Learning Objectives: 1. Recognize a new format to teach end-of-life care. 2. Review the perception of learners using a serious-game framework to learn rapid discussion about goals of care.

Introduction: Emergency departments (ED) care for many patients who are chronically ill and nearing end of life. Establishing goals of care and code status in the ED is an essential skill for Emergency Medicine (EM) residents but is challenging to teach.

Educational Objectives: To develop EM residents’ ability to: 1) identify patients in need of a goals-of-care discussion; 2) interpret advance care planning documents; 3) efficiently conduct an informed code status discussion; and 4) manage the actively dying patient.

Curricular Design: High-fidelity simulation was utilized to replicate the experience of caring for a critically-ill patient in the high-stress ED environment. The scenario involved a live standardized patient with stage 4 pancreatic cancer presenting with sepsis due to pneumonia and who had the goal of comfort-focused care. The simulation utilized the Live-Die-Repeat format, which is a serious-game scheme in which learners are allowed infinite opportunities (“lives”) to progress through a single patient scenario. If learners complete the predetermined critical actions, the game is paused and there is a debriefing to reinforce knowledge and skills before resident’s progress to the next stage of the simulation. Conversely, if learners do not complete critical actions, the game is over and learners must undergo remedial debriefing before they repeat the scenario they previously failed.

Impact/Effectiveness: Eighty percent (16/20) of the residents completed a Simulation Effectiveness Tool-Modified survey and 100% strongly or somewhat agree the simulation improved their skills and confidence at the end of life including: better prepared to respond to changes in condition, more confident in assessment skills, teaching patients, reporting to the medical team, empowered to make clinical decisions, and ability to prioritize care and interventions (Figure). Comments emphasized the impact of simulation on their ability to have a goal of care discussion (Table).

Introduction: Patients who stay in the emergency department (ED) for prolonged periods of time require verification of home medications, a process known as medication reconciliation. The complex nature of medication reconciliation can lead to adverse events and staff dissatisfaction. A multidisciplinary team was formed to improve accuracy, timing, and staff satisfaction with the medication reconciliation process.

Methods: Between November 2021–January 2022, stakeholders were surveyed to identify gaps in the medication reconciliation process. This project implemented education on role-specific tasks, as well as a “Let’s chat!” huddle, bringing together the entire care team to perform medication reconciliation. We used real-time evaluations by frontline staff to evaluate effectiveness during plan- do-study-act cycles and obtain feedback. Following the implementation period, stakeholders completed the post-intervention survey between June-July 2022, using a 4-point Likert scale (0 = very dissatisfied to 3 = very satisfied). We calculated the change in staff satisfaction from pre-intervention to post-intervention. Differences in proportions and 95% confidence intervals are reported. This study adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) and followed the Lean Six Sigma rapid cycle process improvement (define-measure-analyze-improve-control).

Results: A total of 111 front-line ED staff (physicians, nurse practitioners, physician assistants, pharmacists, nurses) completed the pre-intervention survey (of 350 ED staff, corresponding to a 31.7%response rate), and 89 stakeholders completed the post-intervention survey (a 25.4% response rate). Subjective feedback from staff identifying causes of low satisfaction with the initial process included the following: complexity of process; unclear delineation of staff roles; time burden to completion; high patient volume; and lack of standardized communication of task completion. Overall satisfaction improved after the intervention. The greatest improvement was seen in the correct medication (difference 20.7%, confidence interval [CI] 6.3–33.9%, P < 0.01), correct dose (25.6%, CI 11.4–38.6%, P < 0.001) and time last taken (24.5%, CI 11.4–37.0%, P < 0.001).

Conclusion: There is a steep learning curve to educate multidisciplinary staff on a new process and implement the associated changes. With goals to impact the safety of our patients and reduce negative outcomes, engagement and awareness of the team involved in the medication reconciliation process is critical to improve staff satisfaction.