Setting

This intervention was implemented at a county hospital residency program with the support of residency program leadership. Highland Hospital is a public hospital and level one trauma center in Oakland, California, home to a 4‐year Accreditation Council for Graduate Medical Education (ACGME)‐accredited residency in EM with 45 total residents. There is a palliative care consult service available for ED and inpatient consults during business hours.

The ED at Highland Hospital sees over 70,000 patients per year, with approximately one quarter of these patients being evaluated in the contiguous Fast Track (urgent care) system. Fast Track patients were excluded from the analysis. Approximately 21% of patients seen in the main ED are admitted to the hospital, 3.5% to critical care beds. There are also approximately 3500 trauma activations per year. These patients are primarily managed by a surgical team and were also excluded from the analysis. Thus, the total number of patients seen by EM residents during the intervention is estimated to be approximately 53,083 over 13 months.

All active residents (n = 45) were exposed to the intervention, which was led by a team of senior and junior residents with faculty mentorship from the Department of Emergency Medicine and Palliative Care Service at Highland Hospital. As this was an educational intervention, there was no formal consent required. Four residents were part of the intervention team and were excluded from the analysis.