such as high patient-to-nurse ratios, a rapidly changing
Volume , . : September
environment, and limited resources. We aimed to identify common barriers to and solutions for implementation of the CVC checklist in EDs in the United States. Methods: We performed semi-structured interviews and focus groups of key personnel involved in the implementation, maintenance, and use of the CVC checklist in the ED. Interviews were performed using a semi-structured questionnaire and EDs were identified through purposeful sampling using the Institute of Healthcare Improvement CVC Mentor Registry Hospitals and Michigan Keystone hospitals. Staff included administrators, infection control staff, hospital Chief Medical Officers, ED nursing educators, physician chiefs, ED nurses, and emergency physicians. Interviews were iteratively coded using the Grounded Theory method. Results: We have performed interviews with 35 staff at 5 hospitals. Data collection is ongoing and will end once we reach thematic saturation. To date we have identified 8 key themes, each with associated barriers and solutions. These include: (1) staff culture, (2) physical space/layout, (3) physician and nurse staffing, (4) inpatient coordination, (5) equipment/central line kit/central line cart, (6) time, (7) teamwork/information coordination, and (8) protocol implementation. The latter category includes (a) preparation/planning, (b) teaching, and (c) quality assurance/ monitoring/feedback. A leading barrier to implementing the CVC checklist and observer protocol in the EDs appears to be identifying an individual who is qualified and has the time to observe the entire procedure. Conclusion: There are many barriers to the CVC checklist protocol, some of which are unique to emergency medicine. The strategies for implementation used by institutions in this study may facilitate implementation in other EDs, thereby improving compliance with the Joint Commission’s patient safety goal and reducing the rate of central line-related bloodstream infections from the ED.
EMF-10
Emergency Physician Leadership In Acute Stroke Care
Meurer W/University of MI, Dexter, MI
Background: We propose a population-based study to allow the planning of an intervention promoting emergency physician leadership in acute stroke care. Background/Significance: Stroke is the leading cause of disability in the US. Systems to deliver acute stroke treatment are not universally in place. Current treatment rates with FDA-approved acute stroke therapy are in the 1-3% range. Specific Aims: 1) To describe the clinical care delivered to patients with acute ischemic stroke arriving to the emergency department within 3 hours of symptom onset in a community without an academic medical center. 2) To comprehensively and systematically assess the facilitators and barriers to delivering emergency department acute stroke care at the provider, hospital, and health system levels. 3) To prepare an NIH grant application to perform a rigorous, theory-based, multilevel behavioral intervention study to improve the appropriate treatment of acute stroke in patients arriving to the ED within 3 hours. Methods: For specific aim 1, ascertainment and care review of all stroke patients arriving within 3 hours to EDs in Corpus Christi, Texas, from 2000-2006. Rates of treatment, contra-indications, and protocol violations will be calculated. Sex and ethnic specific barriers to care will be assessed by determining the reasons that patients are excluded from therapy. This will provide patient-level data and insight useful in designing the intervention. For specific aim 2 we will perform state-of-the art qualitative research preparing for the intervention. This includes focus groups and interviews with emergency physicians, primary care physicians, nurses, paramedics, hospital administrators and public health officials. The transcripts will be analyzed using grounded theory. Acute stroke scenario modules will be pilot tested. The data from specific aims 1 and 2 will be used to craft a highly competitive NIH grant application to test a professional, emergency physician led intervention. Summary: The proposed research will provide the necessary preliminary data for the applicant to develop an intervention to promote emergency physician leadership in organizing systems for appropriate acute stroke care.
Annals of Emergency Medicine S155
EMF-9
Implementation of the Central Venous Catheter Observer and Checklist Bundle In Emergency Departments: A Qualitative Study
LeMaster C, Hoffart N, Benzer T, Chafe T, Pallin D, Schreiber H, Wang R, Schuur J/Brigham and Women’s Hospital, Boston, MA; Bouve College of Health Sciences, Northeastern University, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard University, Cambridge, MA
Study Objectives: Based on research from intensive care units (ICUs), in 2010 the Joint Commission mandated the use of a central venous catheter (CVC) checklist during CVC placement in all areas of the hospital, including the emergency department (ED). The ED faces unique barriers to implementation of this safety goal because of human factors such as high patient-to-nurse ratios, a rapidly changing
Volume , . : September
environment, and limited resources. We aimed to identify common barriers to and solutions for implementation of the CVC checklist in EDs in the United States. Methods: We performed semi-structured interviews and focus groups of key personnel involved in the implementation, maintenance, and use of the CVC checklist in the ED. Interviews were performed using a semi-structured questionnaire and EDs were identified through purposeful sampling using the Institute of Healthcare Improvement CVC Mentor Registry Hospitals and Michigan Keystone hospitals. Staff included administrators, infection control staff, hospital Chief Medical Officers, ED nursing educators, physician chiefs, ED nurses, and emergency physicians. Interviews were iteratively coded using the Grounded Theory method. Results: We have performed interviews with 35 staff at 5 hospitals. Data collection is ongoing and will end once we reach thematic saturation. To date we have identified 8 key themes, each with associated barriers and solutions. These include: (1) staff culture, (2) physical space/layout, (3) physician and nurse staffing, (4) inpatient coordination, (5) equipment/central line kit/central line cart, (6) time, (7) teamwork/information coordination, and (8) protocol implementation. The latter category includes (a) preparation/planning, (b) teaching, and (c) quality assurance/ monitoring/feedback. A leading barrier to implementing the CVC checklist and observer protocol in the EDs appears to be identifying an individual who is qualified and has the time to observe the entire procedure. Conclusion: There are many barriers to the CVC checklist protocol, some of which are unique to emergency medicine. The strategies for implementation used by institutions in this study may facilitate implementation in other EDs, thereby improving compliance with the Joint Commission’s patient safety goal and reducing the rate of central line-related bloodstream infections from the ED.
EMF-10
Emergency Physician Leadership In Acute Stroke Care
Meurer W/University of MI, Dexter, MI
Background: We propose a population-based study to allow the planning of an intervention promoting emergency physician leadership in acute stroke care. Background/Significance: Stroke is the leading cause of disability in the US. Systems to deliver acute stroke treatment are not universally in place. Current treatment rates with FDA-approved acute stroke therapy are in the 1-3% range. Specific Aims: 1) To describe the clinical care delivered to patients with acute ischemic stroke arriving to the emergency department within 3 hours of symptom onset in a community without an academic medical center. 2) To comprehensively and systematically assess the facilitators and barriers to delivering emergency department acute stroke care at the provider, hospital, and health system levels. 3) To prepare an NIH grant application to perform a rigorous, theory-based, multilevel behavioral intervention study to improve the appropriate treatment of acute stroke in patients arriving to the ED within 3 hours. Methods: For specific aim 1, ascertainment and care review of all stroke patients arriving within 3 hours to EDs in Corpus Christi, Texas, from 2000-2006. Rates of treatment, contra-indications, and protocol violations will be calculated. Sex and ethnic specific barriers to care will be assessed by determining the reasons that patients are excluded from therapy. This will provide patient-level data and insight useful in designing the intervention. For specific aim 2 we will perform state-of-the art qualitative research preparing for the intervention. This includes focus groups and interviews with emergency physicians, primary care physicians, nurses, paramedics, hospital administrators and public health officials. The transcripts will be analyzed using grounded theory. Acute stroke scenario modules will be pilot tested. The data from specific aims 1 and 2 will be used to craft a highly competitive NIH grant application to test a professional, emergency physician led intervention. Summary: The proposed research will provide the necessary preliminary data for the applicant to develop an intervention to promote emergency physician leadership in organizing systems for appropriate acute stroke care.
Annals of Emergency Medicine S155