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Introduction A complete medical school curriculum must include an introduction to first aid; the management of airway, breathing, and circulation; and basic medical emergencies. The September 11, 2001, terrorist attacks in New York underscored the need for such training for US students even in their preclinical years. During that tragedy, many Weill Cornell Medical College (WCMC) preclinical students were eager to volunteer at Ground Zero and in the emergency department, yet it was clear they were not prepared for even basic medical emergencies this early in their training. To address this gap, in 2002 we incorporated this expanded first-responder course into the first-year doctoring class at WCMC. Methods The course includes a morning of lectures followed by related workshops. Students also practice managing ill patients in multiple case scenarios and participate in a tabletop disaster-management exercise. Results This course has become a mainstay of our first-year curriculum, receiving high praise from students annually. It generates tremendous interest in emergency medicine and lays a foundation of basic emergency medicine knowledge for students at an early point in their education. Discussion The unique experience of our medical school during the 9/11 tragedy highlighted the need for a course that would introduce preclinical medical students to the basic skills needed to assist in emergency scenarios in the field. Over the past 13 years, this course has developed into an essential part of our preclinical curriculum and has been strengthened through changes made based on student feedback.

Objectives Of the 1.1 million people in the United States infected with human immunodeficiency virus (HIV), more than 20% are unaware of their infection. To increase early diagnosis and treatment, New York State recently passed legislation mandating that HIV testing be offered to all patients, ages 13 to 64 years, receiving health care services. Implementation of this legislation is complex, especially in the emergency department (ED). This study explores ED providers' perceptions of the factors affecting the implementation of the law. Methods The authors conducted six focus group sessions and three in-depth interviews with ED health care providers from two New York City teaching hospitals. Sessions were audiotaped and transcribed. Data were coded and summarized thematically through an iterative process after each session. Results A total of 49 providers participated and data saturation was achieved. Six factors were identified that predispose a provider to offer an HIV test: 1) self-efficacy, 2) behavioral intention, 3) the testing process, 4) provider knowledge of the legislation, 5) type of HIV test, and 6) follow-up procedures. Five factors were identified that enable providers to offer an HIV test: 1) resources related to time, 2) space, 3) staff, 4) type of test, and 5) timing of the offer. Improving access to HIV testing, linkage to care, and public health were all key factors in reinforcing providers' desire to offer HIV tests. Concerns regarding overall cost saving and coverage for the test were indicated as barriers that needed to be resolved to reinforce the providers to offer an HIV test. Conclusions Understanding the factors influencing the practice of ED providers charged with carrying out this mandate is critical. Despite earlier research that indicated that offering HIV testing to ED patients is largely influenced by cost, this study found additional factors that are important to consider to effectively implementing HIV testing in the ED. Resumen Percepciones de los Sanitarios sobre los Factores que Influyen en la Aplicacion de la Ley Obligatoria del Test de VIH en el Estado de Nueva York en Dos Servicios de Urgencias Universitarios Urbanos Objetivos De los 1,1 millones de personas infectadas en Estados Unidos por el virus de la inmunodeficiencia humana (VIH), mas del 20% desconoce su infeccion. Para incrementar el diagnostico y el tratamiento precoz, el estado de Nueva York aprobo recientemente una ley obligatoria segun la cual el test de VIH se ofrecera a todos los pacientes, entre 13 y 64 anos, que reciban atencion sanitaria. La aplicacion de esta ley es compleja, especialmente en el servicio de urgencias (SU). Este estudio explora las percepciones de los sanitarios de urgencias sobre los factores que afectan a la aplicacion de esta ley. Metodologia Se llevaron a cabo seis sesiones de grupo y tres entrevistas en profundidad con sanitarios del SU de dos hospitales universitarios en la ciudad de Nueva York. Las sesiones fueron grabadas en casete y trascritas. Los datos se codificaron y resumieron tematicamente a traves de un proceso iterativo tras cada sesion. Resultados Un total de 49 sanitarios participaron y se alcanzo la saturacion de los datos. Se identificaron seis factores que predisponian a un sanitario a ofrecer un test de VIH: 1) la autoeficacia, 2) la intencion del comportamiento, 3) el proceso diagnostico, 4) el conocimiento de la ley por el sanitario, 5) el tipo de test de VIH, y 6) el seguimiento de los procedimientos. Se identificaron cinco factores que permitirian a los sanitarios ofertar un test de VIH: 1) los recursos relacionados con el tiempo, 2) el espacio, 3) el personal, 4) el tipo de test, y 5) el tiempo de la oferta. A la hora de reforzar el deseo de los sanitarios a ofertar un test de VIH, la mejora al acceso al test de VIH, vinculado a la atencion, y la salud publica fueron todos ellos factores clave. El ahorro de costes totales y la cobertura del test se senalaron como barreras que son necesarias resolver con el fin de reforzar a los sanitarios a ofertar un diagnostico de VIH. Conclusiones El conocimiento de los factores que influyen en la practica de los sanitarios del SU junto con la aplicacion de este mandato es crucial. A pesar de la investigacion mas reciente que indica que ofrecer un test de VIH a los pacientes del SU esta claramente influida por los costes, este estudio encontro factores adicionales que son importantes considerar para aplicar efectivamente el test de VIH en el SU.

Introduction The annual American Board of Emergency Medicine (ABEM) in-training examination is a tool to assess resident progress and knowledge. We implemented a course at the New York-Presbyterian Emergency Medicine Residency Program to improve ABEM scores and evaluate its effect. Previously, the examination was not emphasized and resident performance was lower than expected. Methods As an adjunct to required weekly residency conferences, an intensive 14-week in-training examination preparation program was developed that included lectures, pre-tests, high-yield study sheets, and a remediation program. We compared each residents in-training examination score to the postgraduate year-matched national mean. Scores before and after course implementation were evaluated by repeat measures regression modeling. Residency performance was evaluated by comparing residency average to the national average each year and by tracking ABEM national written examination pass rates. Results Following the course's introduction, odds of a resident scoring higher than the national average increased by 3.9 (95% CI 1.9-7.3) and percentage of residents exceeding the national average increased by 37% (95% CI 23%-52%). In the time since the course was started the overall residency mean score has outperformed the national average and the first-time ABEM written examination board pass rate has been 100%. Conclusion A multifaceted residency-wide examination curriculum focused around an intensive 14-week course was associated with marked improvement on the in-training examination.

Summary Objective: Based on US. Centers for Disease Control and Prevention recommendations, New York State enacted legislation in 2010 requiring healthcare providers to offer non-targeted human immunodeficiency virus (HIV) testing to all patients aged 13–64. Three New York City adult emergency departments implemented an electronic alert that required clinicians to document whether an HIV test was offered before discharging a patient. The purpose of this study was to assess the impact of the electronic alert on HIV testing rates and diagnosis of HIV positive individuals. Methods: During the pre-intervention period (2.5–4 months), an electronic “HIV Testing” order set was available for clinicians to order a test or document a reason for not offering the test (e.g., patient is not conscious). An electronic alert was then added to enforce completion of the order set, effectively preventing ED discharge until an HIV test was offered to the patient. We analyzed data from 79,786 visits, measuring HIV testing and detection rates during the pre-intervention period and during the six months following the implementation of the alert. Results: The percentage of visits where an HIV test was performed increased from 5.4% in the pre-intervention period to 8.7% (p Conclusions: An electronic alert which enforced non-targeted screening was effective at increasing HIV testing rates but did not significantly increase the detection of persons living with HIV. The impact of this electronic alert on healthcare costs and quality of care merits further examination. Citation: Schnall R, Liu N, Sperling J, Green R, Clark S, Vawdrey D. An electronic alert for HIV screening in the emergency department increases screening but not the diagnosis of HIV. Appl Clin Inf 2014; 5: 299–312 http://dx.doi.org/10.4338/ACI-2013-09-RA-0075

Introduction First responder training for medical students has not been evaluated in the literature. Columbia University College of Physicians & Surgeons (P&S) first-year students participated in a 4-hour first responder course with lectures and eight scenario-based small-group sessions, led by emergency medicine (EM) faculty and residents. The course goals are for students to achieve basic competence in responding to medical emergencies in nonclinical settings before emergency medical services arrive, and for EM residents to teach students. The evaluation assessed the educational quality of the course (effectiveness, efficiency, and appeal). Methods The students rotate through six small groups which are taught via scenarios in which the students are asked to act out their responses as “medical-student-on-scene,” and critical points are taught by the instructors (emergency medicine residents and faculty) as the scene plays out. The six scenarios are: seizure, anaphylaxis, deformed extremity, stroke, choking, and chest pain with loss of consciousness. Results The evaluation assessed the educational quality of the course (effectiveness, efficiency, and appeal). Course effectiveness was assessed with both a one-group pre- and posttest design and a course evaluation questionnaire. Students responded correctly to 73% of pretest and 93% of posttest questions, a statistically significant difference (paired-samples ttest, p < .001). Students gave high ratings to all questions (all > 4.0 on scale of 1–5). Discussion Overall, the course was successful in teaching students how to respond to medical emergencies, with high effectiveness and efficacy. Future courses should continue to emphasize high-quality instructors (including resident-teachers) and small-group design, but should decrease repetitiveness and inconsistency in content.

Introduction: Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students’ knowledge acquisition, comfort, and perceived competence with regards to the AMS patient. Methods: AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS. Results: A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not ( p