Critical care recognition, management and communication skills during an emergency medicine clerkship

Figures & data

Table

Practice points

It is feasible to teach a systematic approach to critical care during a required emergency medicine clerkship. Communication in the critical care encounter is unique and must be integrated in a curriculum to maintain effective and safe patient care. Using interactive teaching methods students should and can be taught to recognize and manage critical patients while integrating the unique and essential communication and interpersonal skills for critical care. Students most often performed skills related to the early recognition and management of airway, breathing and circulatory problems but students need to improve on their use of bedside tests to recognize life-threatening medical conditions, reassessment of the patient's response to treatment, review of records, and interviewing pre-hospital responders. Students showed strong Basic Interpersonal Skills and Efficient Information Gathering but need to improve on their Empathy and Healthcare Team Communication skills.

Table 1.  Curriculum activities

Activity	Duration and timing	Description and objectives of methods
Lecture: ‘Sick vs. Not Sick’	90 minutes during orientation	An interactive lecture to teach the student a systematic approach to the critical patient, ALERT mnemonic introduced and used to manage 5 cases as a group to demonstrate application
Lecture: ‘Critical Care CIPS’	50 minutes in the first week of the clerkship	Discuss, provide examples of unique critical care CIPS, behaviorally-based CIPS are introduced with examples of how to communicate or demonstrate the specific skill
Observe real critical care encounter during ED clinical shift	Must occur in the first 3 weeks	Student observes care start to finish, fills out a worksheet on the healthcare team approach and actions, documents unique CIPS issue
Small group discussion • Of observed real CC encounter • Prepare students for the SP CC encounter	90 minutes to discuss cases, moderated by author SE, occurs at the beginning of the 4th week, before the CC SP encounter	Group convenes to discuss each CC case, discuss medical management and unique CIPS, review a recorded student case SP assessment, and review expectations of CC SP encounter
Instructor-administered single case SP CC Encounter	4 hours, occurs 1–3 days after the small group discussion above	Each student participates in a mock CC encounter which is videotaped. Peers assess CC actions during the live case. EM faculty discuss the expected CC actions with the group for learning purposes
SP CC encounter assessment and feedback	20–25 minutes with each individual student that occurs immediately following the group CC SP encounter exercise	Private video review with the student examinee, SP, and the two faculty. Provides an opportunity for self-assessment, feedback from faculty and the SP. Each student's CIPS are assessed by using the assessment tool by the student, faculty, and SP

CC = critical care, CIPS = communication and interpersonal skill, SP = standardized patient, EM = emergency medicine.

Table 2.  The ALERT mnemonic. The systematic approach should begin with the actions as listed in order from top to bottom. The student is taught that if during the ‘R’ action they do not see a response to their treatment they should, return to the ‘A’ actions at the beginning

Action	Definition	Descriptors or examples of action expected
A Alert Attending ABCs Apply Access	The first action expected in the systematic approach to the patient: Alert Attending, ABC's, Apply OMI, Access	Alert the Attending, Assess ABC's: airway, breathing, and circulation, and Apply ‘OMI’ for oxygen, monitor, and establish intravenous Access Once an abnormality is found it should be treated immediately. For example, if the patient needs intubation then this intervention should occur before addressing the next step in evaluation
L Look for and treat Life-threatening conditions	Look for life- threatening conditions and treat immediately.	This includes secondary survey for life-threatening injuries in trauma patients, identifying hives or a rash that guides diagnosis and treatment of airway compromise and hypotension, treating dysrhythmias discovered with the monitor is applied, etc. This is where the student administers antibiotics, intravenous fluids, and provides trauma care specific to their assessment Students can consider sending laboratory as they build their differential diagnosis from information obtained above
E Examine Evaluate with bedside tests	This is a focused effort to further develop their differential diagnosis. It is a focused examination using bedside tests to evaluate, diagnose, and manage the critical patient.	Examine briefly-a focused examination to diagnose and manage the patient outside their evaluation of the ABCs above. Evaluate with bedside tests-point-of-care tests not used in their inpatient experiences: ECG, arterial blood gas, urinalysis, urine pregnancy test, ultrasound, hemoglobin, serum glucose determination, portable X-rays, stool for occult blood An emphasis on diagnosis that is more urgent. We provide the examples that acute myocardial infarction, ruptured ectopic pregnancy, and stroke are diagnosed with history and physical and bedside tests, not time-consuming laboratory tests.
R Reassess Response to Rx Responders Review records	Now Reassess patient to see if they are more stable. If yes, then continue. If not, move back to the ‘A’ actions above.	Response to treatment-ask the patient how they are feeling Reassess patient-look for objective findings that the patient is improving such as blood pressure, heart rate, oxygen saturation Responders should be interviewed if the patient is too critical to speak. These include family and witnesses and pre-hospital personnel Review Records–if more information is needed the student should consider reviewing hospital records
T Thorough H&P Test results and treat To: disposition	The patient should be more stable and care can proceed to include a thorough history and physical, tests and further treatment.	Thorough history and physical-now that the patient is stable, more information can be obtained. Test results from the laboratory should be reviewed as they are completed and any abnormalities Treated To-Now that the patient's condition is stable and diagnosis has been differentiated, the patient's disposition should be determined. This includes the admitting service, consultations to be obtained, and bed status

Table 3.  CIPS checklist

Skill category (number of items)	Definition	Checklist item
Basic interpersonal skills (6)	Demonstration of respect; laying a foundation for a therapeutic relationship with the patient	Introduces self Addresses patient/family by name Allows patient/family to state the chief complaint in their own words Makes frequent eye contact Allows patient/family to finish sentences Does not express personal opinions during interview
Efficient information gathering (3)	How we gather information in a busy or critical environment	Question style/length appropriate for situation/patient condition Consistently uses lay terms Directs interview with specific questions pertinent to patient case
Healthcare team communication (4)	Demonstration of teamwork; the ability to relay information to all members; directing reassessment of patient condition after intervention; sharing current condition with consultants	Directs nurse/healthcare team to reassess the patient's response to intervention Communicates care plan to healthcare team and acknowledges any concerns Verbalizes specific request to the consultant Presentation to consultant includes: Diagnosis, pertinent history and physical findings, test results, interventions, current condition
On-going patient/family communication (4)	Ability to counsel and educate the patient and family; reassessment of patient condition from the patient	Directly questions the patient about their response to treatment Keeps patient/family informed of results Communicates patient care plan to the patient/family Asks patient/family if they have questions
Empathy (5)	Acknowledgement and response to the patient's perspective and concerns; demonstration of caring behavior	Verbally acknowledges patient's pain/complaint immediately Verbally acknowledge the patient's nonverbal gestures Verbally reassures the patient/family Touches patient in reassuring manner (if culturally appropriate) Verbalizes understanding of patient/family's perspective on illness during care

*Checklist skills are grouped in this table by category and not in the sequence as the items appear on the Checklist instrument.

Figure 1. Case vignette.

Table 4.  Critical care cases

Patient case (N = 46)	Critical medical actions (% of students performing the skill)	Mean percent correct (SD)
Stroke with airway management (6)	(1) Assesses patient's airway and decides to intubate; (66.67%)	75% (17.48%)
	(2) Assesses breathing; (83.33%)
	(3) Assesses circulation; (100%)
	(4) Works-up altered mental status bedside test (EKG, serum glucose level, oxygen, naloxone, thiamine); (50%)
	(5) Orders computed tomography (CT) of the brain; (83.33%)
	(6) Obtains history from family on ‘Do Not Resuscitate’ (DNR) status (66.67%)
Anaphylactic shock (7)	(1) Assesses and recognizes airway compromise; (100%)	83.33% (19.25%)
	(2) Assesses breathing; (85.71%)
	(3) Assesses circulation signs of critical status; (85.71%)
	(4) Administers epinephrine; (85.71%)
	(5) Orders oxygen, monitor, and intravenous access; (85.71%)
	(6) Communicates with paramedic or witnesses for history of wasp sting (85.71%)
Urosepsis (7)	(1) Assess A, B, Cs and treats the patient's hypotension with a fluid bolus, (100%) work-up the patient's altered mental status and order important bedside test:	83.67% (12.85%)
	(2) Serum glucose, (100%)
	(3) Oxygen saturation, (28.57%)
	(4) Urinalysis, (100%)
	(5) Orders head CT; (71.43%)
	(6) Interviews family for history; (100%)
	(7) Explains results and admission to family (85.71%)
Acute myocardial infarction (7)	(1) Recognizes sick patient and alerts attending, (57.14%)	78.02% (16.27%)
	(2) Take a focused history to include the time of onset of symptoms, (85.71%)
	(3) Circumstances and description of chest pain, (71.43%)
	(4) PMH, medications, allergies; (85.71%)
	(5) Performs focused, appropriate examination; (85.71%)
	(6) Asks for oxygen, monitor, IV; (100%)
	(7) Orders EKG AND chest X-ray; (42.86%)
	(8) Directs nitroglycerin, aspirin; (100%)
	(9) Reassesses patient's pain and response to treatment, (71.43%)
	(10) Reassesses vital signs; (57.14%)
	(11) Interprets the ECG as acute myocardial infarction; (100%)
	(12) Communicates the diagnosis and treatment to the patient, (100%)
	(13) Consults cardiologist (57.14%)
Status asthmaticus (7)	(1) Recognizes respiratory distress and alerts the attending, (85.71%)	76.19% (13.50%)
	(2) Orders oxygen, monitor, IV; (100%)
	(3) Administers nebulizer treatments and intravenous steroids, (100%)
	(4) Orders and interprets arterial blood gas (ABG) correctly; (28.57%)
	(5) Fequently reassesses response to treatment with vital signs; (100%)
	(6) Oepeat and frequent Wright peak flows; (57.14%)
	(7) Reassesses lung examination; (42.86%)
	(8) Asks patient about response to treatment; (71.43%)
	(9) Makes decision to admit (100%)
Ruptured ectopic pregnancy (6)	(1) Recognizes that the patient is in shock and alerts the attending; (83.33%)	77.27% (12.53%)
	(2) Questions about last menstrual period; (83.33%)
	(3) Orders oxygen, monitor, IV; (100%)
	(4) Gives intravenous fluid boluses; (66.67%)
	(5) Orders hemocue (bedside hemoglobin); (66.67%)
	(6) Orders urine pregnancy test; (83.33%)
	(7) Orders ED bedside ultrasound; (100%)
	(8) Reassesses patient vital signs and pain level; (50%)
	(9) Orders second large bore IV; (66.67%)
	(10) Orders type and cross-matched blood; (50%)
	(11) Consults gynecologist promptly (100%)
Upper gastrointestinal bleed (4)	(1) Assesses ABCs and recognizes hypotension; (80%)	75% (8.84%)
	(2) Orders oxygen, monitor, IV; (100%)
	(3) Orders two large bore IVs; (20%)
	(4) Orders type and cross-matched blood; (100%)
	(5) Orders units of blood for possible transfusion; (100%)
	(6) Orders transfusion; (100%)
	(7) Reviews records when patient more stable; (0%)
	(8) Consults in organized fashion to admit the patient to the intensive care unit (ICU) (100%)
Acute appendicitis with an acute abdomen (1)	(1) Recognizes sick patient and alerts attending;	(Fewer than 4 students performed this case)
	(2) Orders oxygen, monitor, IV access;
	(3) Recognizes acute abdomen on examination;
	(4) Treats or verbally addresses the patient's pain;
	(5) Reassesses the patient;
	(6) Consults surgery;
	(7) Deals with a difficult consultant and acts as a patient advocate
Meningococcal meningitis (1)	(1) Recognizes sick patient and alerts attending;	(Fewer than 4 students performed this case)
	(2) Orders oxygen, monitor, IV;
	(3) Orders IV fluid bolus and treats fever;
	(4) Orders appropriate antibiotics when petechial rash is discovered;
	(5) Orders head CT;
	(6) Performs lumbar puncture;
	(7) Reassesses patient frequently;
	(8) Admits the patient to an isolation bed

*In all cases students were expected to alert the attending physician, ask for oxygen, monitor, intravenous access (OMI), assess the patient's airway, breathing, and circulation, and examined the patient closely for other signs of a life-threatening condition. If the SP had positive findings related to the diagnosis for the assessment of any of the above, it was considered a ‘critical action’ to the case.

Table 5.  Students’ group performance on CIPS checklist

	Percentage of items performed
Category	Mean (n = 47)	Standard deviation	95% Confidence interval
Basic interpersonal skills	97.9%	5.6%	96.2% to 99.5%
Efficient information gathering	84.4%	21.8%	78.0% to 90.8%
On-going patient/family communication	67.0%	26.1%	59.4% to 74.7%
Healthcare team communication	60.6%	26.4%	52.9% to 68.4%
Empathy	41.7%	23.5%	34.8% to 48.6%

Table 6.  Student group performance by checklist item

Skill category	Checklist item	Mean (n = 47)	Standard deviation	95% Confidence interval
Basic interpersonal skills	Introduces self	100%	0%	N/A*
	Addresses patient/family by name	100%	0%	N/A*
	Allows patient/family to state the chief complaint in their own words	100%	0%	N/A*
	Makes frequent eye contact	98%	14.6%	94% to 102%
	Does not express personal opinions during interview	96%	20.4%	90% to 102%
	Allows the patient/family to finish sentences	94%	24.7%	86% to 101%
Efficient information	Question style/length appropriate for situation/patient condition	98%	14.6%	94% to 102%
Gathering	Directs interview with specific questions pertinent to patient case	91%	28.2%	83% to 100%
	Consistently uses lay terms	64%	48.6%	50% to 78%
Healthcare team communication	Presentation to consultant includes: Diagnosis, pertinent history and physical findings, test results, interventions, current condition	74%	44.1%	62% to 87%
	Verbalizes specific request to the consultant	70%	46.2%	57% to 84%
	Directs the nurse/healthcare team to reassess the patient's response to interventions	57%	50.0%	43% to 72%
	Communicates care plan to healthcare team and acknowledges any concerns	40%	49.6%	26% to 55%
On-going patient/family communication	Communicates patient care plan to the patient/family	83%	38%	72% to 94%
	Asks patient/family if they have questions	66%	47.9%	52% to 80%
	Keeps patient/family informed of results	62%	49.1%	47% to 76%
	Directly questions the patient about their response to treatment	57%	50.0%	43% to 72%
Empathy	Verbalizes understanding of patient/family's perspective on illness during care	51%	50.5%	36% to 66%
	Verbally acknowledges patient's pain/complaint immediately	49%	50.5%	34% to 64%
	Verbally reassures the patient/family	40%	49.6%	26% to 55%
	Touches patient in reassuring manner (if culturally appropriate)	38%	49.1%	24% to 53%
	Verbally acknowledge the patient's nonverbal gestures	30%	46.2%	16% to 43%

*95% confidence intervals could not be determined because standard deviation was 0%.