UMEM Educational Pearls - By Mercedes Torres

• Did you know that emergency physicians spend nearly 1/3 of their handoff time responding to interruptions?
• EPs are interrupted around 7-11 times during handoffs, accounting for 11% of the total adverse events, a third of which are considered preventable.
• This study examined the number of interruptions and perception of collaboration in three different physical spaces in the same ED: an open workstation, an enclosed workstation, and a semi-open workstation (see photos and blueprints below).
• Most EDs have open workstations as they are thought to optimize visibility and opportunities for collaboration among team members of all levels.
• EPs conducting handoffs in open workstations experienced more interruptions (patient care-related or not) as compared to those in the enclosed workstations. 
• Investigators found that enclosure of the physicians’ workstation can decrease the number of times physicians are interrupted during critical tasks like handoffs, therefore decreasing the risk of errors and adverse events.
• EPs perceived a high degree of collaboration with colleagues in the enclosed workstation during handoff and felt less interrupted.
• While the number of documented handoff interruptions in the semi-open plan were lower than the open workstation, EPs still perceived interruptions as frequent. 
• While there are clear benefits of the open workstation in the ED, it may be worth considering a different venue, specifically for handoffs, such as a “No Interruptions Zone” (NIZ) to decrease the perceived and actual frequency of interruptions, while also improving the sense of collaboration between team members during the handoff process.

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Background:

• Monkeypox virus (MPXV) has two distinct genetic clades (subtypes of MPXV), I and II, which are endemic to central and west Africa, respectively. 
• The global mpox outbreak that began in 2022 is caused by MPXV II
• The recent outbreak in Democratic Republic of Congo (DRC) is caused by MPXV I

What’s new?

• Democratic Republic of Congo (DRC) has reported more than 22,000 suspect cases of MPXV I since January 1, 2023 (annual median of 3,767 suspect MPXV I cases in prior 6 years)
• Largest number of yearly suspected MPXV I cases ever recorded 
• More widespread than any previous outbreak, resulting in transmission to neighboring countries [Republic of the Congo (ROC), the Central African Republic (CAR), Burundi, Rwanda, and Uganda].

Who is at risk?

Patients with epidemiologic characteristics and lesions or other signs and symptoms consistent with mpox. This includes anyone with travel to DRC or any of its neighboring countries (ROC, CAR, Rwanda, Burundi, Uganda, Zambia, Angola, Tanzania, and South Sudan) in the previous 21 days.

What to look for? 

• Rash that may be located on the hands, feet, chest, face, mouth, anus or near the genitals
• Lesions are firm or rubbery, well-circumscribed, deep-seated, and often develop umbilication (see below).

(Above photos from https://www.cdc.gov/poxvirus/mpox/clinicians/clinical-recognition.html)

• Lesions progress through four stages—macular, papular, vesicular, to pustular—before scabbing over and desquamation. They are often described as painful until the healing phase when they become itchy (crusts).
• Fever, chills, swollen lymph nodes 
• Fatigue, myalgia (muscle aches and backache), headache
• Respiratory symptoms like sore throat, nasal congestion, and cough
• Illness lasts 2-4 weeks
• Once all scabs have fallen off and a fresh layer of skin has formed, a person is no longer contagious.

What to do?

If mpox is suspected in a patient:

• Isolate the patient in a single patient room (no special air filtration is required).
• Use PPE (Gown, gloves, eye protection, and NIOSH-approved particulate respirator equipped with N95 filters or higher).
• Intubation and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
• Notify your local health department immediately.
• Evaluate all suspected cases related to DRC or its neighboring countries with laboratory testing (rather than clinical diagnosis alone). 
• Counsel patients about staying away from other people and not sharing things they have touched with others; and cleaning and disinfecting the spaces they occupy regularly to limit household contamination.
• Recommend mpox vaccine to asymptomatic close contacts of cases of MPXV.
• Offer treatment with oral tecovirimat (TPOXX), available through the STOMP Trial. To enroll in STOMP, in the US call 1-855-876-9997.

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Participation in meetings is an expected part of most (if not all) of our jobs.  How many of these meetings are necessary?  Could some of the “work” of meetings be accomplished with a few emails or other asynchronous forms of communication?  Are meetings cluttering your schedule and making it impossible to get any real work done?

Some answers to these questions are offered in a Harvard Business Review article from March 2022.  

Key points include:

• 70% of all meetings keep employees from working and completing all their tasks.
• Ineffective meetings that waste our time can negatively impact psychological, physical, and mental wellbeing.

Advantages to fewer meetings:

• Productivity was 71% higher when meetings were reduced by 40%.
• Employees feel empowered and more autonomous, increasing their job satisfaction by 52%.
• Removing 60% of meetings increased cooperation by 55%.

Authors recommend holding meetings only when “absolutely” necessary. That typically includes:

• To review work that’s occurred (what worked or didn’t and why)
• To clarify and validate something (policies, team goals, etc.)
• To distribute work appropriately among your team

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There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic EDs.

• Supporters of this trend argue that:
  • They provide better care at lower cost.
  • They reduce the overall burden of patients in the general ED.
  • They prevent hospitalizations and improve discharge rates due to specialty services and outpatient resources not otherwise available in the general ED (especially with complex patient populations like geriatrics or oncology).
  • They streamline care for vulnerable populations and decrease ED LOS.
• On the other hand:
  • Their establishment requires a substantial financial investment.
  • Patients are less likely to use them because they don’t know that they exist.
  • One of the largest studies of Geriatric EDs in the country did not show significantly different discharge rates or 72-hour revisit rates when compared with general EDs.

Will this trend continue? Is the segmentation of emergency care in our future?  The author of this article opines that the answer depends on future outcomes research in this area.

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Do microaggressions and discrimination impact the patient experience in your ED?  How can we address this?

This article is one of few studies to address this topic specifically in the ED. Authors used quantitative (discrimination scale) and qualitative (follow-up interviews) methods to answer this question in two urban academic EDs.  

Common themes from patient responses provide food for thought and action in this regard:

• Clinician behaviors: Positive behaviors included frequent communication, reassurance, privacy, respect, and validation of concerns. Empathy and eye contact were also mentioned.
• Healthcare team actions: Positive interactions with clinicians reassured confidence in the emergency care visit and willingness to return for future health care.
• Environmental pressures in the ED: Participants often noted long wait times and busy staff when describing negative ED experiences.
• Hesitancy to Complain: Patients were hesitant to identify staff members, did not feel that the complaint would be acted on, and worried that their medical care would suffer if they brought up their concerns.

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A recently published study of ED APPs, residents, attendings, and nurses attempted to assess clinician's perspectives on how ED boarding impacts ED staff and patients.  Authors performed a survey followed by focus group sessions to obtain qualitative insignts from participants. 

All respondents associated boarding with feelings of burnout and self-reported poor satisfaction with communication and the process of boarding care.

Several key themes emerged which are outlined below:

1. Clinicians perceived that boarding leads to increased patient safety events.
2. Clinicians desired standardization for the boarding care process.
3. Clinicians felt they had a lack of knowledge, resources, and training to care for boarding patients.
4. Clinicians desired proactive bed and resource planning for boarding patients.
5. Clinicians advocated for improved communication among the team and to patients.
6. Clinicians identified a need for culture change regarding boarding care.

This publication highlights the negative workforce and patient safety effects of ED boarding.  It amplifies the voices of our colleagues who work towards change to improve both the health of our wrokforce as well as that of our patients and the communities that we serve.

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Physician Workforce Diversity in EM

Health inequities along racial, ethnic, and socioeconomic lines are a brutal reality of the current state of health care in the US.  One way to attempt to address these inequities is to make a concerted effort to diversify our physician workforce.  As authors have noted, “Having physicians from diverse backgrounds as colleagues and role models can promote understanding and tolerance in nonminority physicians, ultimately improving medical care for patients who are part of these racial and ethnic groups. Increasing the population of underrepresented minority (URM) physicians in the workforce also directly improves health care for medically underserved populations from all racial and ethnic backgrounds, as studies have shown that physicians from URM backgrounds are more likely to work with these patients.”

Administrators are often tasked with the difficult job of creating a cohesive group of emergency physicians to meet the needs of the community they serve.  Strategies to diversify that workforce would benefit from a multi-level approach, including the following:

• Focus on the high school and college pipeline to increase the number of URM entering the field of medicine and emergency medicine more specifically.
• Make a conscious effort to recruit and interview URM candidates for open positions.
• In meetings, ask specific questions from individuals whose voices are often marginalized.
• In group settings, pay attention to your physical position; if you are a White male, let your URM colleagues position themselves at the head of the table.

 Small steps can create big changes.

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In a recent study of emergency physicians (EPs) who left the workforce between 2013 and 2020, authors sought to investigate their age and number of years since residency graduation for males and females.

A total of 25,839 (70.2%) male and 10,954 (29.8%) female EPs were included.

Female gender (adjusted odds ratio 2.30) was significantly associated with attrition from the workforce.

Of those who left the workforce, the median number of years after residency that males left was 17.5, as compared with only 10.5 years for females.

Furthermore, among those who exhibited attrition, one in 13 males and one in 10 females exited clinical practice within 5 years of residency graduation.

As authors emphasize, these data identify widespread gender-based disparities regarding EM workforce attrition that are critical to address to ensure stability, longevity, and diversity in the EP workforce.

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Clinician Well-Being and the Patient Experience

Did you know that most patient experience responses are overwhelmingly positive?  Rather than focusing all our attention on the bad, let’s focus on the good to promote clinician well-being.  See below for a few key points from a recent study on this:

• Physicians worry that the people who respond to patient experience surveys are more likely to be critical of their care.  The opposite is actually true.
• The authors found a 4:1 positive-to-negative ratio among 2.2 million patient experience responses collected by these authors.
• Physicians and everyone else in health care are deeply motivated by the experience of giving good, patient-centered care.

Consider emphasizing positive patient experiences when providing feedback to emergency physicians.  It will promote clinician well-being and help improve performance in your practice.

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