Bacterial Meningitis With Cerebral Edema in a Young Adult: A Simulation Case for Medical Students

Introduction

Simulation in the preclinical medical education setting is a beneficial tool for students to develop clinical skills, supplement preexisting knowledge, and prepare for clinical rotations and beyond. We detail the complete simulation scenario, including a participant postresponse questionnaire, of a 28-year-old male who developed bacterial meningitis after experiencing an upper respiratory infection in the days prior.

Methods

Simulation fellows and faculty at the Alabama College of Osteopathic Medicine created a simulation scenario pertaining to bacterial meningitis. The scenario utilized a high-fidelity patient simulator, one standardized participant for patient voiceover, one standardized participant as a patient family member, and one standardized participant as a physician consultant on an as-needed basis. Sixteen preclinical medical students from various specialty interest groups were recruited to participate in the scenario and complete the postscenario questionnaire.

Results

The simulation scenario was well received by the participants, and 15 of 16 completed the postscenario questionnaire. Ninety-three percent strongly agreed the simulation was a valuable clinical experience. Additionally, 73% of participants strongly agreed that the simulation experience was realistic, 80% strongly agreed that it tested their clinical reasoning ability, and 53% strongly agreed it was appropriate for their level of clinical knowledge.

Discussion

Medical simulation is a valuable educational tool tailored to maximize student learning and supplement the traditional didactic curriculum. The successful development and implementation of our meningitis simulation case further supports the continued use of medical simulation in the preclinical setting.

Airborne Isolation Cardiac Arrest: A Simulation Program for Interdisciplinary Code Blue Team Training

INTRODUCTION

In-hospital cardiac arrest in patients with COVID-19 presents significant challenges to health care teams. Airborne precautions can delay patient care, place providers at high risk of virus exposure, and exacerbate an already stressful environment. Within the constraints of an ongoing pandemic, an efficient educational program is required to prepare health care teams for airborne isolation code blue.

METHODS

This simulation was conducted in a room on the target unit using a CPR manikin to represent the patient. A "talk-through walk-through" scripted simulation directed learners (internal medicine residents, unit nurses, and other code blue responders) through a resuscitation using an airborne isolation code blue protocol. Key scripted events prompted role identification, communication, and item transfer. Learners self-assessed their airborne isolation code blue knowledge and skills and their confidence in providing quality care while maintaining safety using a pre-/posttraining 5-point Likert-scale survey.

RESULTS

We trained 100 participants over a 5-month period, with 65 participants surveyed (43 respondents; 16 residents, 22 nurses). Following training, participants had a statistically significant (p < .001) increase in percentage selecting agree/strongly agree for all statements related to knowledge and skills specific to airborne isolation code blue protocol, as well as confidence in providing care while keeping themselves and their colleagues safe.

DISCUSSION

Our simulation program allowed a small number of educators to feasibly train a large number of learners, let learners practice required skills, and improved learners' self-assessed knowledge, skills, and confidence regarding quality and safety of care.

Analysis of catheter utilization, central line associated bloodstream infections, and costs associated with an inpatient critical care-driven vascular access model

BACKGROUND

Central line-associated bloodstream infections (CLABSI) carry serious risks for patients and financial consequences for hospitals. Avoiding unnecessary temporary central venous catheters (CVC) can reduce CLABSI. Critical Care Medicine (CCM) is often consulted to insert CVC when alternatives are unavailable. We aim to describe clinical and financial implications of a CCM-driven vascular access model.

METHODS

In this retrospective, observational cohort study, all CLABSI and a sample of CCM consults for CVC insertion on adult medical-surgical inpatient units were reviewed in 2019. Assessment of CVC appropriateness and financial analysis of labor, reimbursement, and attributable CLABSI cost was conducted.

RESULTS

Of 554 CCM consult requests, 75 (13.5%) were for CVC and 36 (48.0%) resulted in CVC insertion; 6 (16.7%) CVC were avoidable. Three CLABSI occurred in avoidable CVC with estimated annual attributable cost of $165,099. Estimated annual CCM consultant cost for CVC was $78,094 generating $110,733 in reimbursement. Overall estimated annual loss was $132,460.

DISCUSSION

Reliance on CCM for intravenous access resulted in avoidable CVC, CLABSI, inefficient physician effort, and financial losses; nurse-driven vascular access models offer potential cost savings and risk reduction.

CONCLUSIONS

CCM-driven vascular access models may not be cost-effective; alternatives should be considered for utilization reduction, CLABSI prevention, and financial viability.

Common Complications of Sickle Cell Disease: A Simulation-Based Curriculum

INTRODUCTION

Sickle cell disease (SCD), the most common autosomal recessive genetic disorder worldwide, affects nearly every organ of the body and results in accelerated mortality. Nationally, internal medicine physicians lack a complete understanding of morbidity and mortality in this population leading to health care disparities.

METHODS

We created a 2-hour curriculum consisting of three SCD case vignettes representing common disease complications (acute stroke, acute chest syndrome, and septic shock) with the goal to increase medicine house staff knowledge and confidence in patient management. Residents completed a pretest to assess baseline knowledge and were divided into groups of four to five. Three simulation cases were completed by each group; learners needed to work through a differential diagnosis and describe key management steps. Each group was graded on achieving the 10 critical actions for each case. Following each case, there was a faculty-led debriefing session. Residents repeated the pretest 30 days after completion of the curriculum (posttest).

RESULTS

Thirty-six second year internal medicine residents participated in this curriculum. After completing this curriculum, residents improved their test score from 33% (SD = 12%) to 57% (SD = 18%) (p < .0001). Additionally, self-reported confidence in management scores increased from 2.6 (SD = 0.8) in the pretest to 3.5 (SD = 0.4) in the posttest (p = .02) on a 5-point Likert scale (1 = not very confident, 5 = very confident).

DISCUSSION

Use of a simulation curriculum increased knowledge and confidence of internal medicine residents in the management of critical illness in patients with SCD.

A Case-Based Critical Care Curriculum for Internal Medicine Residents Addressing Social Determinants of Health

INTRODUCTION

Graduate medical education on social determinants of health (SDOH) is limited. Residents often directly care for vulnerable populations at safety-net hospitals, yet curricula thus far are based in the ambulatory setting.

METHODS

We developed a case-based curriculum integrating SDOH with critical care topics to standardize knowledge and improve skills and attitudes of internal medicine residents working with these patients. We conducted a needs assessment, identified systematic social risk domains, and modified a published curriculum to develop the content. Case-based discussions were conducted weekly in the medical intensive care unit, while knowledge, attitudes, and skills were assessed daily during multidisciplinary rounds. A 360-degree assessment was completed with pre- and postcurriculum surveys and self-reflection.

RESULTS

Eleven residents completed postcurriculum surveys. Both pre- and postcurriculum, residents reported confidence in identifying and describing how SDOH affect care. After the curriculum, residents could name more resources for patients experiencing health disparities due to substance abuse (pre: 47%, post: 73%) and financial constraints (pre: 50%, post:64%). This curriculum was recognized as the first training many residents received (pre: 31%, post: 91%) with formal feedback (pre: 16%, post: 64%).

DISCUSSION

Implementing a curriculum of social risk assessment in critically ill patients was difficult due to competition with clinical care. Participating residents said they "loved the open dialogue" to reflect on their experiences; this became an avenue to "debrief on specific patient encounters and [how] SDOH brought [patients] to the ICU." Future directions include qualitative analysis of reflections and assessment of curricular impact on trainee resiliency.

Cardiopulmonary Arrest and Resuscitation in the Prone Patient: An Adult Simulation Case for Internal Medicine Residents

INTRODUCTION

Acute respiratory distress syndrome (ARDS) is present in approximately 10% of ICU admissions and is associated with great morbidity and mortality. Prone ventilation has been shown to improve refractory hypoxemia and mortality in patients with ARDS.

METHODS

In this simulation, a 70-year-old male had been transferred to the ICU for ARDS and was undergoing scheduled prone ventilation as part of his care when he experienced a cardiopulmonary arrest secondary to a tension pneumothorax. Learners demonstrated how to manage cardiac arrest in a prone patient and subsequently identified and treated the tension pneumothorax that was the cause of his initial arrest. This single-session simulation for internal medicine residents (PGY 1-PGY 4) utilized a prone mannequin connected to a ventilator in a high-fidelity simulation center. Following the simulation, facilitators led a team debriefing and reviewed key learning objectives.

RESULTS

A total of 103 internal medicine residents participated in this simulation. Of those, 43 responded to a postsimulation survey. Forty-two of 43 agreed or strongly agreed that all learning objectives were met, that the simulation was appropriate for their level of training, and that their participation would be useful for their future practice.

DISCUSSION

We designed this simulation to improve learners' familiarity with prone cardiopulmonary resuscitation and to enhance overall comfort with cardiac arrest management. Postsimulation survey results and debriefings revealed that the simulation was a valuable education opportunity, and learners felt that their participation in this simulation would be helpful in their future practice.

Integrated Critical Care Curriculum for the Third-Year Internal Medicine Clerkship

INTRODUCTION

A majority of residents provide care for critically ill patients, yet only a minority of medical schools require ICU rotations. Therefore, many medical students enter residency without prior ICU experience. The third-year internal medicine (IM) clerkship at our institution's Veterans Affairs Medical Center (VAMC) provided an opportunity for medical students to rotate through an open ICU as part of their inpatient ward rotation. Prior to March 2019, no structured critical care curriculum existed within the IM clerkship to prepare students for this experience.

METHODS

We created a seven-session ICU curriculum integrated within the VAMC IM clerkship addressing core critical care topics and skills including bedside presentations, shock, and respiratory failure. IM residents facilitated the curriculum's case-based, small-group discussions. We assessed curricular efficacy and impact with a pre- and posttest and end-of-curriculum survey.

RESULTS

Forty-one students participated in the curriculum from March to November 2019. As a result, students agreed that their overall clerkship experience improved (73% strongly agree, 24% agree). Students also reported increased comfort in their ability to participate in the management of critically ill patients (44% strongly agree, 51% agree). Objectively, student performance on a 15-question pre- and posttest improved from a precurricular average of 7.5 (50%) questions correct to a postcurricular average of 10.7 (71%) questions correct (p <.0001; CI 2.2-4.4).

DISCUSSION

Following implementation of our ICU curriculum, medical student attitudes regarding overall IM clerkship experience, self-perceived confidence in critically ill patient management, and medical knowledge all improved.

Improving Resident Self-Efficacy in Tracheostomy Management Using a Novel Curriculum

INTRODUCTION

Patients receiving pediatric tracheostomy have significant risk for mortality due to compromised airway. Timely management of airway emergencies in children with tracheostomies is an important clinical skill for pediatricians. We developed this curriculum to improve residents' self-efficacy with tracheostomy management.

METHODS

We collected baseline data on 67 residents from two hospitals while creating a blended curriculum with video-based instruction on routine tracheostomy change and team management of tracheostomy emergency. Forty residents enrolled in the curriculum. During an ICU rotation, they received face-to-face instruction on routine tracheostomy change in small groups, followed by assessment of managing a tracheostomy emergency during a simulation. A video completed prior to the simulation took 9 minutes, the routine tracheostomy change didactic session took 15 minutes, and the simulation instruction was completed in 10-15 minutes. We collected feedback on the effectiveness of the curriculum from the participants.

RESULTS

All 107 residents from the baseline and intervention groups completed the self-efficacy survey. The intervention group had significantly higher changes in scores across all self-efficacy domains than the baseline group. On the curriculum feedback survey, residents rated the curriculum very highly, between 4.4 and 4.8 on a 5-point Likert scale.

DISCUSSION

Our blended curriculum increased learners' self-efficacy and promoted learner competence in tracheostomy management. Residents scored more than 80% across all aspects of simulation assessment and reported higher self-efficacy scores following our curricular intervention.

Pediatric Intensive Care Unit Resident Educational Curriculum

INTRODUCTION

Consistent medical knowledge acquisition while caring for the critically ill can be challenging for learners and educators in the pediatric intensive care unit (PICU), a unit often distinguished by fluctuating acuity and severity. We implemented a standardized didactic curriculum for PICU residents to facilitate their acquisition and retention of knowledge in core PICU topics.

METHODS

We developed a comprehensive standardized curriculum for PGY 2-PGY 4 PICU pediatric and internal medicine-pediatric residents. Thirteen core topics were administered as 30-minute didactic sessions during the rotation, using either PowerPoint slides or a dry-erase board. Residents were tested to assess knowledge acquisition and retention.

RESULTS

Seventy-eight residents participated, 86% of whom completed posttests. Seventeen percent completed follow-up tests. Of the learners who participated, 60 (77%) completed pretests and posttests, indicating their confidence level each time. The pretest mean was 55% (SD = 14.4%), and the posttest mean was 64% (SD = 15.6%). This 9% increase was statistically significant (p = .001; CI, 3.9% to 14.8%). The follow-up test at 3 months, completed by 15% of this subgroup, demonstrated a mean score of 62% (SD = 14.5%). When matched with posttest scores (mean score of 64%, SD = 13.3%), there was no significant difference (p = .7398; CI, -11.7% to 16.2%), suggesting retention of previously acquired knowledge.

DISCUSSION

Our standardized didactic curriculum effectively facilitated the acquisition and retention of the medical knowledge of core PICU topics among PICU residents, in addition to their usual experiential learning.

Brain Death Determination: An Interprofessional Simulation to Determine Brain Death and Communicate with Families Focused on Neurology Residents

INTRODUCTION

Significant variation exists in determining brain death despite an expectation of competence for all neurology residents. In addition, family discussions regarding brain death are challenging and may influence organ donation.

METHODS

We developed two simulations of increasing complexity for PGY 2 and PGY 3 neurology residents. High-fidelity mannequins were used to simulate patients; standardized actors portrayed family members. In the first simulation, residents determined brain death and shared this information with a grieving family. In the second simulation, residents determined brain death in a more complicated scenario, requiring ancillary testing and accurate result interpretation. Following the determination, residents met with a challenging family. The residents worked with an interdisciplinary team and responded to the family's emotions, used active listening skills, and supported the family through next steps.

RESULTS

Twelve residents completed the simulations. Prior to the simulation, three (25%) residents felt comfortable discussing a brain death diagnosis; following the simulation, eight (67%) residents felt comfortable/very comfortable discussing brain death. Prior to the simulation, eight (67%) residents stated they knew prerequisites for performing a brain death examination and seven (58%) agreed they knew indications for ancillary testing; these numbers increased to 100% following the simulation. The number of residents who felt comfortable performing the brain death exam increased from five (42%) to 10 (83%).

DISCUSSION

This simulation of determining brain death and leading difficult family meetings was well-received by neurology residents. Further work should focus on the effects of simulation-based education on practice variation and organ donation consent rates.

Intraoperative Sepsis: A Simulation Case for Anesthesiology Residents

INTRODUCTION

Sepsis is a major cause of morbidity and mortality in medicine and is managed in ICUs daily. Critical care training is a vital part of anesthesiology residency, and understanding the presentation, management, and treatment of septic shock is fundamental to intraoperative patient care.

METHODS

This simulation involved a 58-year-old man undergoing surgical debridement of a peripancreatic cyst with hemodynamic instability and septic shock. We conducted the simulation yearly for clinical anesthesia year 2 residents (n = 26) in 1-hour sessions with three to five learners at a time. The simulation covered the six Anesthesiology Milestones related to sepsis and septic shock as outlined in the Anesthesiology Milestones Project.

RESULTS

To date, 155 anesthesiology residents have completed the simulation. Commonly missed critical actions included failure to recognize the need for invasive lines, provide appropriate volumes of fluid resuscitation, inquire about blood cultures and antibiotics, and recognize the need for the patient to remain intubated. Most participants could appropriately diagnose and treat intraoperative septic shock, but all had moments of action or inaction to discuss and improve upon, and all learned from this scenario.

DISCUSSION

Simulation is an optimal way to practice the more rare and life-threatening clinical events in medicine. Even though septic shock is commonly managed in the ICU, it is relatively uncommon for it to develop acutely in the OR. This simulation is an effective and educational way to discuss the most recent sepsis/septic shock definition and review evidence-based guidelines for treatment.

Family Meeting Training Curriculum: A Multimedia Approach With Real-Time Experiential Learning for Residents

INTRODUCTION

Effective communication skills are widely recognized as an important aspect of medical practice. Several tools and curricula for communications training in medicine have been proposed, with increasing attention to the need for an evidence-based curriculum for communication with families of patients in the intensive care unit (ICU).

METHODS

We developed a curriculum for internal medicine residents rotating through the medical ICU that consisted of a didactic session introducing basic and advanced communication skills, computer-based scenarios exposing participants to commonly encountered dilemmas in simulated family meetings, and experiential learning through the opportunity to identify potential communication challenges prior to facilitating actual family meetings, followed by structured peer debriefing. Seventeen residents participated in the study.

RESULTS

We administered the Communication Skills Attitude Scale to participants before and after participation in the curriculum, as well as a global self-efficacy survey, with some items based on the Common Ground rating instrument, at the end of the academic year. There were no significant changes in either positive or negative attitudes toward learning communication skills. Resident self-perceived efficacy in several content domains improved but did not reach statistical significance.

DISCUSSION

Our curriculum provided interactive preparatory training and an authentic experience for learners to develop skills in family meeting facilitation. Learners responded favorably to the curriculum. Use of the Family Meeting Behavioral Skills (FMBS) tool helped residents and educators identify and focus on specific skills related to the family meeting. Next steps include gathering and analyzing data from the FMBS tool.

Perineal Laceration and Episiotomy Repair Using a Beef Tongue Model

INTRODUCTION

Declining rates of operative vaginal deliveries and routine episiotomy in obstetric practice, along with rising cesarean section rates, have decreased OB/GYN resident experience with episiotomy repair and obstetric anal sphincter injuries (OASIS). Simulation models are valuable educational tools in procedural training. Several models have been reported, each with its own limitations and benefits.

METHODS

We developed a 1-hour workshop to teach novice OB/GYN residents perineal laceration repair skills on a modified beef tongue model. The model required 5-10 minutes to assemble following written and video instruction, and learners had 30-50 minutes to practice using learner instructions. Learners were evaluated using a procedure checklist and global objective structured assessment of technical skills. To evaluate the session, we surveyed current faculty and residents, as well as residency graduates.

RESULTS

Between 2008 and 2017, an estimated 82 OB/GYN residents participated in this activity, and 95 participants and facilitators received the survey. Forty-one (59%) respondents agreed that this model was similar to repairing OASIS in clinical practice. Our trainees reported that the optimal time for simulated OASIS repair was the R2 and R3 years; however, 90% of respondents felt residents should be offered this simulation yearly.

DISCUSSION

Based on our survey of trainees, graduates, and faculty, we created a realistic simulated OASIS repair training, despite the limitation that the model lacked a rectum. Learners reported an interest in repeating the simulation frequently during residency to augment their clinical experience and increase perceived competence in third- and fourth-degree laceration repair by their graduation.

Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings

INTRODUCTION

There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels.

METHODS

Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning. Descriptive statistics were used to analyze the initial implementation evaluation results.

RESULTS

Twenty physicians from multiple training stages and specialties (interns, residents, attendings, family physicians, internists, surgeons) underwent the simulated scenario. Participants engaged in clinical reasoning processes consistent with the design, considering a total of 19 differential diagnoses. Ten participants provided the correct leading diagnosis, tension pneumothorax, with an additional eight providing pneumothorax and all participants offering relevant supporting evidence. There was also good evidence of management reasoning, with all participants either performing an intervention or calling for assistance and reflecting on management plans in the think-aloud. The scenario was a reasonable approximation of clinical practice, with a mean authenticity rating of 4.15 out of 5. Finally, the scenario presented adequate challenge, with interns and residents rating it as only slightly more challenging (means of 7.83 and 7.17, respectively) than attendings (mean of 6.63 out of 10).

DISCUSSION

Despite the challenges of scenario complexity, evaluation results indicate that this resource supports the observation and analysis of diagnostic and management reasoning of diverse specialties from interns through attendings.

The Treatment of Metabolic Acidosis: An Interactive Case-Based Learning Activity

Introduction

Metabolic acidosis is a dangerous and potentially life-threatening condition encountered in the inpatient and emergency department setting. Metabolic acidoses due to renal failure, bicarbonate losses, or lactic acidosis are common conditions, and the appropriate medical management of each is relevant to any inpatient medical provider. Therefore, we created a learning activity that utilizes blackboard-style videos followed by an interactive case-based learning session to help the medical student recognize, diagnose, and manage common causes of metabolic acidosis.

Methods

We organized this learning activity by assigning digital videos, followed by application in an interactive team-based format. We created electronic blackboard-style videos and a quiz to assess medical knowledge related to concepts discussed in the videos. Next, we created case resources that facilitate an interactive case-based teaching session so the learners could apply their knowledge and simulate the management of metabolic acidosis.

Results

We implemented this activity for 34 medical students. All students viewed the videos prior to the in-class session. In a pre/post assessment of medical knowledge, we observed a significant improvement in quiz scores. Next, we successfully facilitated the case-based active learning session, allowing the assessment of higher-order cognitive skills related to management of patients with metabolic acidosis. Our medical students felt highly satisfied and competent at the completion of our course.

Discussion

Our medical students rated this as an excellent learning activity. Others may find this activity useful within the context of any course or rotation related to patients with metabolic acidosis.

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis

OBJECTIVES

To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications.

DESIGN

A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge.

SETTING

The department of Critical Care Medicine of a university hospital.

PATIENTS

All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration.

INTERVENTIONS

Determination of serum 25(OH)D levels within the first 24h following admission to the ICU.

MAIN VARIABLES OF INTEREST

Prevalence and mortality at 28 days.

RESULTS

The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02).

CONCLUSION

Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality.

Critical Care In Korea: Present and Future

Critical (or intensive) care medicine (CCM) is a branch of medicine concerned with the care of patients with potentially reversible life-threatening conditions. Numerous studies have demonstrated that adequate staffing is of crucial importance for patient outcome. Adequate staffing also showed favorable cost-effectiveness in terms of ICU stay, decreased use of resources, and lower re-admission rates. The current status of CCM of our country is not comparable to that of advanced countries. The global pandemic episodes in the past decade showed that our society is not well prepared for severe illnesses or mass casualty. To improve CCM in Korea, reimbursement of the government must be amended such that referral hospitals can hire sufficient number of qualified intensivists and nurses. For the government to address these urgent issues, public awareness of the role of CCM is also required.