1. Methods Introduction Results Conclusions Figures Quick Hits - Structured On-Shift Teaching Designed for the Busy Academic Emergency Center It can be difficult to conduct structured on-shift didactics in a busy Emergency Department, especially in a setting with continuous interruptions, rapid patient turnover and multiple concurrent high acuity arrivals. To our knowledge, while many Emergency Medicine residency programs practice some type of recognized on-shift teaching (bedside rounds, morning report, resident case presentations, etc.) no formal study/review has yet to compare these methods or assess their effectiveness. No formal on-shift didactics existed in our program before the Quick Hits project. The first program design yielded 31.9% overall compliance within a 6-month period based on posted checklists. The new program design has yielded 41.6% overall compliance within a 6- month period thus far. The total teaching points across all resident shifts at two hospitals are now 6.5 times greater with the new design, despite no change in the method of tracking compliance. Resident and faculty feedback has favored the new program over the first and there is no evidence that the sign-out process has been prolonged significantly with the new program in place. A committee of faculty and senior residents met to re- implement a new program for on-shift didactics entitled the "Quick Hits" program. The initial program at our institution had consisted of an untimed presentation by oncoming faculty during the sign-out process at the 3pm transition at one of our two main institutions (two of ten total sign-out periods in 24 hours at both of our institutions). A new program was implemented that required the outgoing faculty, senior resident, or both to give a brief 1-3 minute presentation on a topic related to a patient presentation seen on shift the same day. If no teaching point could be obtained from the current shift, the outgoing faculty/resident was free to discuss any recent topic (interesting cases, clinical pearls, recent EM literature). The overall presentation was kept strictly to 3 minutes maximum. The Quick Hit took place just prior to sign-out at both institutions for every resident transition. An example presentation might describe an interesting patient from the current shift, a brief novel treatment based on a recent review paper, and why the treatment was or was not successful in that particular patient. Record sheets were kept with daily presenters and topics. Introduction/Background: Formal/structured teaching in a busy Emergency Department (ED) can be challenging. Many Emergency Medicine (EM) residency programs practice some type of structured on-shift teaching, but to our knowledge there is limited description of these efforts or their utility. Educational Objectives: We implemented a structured on-shift teaching program with the goals of being practical, efficient, and easily replicable in the academic ED. Curricular Design: We revised a pilot program for on-shift didactics entitled "Quick Hits (QH).” QH consisted of a clinical pearl delivered by on-coming faculty during the sign-out process at two of the ten available sign-out transitions each day. This pilot project had an inauspicious trial and a second iteration was then implemented with several changes to address the challenges identified. The responsibility for giving QH was changed to the outgoing faculty who simply used a teaching point based on a patient presentation from the current shift for the QH (residents had the option to give the QH, but ultimately it was the faculty’s job to ensure compliance). The overall presentation was given a strict time limit of 1-3 minutes; and it was to take place at the beginning of EVERY sign-out (all ten available sign-outs to address faculty forgetfulness and resident requests for more teaching). Impact/Effectiveness: Prior to implementing QH we had no formal on-shift didactic program. The first iteration had 31.9% overall compliance over a 6 month period. The revised design has yielded 41.6% overall compliance within a 6-month period and has generated 6.5 times as many teaching points across all resident shifts. The method of tracking compliance did not change between the two designs. There is no evidence that the sign-out process has been delayed in any meaningful way. Key elements contributing to this success include a truncated time limit to avoid delays in patient care and post-shift physician departure; content taken real-time from on-shift encounters to decrease preparation time; and placing the QH at the start of every shift to better integrate teaching into the culture of our sign-out process. We feel that the increased compliance rate and positive feedback was a result of the more streamlined and pragmatic approach to the new design. Benefits of this new design include a short and rigid time limit to thus not delay patient care, resident involvement near sign- out to increase teaching efficiency and standardize the process, and curriculum taken from on-shift encounters to decrease preparation time and maximize resident knowledge retention after shift. We are currently working on an electronic database of Quick Hit resources taken both from weekly conference and open-access EM literature. Benjamin Lo, MD and Michael Van Meter, MD Department of Emergency Medicine, University of Texas Health Science Center at Houston Abstract

2. Methods Oncoming faculty gives one 5-minute presentation on topic of their choice Takes place at the 3pm shift transition at 1 of 2 hospitals prior to sign-out Quick Hits given at 2 of the 10 total resident sign-outs in 24 hours Outgoing faculty gives 1-3 minute presentation on clinical pearl/teaching point taken from current shift that day Topics include interesting patient presentations, novel treatments/therapies, procedural technique, etc. Senior resident has option to give the Quick Hit along with faculty Sign-out resident prompts the Quick Hit and enforces time Takes place at the all shift transitions at both hospitals prior to sign-out Quick Hits given at 10 of the 10 total resident sign-outs in 24 hours Initial Quick Hits Design New Quick Hits Design

3. Results Compliance Total Quick Hits per 24 Hours

4. Conclusions New Key Elements Brief presentation with strict time limit to not delay sign-out process Takes place at sign-out to maximize efficiency as both teams present during this time Outgoing faculty (rather than incoming) can use real- time teaching point from current shift Discussions about interesting patients/cases already taking place in the ED- easy to transform this to structured teaching A single quick teaching point is more easily retained if outgoing team busy/fatigued No preparation ahead of shift Resident able to recall current shift encounter, review teaching point, and then teach oncoming team which increases knowledge retention Better structure helps integrate teaching into sign-out culture Initial Barriers Sign-out often delayed significantly Difficult to prepare topic prior to every shift Speakers over time limit Topics not relevant to resident education/clinical practice