Objectives: Ultrasound (US) has been shown to facilitate peripheral intravenous (IV) placement in emergency department (ED) patients with difficult IV access (DIVA). This study sought to define patient and vein characteristics that affect successful US-guided peripheral IV placement.Methods: This was a prospective observational study of US-guided IV placement in a convenience sample of DIVA patients in an urban, tertiary care ED. DIVA patients were defined as having any of the following: at least two failed IV attempts or a history of difficult access plus the inability to visualize or palpate any veins on physical exam. Patient characteristics (demographic information, vital signs, and medical history) were collected on enrolled patients. The relationships between patient characteristics, vein depth and diameter, US probe orientation, and successful IV placement were analyzed.Results: A total of 169 patients were enrolled, with 236 attempts at access. Increasing vessel diameter was associated with a higher likelihood of success (odds ratio [OR] = 1.79 per 0.1-cm increase in vessel diameter, 95% confidence interval [CI] = 1.37 to 2.34). Increasing vessel depth did not affect success rates (OR = 0.96 per 0.1-cm increase of depth, 95% CI = 0.89 to 1.04) until a threshold depth of 1.6 cm, beyond which no vessels were successfully cannulated. Probe orientation and patient characteristics were unrelated to success.Conclusions: Success was solely related to vessel characteristics detected with US and not influenced by patient characteristics or probe orientation. Successful DIVA was primarily associated with larger vessel, while vessel depth up to >1.6 cm and patient characteristics were unrelated to success. Clinically, if two vessels are identified at a depth of <1.6 cm, the larger diameter vessel, even if comparatively deeper, should yield the greatest likelihood of success.

Deliberate practice is an important skill-training strategy in emergency medicine (EM) education. Learning curves display the relationship between practice and proficiency. Forgetting curves show the opposite, and demonstrate how skill decays over time when it is not reinforced. Using examples of published studies of deliberate practice in EM we list the properties of learning and forgetting curves and suggest how they can be combined to create experience curves: a longitudinal representation of the relationship between practice, skill acquisition, and decay over time. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and assessment in favor of more emphasis on what can be done to improve durability of competence over time. The authors highlight the implications for both educators and education researchers.ACADEMIC EMERGENCY MEDICINE 2012; 19:1476-1480 by the Society for Academic Emergency Medicine E mergency physicians (EPs) intervene cognitively or physically to ameliorate any of a number of health conditions ranging from simple laceration repairs to managing massive multitrauma disaster situations. One of the fundamental tasks in medical education is the teaching and learning of these cognitive and kinesthetic skills. To gain these skills, novices use a number of instructional strategies, ranging from mental imagery to practicing on high-fidelity simulators. Some of these skills are amenable to deliberate practice, in which the learner repeats the given skill with informative feedback, in the hopes of progressive improvement to a recognized level of mastery.1,2 Once mastery is achieved, issues of skill retention supervene.3 Skills not practiced can degrade at a startling rate.In this article, we present experience curves, which are combinations of learning and forgetting curves that can demonstrate a single, longitudinal representation of knowledge and skill acquisition and decay over time. We will focus on discrete skills that are amenable to deliberate practice as defined by Ericsson.1 Deliberate practice consists of repetition with tailored feedback, is effortful, and is best done over an extended period. Examples could be cognitive (interpreting a radiograph, doing a calculation, applying knowledge to a medical decision, etc.), kinesthetic (performing a cricothyroidotomy), or mixed (leading a resuscitation).Informed by selected research in the medical and general education literatures, we first describe the educational properties of learning curves and forgetting curves. [4][5][6] We then show how these concepts can be united to make up experience curves.7 Our goal in writing this concept article is to promote a longitudinal approach to how these sorts of skills could be practiced in emergency medicine (EM) simulation environments. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and

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The COVID-19 pandemic has instigated significant changes for health care systems. With clinician burnout rising, efforts to promote clinician resilience are essential. Within this quality improvement project, an interprofessional debriefing program (Brigham Resilience in COVID-19-pandemic Emergency Forum-BRIEF) was developed within two emergency departments (EDs). An interprofessional group of ED providers led optional, nightly debriefings using a web-based portal to connect with ED clinicians for six weeks. In total, 81 interprofessional staff participated in nightly debriefings with a 47% attendance rate. On average, three participants attended the BRIEF nightly (range = 2-8) to discuss the challenges of social distancing, scarce resources, high acuity, clinician burnout and mental health. Participation increased as rates of COVID-19 positive patients rose. Debriefing leaders provided ED leadership with summaries of clinician experiences and suggestions for improvements. Feedback supported quality improvement initiatives within the ED and greater mental health support for staff. Clinicians and administrators provided positive feedback regarding the program's impact on clinician morale, and clinical processes that promoted the safety and quality of patient care. Optional debriefing with receptive departmental leadership may be a successful tool to support clinicians and hospitals during critical events.