Department Of

Brown University Department of Department of Emergency Medicine Newsletter mergency Our newsletter is edicine published twice a E M year to provide news and information O PROVIDE EXCEPTIONAL EMERGENCY MEDICAL CARE EDUCATION RESEARCH AND about Emergency T , , SERVICE TO THE PEOPLE OF RHODE ISLAND AND BEYOND. Medicine to the health system, VOLUME 8, ISSUE 1 SPRING 2013 medical school, our alumni and friends. Message from the Chair Academic when we know that better communication gets better results. We tolerate long Emergency Medicine’s waits, and make excuses for poor service. Accountability Gap And rather than taking control of what we can control, we blame others – “the hospi- Academic emergency physi- INSIDE THIS tal”, “administration”, “the system”. We also cians are under some pressure as of late. account for a substantial amount of health ISSUE: As ED visits rise, we are asked to see sicker, care spending, and could be more in- more complex patients. With inadequate volved in controlling excessive health care Anderson AC 3 community resources and a persistent lack costs. Until we hold ourselves and each of primary care, we continue to be the Brown Faculty 5 other accountable in the clinical arena, we safety net for the world of medicine and will not deliver the type of emergency care Chest Pain Center 7 beyond. Ten years ago there was a sense that we all want to deliver. EM Residency 6 of appreciation for this safety net role of emergency medicine (EM). How things Education: Part of the accountability gap EMS 5 have changed. Now ED’s are derided by in education is our lack of training as medi- Grand Rounds 14 policy makers and the media, and some- cal educators. For too long we have relied Hamolsky Award 20 times other academic physicians, as ven- on the few “naturals” in our departments ues of “inappropriate” visits where we test who can teach well and connect with International EM 16 too much and rack up huge health care trainees without much help. But most of In the Spotlight 17 bills and keep patients from using their us have deficiencies in our ability to teach primary care doctor. While we know that – we could be much better. Whether it is Injury Prevention 8 this is a gross misrepresentation of EM, giving feedback, presenting a high quality Medical 19 and must constantly push back with facts lecture, or assessment and evaluation, spe- Humanities and data to correct wrong impressions, cific training can make us better. We won’t The Miriam ED 3 there are some things that we must own. I all be able to get Masters degrees in medi- Pediatric EM 4 think medicine, including EM, suffers from cal education, but we can aspire to learn an accountability gap. Accountability is to be better teachers through study, work- Publications 12 the willingness to accept (“own”) responsi- shops, courses, etc. Another part of the Regional/ 13 bility for our actions and approaches. As accountability gap in EM education is how National we look at our traditional tripartite aca- we handle burgeoning clinical volume Research 10 demic mission there are significant gaps in without sacrificing bedside teaching. If we Simulation Center 15 accountability in each area. rely too heavily on our residents for service, we are not fulfilling the promise that Clinical Care: While there have been some Sports Medicine 8 we made when these residents were appli- champions of quality and patient safety for Toxicology 18 cants. We must preserve teaching mo- over 20 years, EM, like the rest of medicine ments, rounds, and time for feedback in Women’s Health 18 has been far too slow to adopt the practic- our busy shifts. es that improve quality and safety (see Re- search below). We still find reasons NOT to Research: The amazing growth of EM re- practice evidence-based medicine, and search has produced a wide variety of resist standardization of practice. We accept poor communication and teamwork (continued on page 2) PAGE 2 Message from the Chair (continued from page 1) new knowledge, but the accountability deficit here is I will close with a few examples where EM has dealt one of dissemination in to practice. We have created with an issue of accountability and did the right the evidence but too often it sits in magnificent peer- thing for patients and our field. In the clinical arena reviewed journal articles and does not result in evi- we have responded to less than stellar performance dence-based practice. The accountability equation in with quality improvement changes to improve out- this case is simple, but hard to achieve - investigators comes in some of our sickest patients – acute MI and who do the research must own their work all the stroke – by pushing down the time to diagnosis and way to changes in clinical care, and clinicians must treatment. This has required meticulous attention to pull evidence-based research in to their practices. detail, constant reinforcement, and measurement Otherwise the millions of dollars that we spend in and reporting – and it is now routine for us to have basic science and clinical research have not top decile performance in these areas. In the been a meaningful investment. Accountability area of resident education, faculty supervi- can be the thread sion of residents on a 24 hour a day basis Before you accuse Dr. Eternal Optimist of to weave our way was not routine even in to the late 1980’s. getting off to a grumpy start in 2013, know to future success. Some in EM began to push for 24 hour facul- that I am still bullish on academic medicine, ty supervision, but many resisted doing this, and particularly academic EM. But I strug- with rationalizations and arguments playing out in gle with the big bear of accountability just as you do. the editorial pages of our journals. Finally, the RRC- So how do we get more accountable? In most situa- EM mandated 24 hour faculty supervision in 1989 tions, it is not a lack of knowledge, or methods, or and we were fully accountable in providing resident resources that creates the accountability gap – it is supervision. It took a long time, but EM eventually the inability to change our culture. Solutions to en- led the way among specialties in full-time supervision hance accountability in any of the areas of our mis- of residents. In the research realm we have used EM- sion are not accomplished in a month –they make derived research to change clinical practice with ap- take a decade - but we need to own every step for- plication of the NEXUS cervical spine clearance rules, ward, and confront the forces that hold us back. and the implementation of early goal-directed thera- The process of “holding you accountable” invokes py in sepsis. mental images of finger wagging, a looming pres- Accountability can be elusive and take a while to ence, and growling voice. But, we don’t have to be achieve, but it is clearly possible. It can be the thread confrontational or irascible in our push for accounta- that we use to weave our way to future success in bility. Excessively demanding, punitive behavior academic emergency medicine. might get a short term result, but is not a long term solution for change. The more enduring approach is If you have thoughts on this essay, to involve the entire team in identifying accountabil- or anything else in this Newsletter, ity gaps, make a plan together for how to gain ac- please email me at countability through small changes, collect data, set [email protected] Happy 2013. standards, define and regularly share metrics, and Please enjoy this edition of our then incentivize for strong performance. With this Brian J. Zink, MD Newsletter, and keep in touch. approach, penalties and confrontations can be few – Frances Weeden Gibson—Edward A. Iannuccilli, MD as long as the whole team is willing to hold each Professor & Chair, Physician-in-Chief Department of Emergency Medicine other accountable. And the best thing we can each Alpert Medical School of Brown University do is lead by example. Rhode Island & The Miriam Hospitals Assistant Dean, Medical Student Career Development RIH—150 Years Celebration Rhode Island Hospital has planned various events through- out 2013 commemorating the hospital’s 150 years of providing quality health care to the State of Rhode Island & beyond. Check out the website: www.rhodeislandhospital.org/150th-Anniversary DEPARTMENT OF EMERGENCY MEDICINE PAGE 3 Frantz Gibbs, MD, Medical Director, Anderson Emergency Center Rhode Island Hospital, Anderson Emergency Center We have seen patient volume Our C-Pod has been converted into an ur- increase over the past year. Pa- New staffing & gent area and care for more acute patients. tients continue to select us as space utilization The physician, midlevel and nursing staff- their provider of choice for plans are already ing has been increased accordingly to cov- emergency care and our care- improving er these patients. The Pod opens earlier in teams work hard every day to meet their patient flow. the day, having all rooms available at 8 am, expectations. In January, we made adjust- and remain open until 1 am. This area has ments to the staffing and Pod utilization to better helped us increase the throughput of ESI 2 and 3 accommodate the growing patient volume. The patients over more of the day. changes increase the areas we use for patient The E-Pod serves to concentrate patients coming care and make more spaces available for waiting out of the Critical Care area and continue to tran- patients.

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