Emergency cricothyrotomy during the COVID-19 pandemic: how to suppress aerosolization

Background

Cricothyrotomy is associated with significant aerosolization that increases the potential risk of infection among healthcare providers. It is important to identify simple yet effective methods to suppress aerosolization and improve the safety of healthcare providers.

Methods

5 ear, nose and throat and general surgeons used a locally developed hybrid cricothyrotomy simulator with a porcine trachea to test three draping methods to suppress aerosolization during the procedure: an X-ray cassette drape, dry operating room (OR) towels and wet OR towels. The three methods were judged based on three categories: effectiveness of suppression, availability in all healthcare systems and ease of handling.

Results

All five surgeons performed the procedure independently using each of the three suppression methods. The wet OR towel drape was found to be an effective method to suppress aerosolization, and it did not hinder the surgeons from performing the procedure accurately. This finding was confirmed by using an atomized fluorescein dye injection into the porcine trachea, representing aerosolized material while performing the procedure.

Conclusions

We present a novel intervention using wet towels to suppress aerosolization during cricothyrotomy. Wet towels are cheap and readily available within any healthcare setting regardless of the financial resources available.

Improving cardiology fellow education of right heart catheterization using a simulation based curriculum

BACKGROUND

Medical procedures are traditionally taught informally at patients' bedside through observation and practice using the adage "see one, do one, teach one." This lack of formalized training can cause trainees to be unprepared to perform procedures independently. Simulation based education (SBE) increases competence, reduces complications, and decreases costs. We developed, implemented, and evaluated the efficacy of a right heart catheterization (RHC) SBE curriculum.

METHODS

The RHC curriculum consisted of a pretest, video didactics, deliberate practice, and a posttest. Pre-and posttest skills examinations consisted of a dichotomous 43-item checklist on RHC skills and a 14-item hemodynamic waveform quiz. We enrolled two groups of fellows: 6 first-year, novice cardiology fellows at Northwestern University in their first month of training, and 11 second- and third-year fellows who had completed traditional required, level I training in RHC. We trained the first-year fellows at the beginning of the 2018-2019 year using the SBE curriculum and compared them to the traditionally-trained cardiology fellows who did not complete SBE.

RESULTS

The SBE-trained fellows significantly improved RHC skills, hemodynamic knowledge, and confidence from pre- to posttesting. SBE-trained fellows performed similarly to traditionally-trained fellows on simulated RHC skills checklists (88.4% correct vs. 89.2%, p = .84), hemodynamic quizzes (94.0% correct vs. 86.4%, p = .12), and confidence (79.4 vs. 85.9 out of 100, p = .15) despite less clinical experience.

CONCLUSIONS

A SBE curriculum for RHC allowed novice cardiology fellows to achieve level I skills and knowledge at the beginning of fellowship and can train cardiology fellows before patient contact.

Patient, Caregiver, and Clinician Perceptions of Ventricular Assist Device Self-care Education Inform the Development of a Simulation-based Mastery Learning Curriculum

BACKGROUND

Patients who undergo ventricular assist device (VAD) implantation and their caregivers must rapidly learn a significant amount of self-care skills and knowledge.

OBJECTIVE

The aim of this study was to explore patient, caregiver, VAD coordinator, and physician perspectives and perceptions of existing VAD self-care training to inform development of a simulation-based mastery learning (SBML) curriculum to teach patients and caregivers VAD self-care skills and knowledge.

METHODS

We conducted semistructured, in-person interviews with patients with a VAD, their caregivers, VAD coordinators, and physicians (cardiac surgeons, an infectious disease physician, and advanced heart failure cardiologists). We used a 2-cycle team-based iterative inductive approach to coding and analysis.

RESULTS

We interviewed 16 patients, 12 caregivers, 7 VAD coordinators, and 11 physicians. Seven major themes were derived from the interviews including (1) identification of critical curricular content, (2) need for standardization and assessment, (3) training modalities, (4) benefits of repetition, (5) piercing it all together, (6) need for refresher training, and (7) provision of training before implant.

CONCLUSIONS

Findings from this study suggest that SBML is a natural fit for the high-risk tasks needed to save VAD self-care. The 7 unique training-related themes derived from the qualitative data informed the design and development of a VAD SBML self-care curriculum.

Simulation-Based Mastery Learning Improves Patient and Caregiver Ventricular Assist Device Self-Care Skills: A Randomized Pilot Trial

BACKGROUND

No recognized standards exist for teaching patients and their caregivers ventricular assist device (VAD) self-care skills. We compared the effectiveness of a VAD simulation-based mastery learning (SBML) self-care training curriculum with usual VAD self-care training.

METHODS AND RESULTS

VAD patients and their caregivers were randomized to SBML or usual training during their implant hospitalization. The SBML group completed a pretest on 3 VAD self-care skills (controller, power source, and dressing change), then viewed videos and participated in deliberate practice on a simulator. SBML participants took a posttest and were required to meet or exceed a minimum passing standard for each of the skills. The usual training group completed the existing institutional VAD self-care teaching protocol. Before hospital discharge, the SBML and usual training groups took the same 3 VAD self-care skills tests. We compared demographic and clinical information, self-confidence, total participant training time, and skills performance between groups. Forty participants completed the study in each group. There were no differences in demographic and clinical information, self-confidence, or training time between groups. More participants in the SBML group met the minimum passing standard compared with the usual training group for controller (37/40 [93%] versus 25/40 [63%]; P=0.001), power source (36/40 [90%] versus 9/40 [23%]; P<0.001), and dressing change skills (19/20 [95%] versus 0/20; P<0.001).

CONCLUSIONS

SBML provided superior VAD self-care skills learning outcomes compared with usual training. This study has important implications for patients due to the morbidity and mortality associated with improper VAD self-care.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT03073005.

Development of a Simulation-Based Mastery Learning Curriculum for Breaking Bad News

INTRODUCTION

Physician communication impacts patient outcomes. However, communication skills, especially around difficult conversations, remain suboptimal, and there is no clear way to determine the validity of entrustment decisions. The aims of this study were to 1) describe the development of a simulation-based mastery learning (SBML) curriculum for breaking bad news (BBN) conversation skills and 2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners.

INNOVATION

An SBML BBN curriculum was developed for fourth-year medical students. An assessment tool was created to evaluate the acquisition of skills involved in a BBN conversation. Pilot testing was completed to confirm improvement in skill acquisition and set the MPS.

OUTCOMES

A BBN assessment tool containing a 15-item checklist and six scaled items was developed. Students' checklist performance improved significantly at post-test compared to baseline (mean 65.33%, SD = 12.09% vs mean 88.67%, SD = 9.45%, P < 0.001). Students were also significantly more likely to have at least a score of 4 (on a five-point scale) for the six scaled questions at post-test. The MPS was set at 80%, requiring a score of 12 items on the checklist and at least 4 of 5 for each scaled item. Using the MPS, 30% of students would require additional training after post-testing.

COMMENTS

We developed a SBML curriculum with a comprehensive assessment of BBN skills and a defensible competency standard. Future efforts will expand the mastery model to larger cohorts and assess the impact of rigorous education on patient care outcomes.

The Effect of Judge Selection on Standard Setting Using the Mastery Angoff Method during Development of a Ventricular Assist Device Self-Care Curriculum

Background

Patients and caregivers need to perform ventricular assist device (VAD) self-care safely to help prevent complications (e.g., infection). We developed a VAD self-care simulation-based mastery learning (SBML) curriculum. We determined optimal minimum passing scores (MPSs) and evaluated effects of judge selection.

Methods

A multidisciplinary team created a VAD self-care SBML curriculum including simulated skills and knowledge examinations. Patients, caregivers, VAD coordinators, and physicians were expert judges who determined MPSs using the Mastery Angoff method.

Results

MPSs for the skills and knowledge examinations were high (range = 94-99% and 97% correct), respectively. Judges closely agreed on MPSs.

Conclusions

Stakeholders set stringent MPSs for high-stakes VAD self-care.

A Comparison of Approaches for Mastery Learning Standard Setting

PURPOSE

Defensible minimum passing standards (MPSs) must be used to evaluate learner performance outcomes in health professions education. In this study, the authors compared the results of traditional Angoff and Hofstee standard-setting exercises with the Mastery Angoff and Patient-Safety approaches for central venous catheter (CVC) insertion skills examinations. The authors also evaluated how these standards affected the historical performance of residents who participated in a simulation-based mastery learning (SBML) curriculum for CVC insertion skills.

METHOD

In April and May 2015, 12 physicians with expertise in CVC insertion set MPSs for previously published internal jugular (IJ) and subclavian (SC) CVC insertion checklists using Angoff, Hofstee, Mastery Angoff, and Patient-Safety approaches. The resulting MPSs were compared using historical performance of internal medicine and emergency medicine residents who participated in CVC insertion SBML.

RESULTS

The MPSs were set as follows: Angoff: IJ 91% checklist items correct, SC 90%. Hofstee: IJ 88%, SC 90%. Mastery Angoff: IJ 98%, SC 98%. Patient-Safety: IJ 98%, SC 98%. Based on the historical performance of 143 residents assessed on IJ and SC insertion, applying the 98% MPS would result in additional practice and retesting of 55/123 residents (45%) who had previously passed the IJ examination and 36/130 residents (28%) who had passed the SC examination using the Angoff and Hofstee MPSs.

CONCLUSIONS

The Mastery Angoff and Patient-Safety standard-setting approaches resulted in higher CVC insertion SBML MPSs compared with traditional standard-setting methods. Further study should assess the impact of these more rigorous standards on patient outcomes.

Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial

PURPOSE

Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE).

METHOD

The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR).

RESULTS

During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008).

CONCLUSIONS

Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.

Healthcare Providers' Awareness and Perceptions of Competency Requirements in Central Venous Catheter Insertion

This article was migrated. The article was marked as recommended. Background Studies show that medical residents do not feel comfortable and lack the skills and confidence to perform common bedside procedures. Regulatory bodies often require a set number of procedures to determine resident competence, yet medical providers' knowledge of competency guidelines are less well known. This study aimed to qualitatively assess existing practices relevant to documentation of competency in central venous catheter (CVC) insertion and explore healthcare providers' awareness and perceptions of those practices at their institutions. Methods The authors performed a qualitative study at Veterans Affairs Medical Centers (VAMCs) from February to December 2014 as part of a larger project related to the dissemination of a simulation-based CVC insertion curriculum. Two authors conducted interviews with hospital staff (including attending physicians, nurses, and residents) at selected VAMCs. Recordings of interviews were transcribed, coded, and analyzed using a grounded theory approach and constant comparative techniques. Results Twenty-six participants were interviewed at six VAMCs. Participants reported varying perspectives regarding their institutions' policies about CVC insertion. Four major themes emerged: (1) knowledge of institutional policy; (2) competency by numbers; (3) documentation of competency; and (4) perceptions of competency measures. Participants reported concern about the reliability of these policies and measures of competence. Conclusions This study demonstrates that healthcare providers' knowledge and perceptions about institutional requirements for procedural competency vary widely. Our findings suggest the need for establishment of consistent competency policies based on evidence-based practices, and highlight the need for increased communication regarding individual institutional policies. Integration of rigorous simulation-based education, implemented consistently across institutions, can provide a reliable mechanism to train and assess procedural competence and ensure patient safety.

Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding

Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.

An institution-wide approach to submission, review, and funding of simulation-based curricula

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.

Residents' Procedural Experience Does Not Ensure Competence: A Research Synthesis

BACKGROUND

Many medical certifying bodies require that a minimum number of clinical procedures be completed during residency training to obtain board eligibility. However, little is known about the relationship between the number of procedures residents perform and their clinical competence.

OBJECTIVE

This study evaluated associations between residents' medical procedure skills measured in a simulation laboratory and self-reported procedure experience and year of training.

METHODS

This research synthesis extracted and summarized data from multiple cohorts of internal medicine, emergency medicine, anesthesiology, and neurology resident physicians who performed simulated clinical procedures. The procedures were central venous catheter insertion, lumbar puncture, paracentesis, and thoracentesis. We compared residents' baseline simulated performance to their self-reported procedure experience using data from 7 research reports written by Northwestern University investigators between 2006 and 2016. We also evaluated how performance differed by postgraduate year (PGY).

RESULTS

A total of 588 simulated procedures were performed during the study period. We found significant associations between passing the skills examinations and higher number of self-reported procedures performed (P = .011) and higher PGY (P < .001). However, performance for all procedures was poor, as only 10% of residents passed the assessments with a mean of 48% of checklist items correct (SD = 24.2). The association between passing the skills examination and year of training was mostly due to differences between PGY-1 and subsequent years of training.

CONCLUSIONS

Despite positive associations between self-reported experience and simulated procedure performance, overall performance was poor. Residents' clinical experience is not a proxy for skill.

Safe and Effective Bedside Thoracentesis: A Review of the Evidence for Practicing Clinicians

BACKGROUND

Physicians often care for patients with pleural effusion, a condition that requires thoracentesis for evaluation and treatment. We aim to identify the most recent advances related to safe and effective performance of thoracentesis.

METHODS

We performed a narrative review with a systematic search of the literature. Two authors independently reviewed search results and selected studies based on relevance to thoracentesis; disagreements were resolved by consensus. Articles were categorized as those related to the pre-, intra- and postprocedural aspects of thoracentesis.

RESULTS

Sixty relevant studies were identified and included. Pre-procedural topics included methods for physician training and maintenance of skills, such as simulation with direct observation. Additionally, pre-procedural topics included the finding that moderate coagulopathies (international normalized ratio less than 3 or a platelet count greater than 25,000/μL) and mechanical ventilation did not increase risk of postprocedural complications. Intraprocedurally, ultrasound use was associated with lower risk of pneumothorax, while pleural manometry can identify a nonexpanding lung and may help reduce risk of re-expansion pulmonary edema. Postprocedurally, studies indicate that routine chest X-ray is unwarranted, because bedside ultrasound can identify pneumothorax.

CONCLUSIONS

While the performance of thoracentesis is not without risk, clinicians can incorporate recent advances into practice to mitigate patient harm and improve effectiveness. Journal of Hospital Medicine 2017;12:266-276.

Achieving Procedural Competence during Nephrology Fellowship Training: Current Requirements and Educational Research

Concerns have previously been raised as to whether training programs are ensuring that nephrology fellows achieve competence in the procedural skills required for independent practice. We sought to review the current requirements for procedural training as well as educational research pertaining to achieving competence in the core nephrology procedures of nontunneled (temporary) hemodialysis catheter insertion and percutaneous kidney biopsy. At this time, there is no universal approach to procedural training and assessment during nephrology fellowship. Nonetheless, simulation-based mastery learning programs have been shown to be effective in improving fellows' skills in nontunneled (temporary) hemodialysis catheter insertion and should be provided by all nephrology training programs. For percutaneous kidney biopsy, the development and evaluation of inexpensive simulators are a promising starting point for future study. Current practice with respect to procedural training during nephrology fellowship remains imperfect; however, the ongoing shift toward competency-based evaluation provides opportunities to refocus on improvement.

The effect of simulation-based mastery learning on thoracentesis referral patterns

Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, self-confidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBML-trained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Journal of Hospital Medicine 2016;11:792-795. © 2016 Society of Hospital Medicine.