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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

physicians seldom document these discussions. We sought to design and pilot test an intervention that increases the rate at which emergency physicians document goals of care discussions among end-of-life patients admitted to the intensive care unit.Methods: In an emergency department with annual census of approximately 88,000 patients at a tertiary urban academic medical center, electronic medical record review of intensive care unit admissions by a physician champion revealed a very low rate of emergency physician goals of care documentation. The physician champion and emergency department co-chairmen developed an intervention. From June 2015 through October 2016 the champion reviewed emergency physician documentation among intensive care unit admissions who appeared to be near the end-of-life, and submitted reports to the co-chairmen for further review. Severe trauma, acute stroke and acute coronary syndrome patients were excluded since consultants typically have these goals of care discussions in the emergency department. End of life was defined as patients with a reviewer-estimated life expectancy of six months or less, and categorized according to previously described trajectories of dying: (1) advanced cancer, (2) bed bound from severe neurologic disease such as dementia or stroke, or (3) advanced organ system failure. Emergency physician-documented review of pre-existing goals of care documentation was in cases where patients lacked capacity and no surrogate was available. Reviewers e-mailed positive feedback to emergency physicians for documenting goals of care. Co-chairmen performed academic detailing per their discretion when goals of care were not documented.Results: We reviewed 1286 intensive care unit admissions and identified 151 patients who appeared to be near the end of life. Seventy-eight (52%) had advanced cancer, 43 (28%) were bed bound from severe neurologic disease, 26 (17%) had advanced organ system failure, and 4 (3%) were severely disabled due to other conditions. Ninety-five (63%) of the end-of-life patients died, including 80 (52%) deaths within 6 months and 55 (36%) during the same admission. Mortality could not be determined for the remaining 56 patients through electronic medical record review alone, but 9 of these were discharged on hospice. Emergency physicians were receptive to the intervention. The emergency physician goals of care discussion documentation rate rose from 1 of 16 (6%) end-of-life patients in June 2015 to 9 of 17 (52%) in October 2016.Conclusions: We found it feasible to implement a quality improvement intervention that promotes emergency physician goals of care documentation for intensive care unit admissions appearing to be near the end of life. We plan to conduct a linear time-series analysis to formally evaluate effectiveness.

Objective The aim of the study was to measure the short- and long-term impact of a virtual disability education curriculum associated with a 2-wk mandatory physical medicine and rehabilitation clerkship for fourth-year medical students. Design A prospective pre-post intervention survey-based study measuring the impact of a virtual disability education series at 1-wk and 6-mo time points after a mandatory physical medicine and rehabilitation clerkship including 8 hrs of virtual didactics with an emphasis on physical disabilities. The surveys assessed the overall virtual curriculum, perceived benefit of a virtual encounter, and the long-term applicability of the information learned from the clerkship. Results The physical medicine and rehabilitation clerkship was effective in improving medical students’ perceived comfort and clinical knowledge regarding treatment of persons with disabilities (P < 0.01). There were no statistical differences at the 6-mo time point, indicating sustained benefit and integration of knowledge in the long term (P > 0.05). In addition, 84% of students reported using the information in clinical experiences at 6 mos. Conclusions The physical medicine and rehabilitation clerkship including a virtual disability education curriculum improved long-term perceived medical student comfort and knowledge of treating persons with disabilities, with a focus on those with physical disabilities. Virtual encounters with persons with disabilities are viable and impactful avenues to provide this education.