An Innovative Virtual ECG curriculum to Address Clinical Experience Gaps in Fourth-Year Medical Students Due to COVID-19

Study Objectives: COVID-19, due to the cancellation of many clinical rotations, has introduced new challenges as graduating students prepare to start residency with less direct patient care experience compared to prior years. In many schools, clinically relevant ECG interpretation is typically learned in a longitudinal fashion at the bedside and this lack of clinical experience may affect acquisition of this key skill. To bridge this gap in knowledge within the requirements of social distancing the investigators developed a novel, virtual ECG curriculum designed for MS-4 students entering residency. Our objectives include increased self-confidence with ECG interpretation, recognition of key ECG patterns and arrhythmias, and understanding pathologies related to ECG findings. Methods: Learners were MS-4 students self-selected from a single osteopathic medical school. Using Kern’s Six Steps of Curriculum Design, the investigators adapted an existing ECG curriculum that was originally developed for emergency medicine PGY-1s. The curriculum consisted of biweekly Zoom lectures over 4 weeks for a total of 8 sessions and 12 hours. Each session included additional readings, homework, weekly summaries, and an end-of-course project. Outcomes were measured according to the Kirkpatrick model. Learner reaction was assessed using a Too-Much-Too-Little (TMTL) scale from 1-5, with 3 indicating a perfect score. Knowledge acquisition was assessed using a pre- and post-course test. Although we have collected preliminary feedback for behavioral changes, we plan to formally assess for level 3 outcomes in a follow-up survey after July 1, 2021. Anonymous surveys were used for data collection, and statistical analysis was conducted using a percentages independent sample t-test. Results: The total sample size was 27 self-selected MS-4 students who met inclusion criteria. Learner reactions were overwhelmingly positive, with 100% (27) indicating they would take the course again or recommend it to a friend. Using a TMTL scale, 77% (21) of participants gave a 3 for lecture length, 58% (16) gave a 3 for time commitment (with 42% stating time commitment was too low and 0% too high), and 77% (21) gave a 3 for level of detail the course provided. The average score between the pre- (M = 56%, SD = 14) and post-tests (M = 73%, SD = 12) showed a statistically significant improvement (p<0.0001). Student’s confidence with interpreting ECGs, understanding ECG rhythms, and ability to call a “Code STEMI” all improved (2.59 to 3.59, 2.67 to 3.74, 2.56 to 3.67 respectively;p<0.0001 for all comparisons). Preliminary behavioral feedback from students following the course included the ability to identify and interpret pathology such as Wellen’s waves, hypothermia, and Wolf-Parkinson-White Syndrome during clinical rotations. Conclusion: This study demonstrated that virtual teaching is a satisfactory method for medical students to learn ECG interpretation and provides an additional mode that medical educators can use in the future. Learners drastically improved their self-confidence and knowledge with ECG interpretation following participation in a novel, virtual learning curriculum.

A qualitative needs assessment of covid-19's impact on em interns

Learning Objectives: To characterize the impact that COVID-19 has had on the well-being and educational experience of EM interns in 2020 Background: The COVID-19 pandemic posed an unprecedented challenge to our learners. EM interns this year began their training during a time of great need and with less clinical experience than those of prior years. Objectives: To characterize the impact that COVID-19 has had on the well-being and educational experience of EM interns in 2020. Methods: We conducted a 60-minute semi-structured focus group with 18 interns at a single residency program in July 2020. A recording of the interview was transcribed and de-identified. Using qualitative methods, initial coding was performed independently using an inductive and iterative process by two study authors with experience in qualitative methodology. Once saturation was achieved, final codes were re-applied by an initial coder and a third author. After consensus discussion, agreement reached 100%, and codes were grouped for thematic analysis. Results: We identified two major themes: education and professional identity formation. Interns expressed concerns about the quality and breadth of their medical training during COVID. Interns also voiced frustration with the politicization of medicine and uncertainty about their roles as physicians during the pandemic. Minor themes included physical health, mental health, and grief related to COVID-19. Conclusions: Our analysis suggests that new EM interns have significant concerns about their medical knowledge and the quality of their education as well as their identity as emergency physicians and public health advocates. These results may inform future decisions regarding dedicated support and training necessary for this unique group of learners.

A just-in-time peer driven critical care curriculum for emergency medicine residents in a covid-19 “hot zone”

Learning Objectives: After participating in this educational intervention, junior EM residents were able to discuss the basics of ventilator management and critical care pharmacology, as well as identify an approach to the deteriorating ventilated patient. : Background: The rapid rise of COVID-19 cases posed a unique staffing challenge to residency programs. The addition of ICU assignments, particularly for junior residents who may not have had prior critical care exposure, led to the development of a just-in-time curriculum to address this training gap. Seniors residents, with ample and recent critical care experience, were in a unique position to provide education and guidance to junior learners. Educational Objectives: After participating in this educational intervention, junior EM residents were able to discuss the basics of ventilator management and critical care pharmacology, as well as identify an approach to the deteriorating ventilated patient. Curricular Design: Following Kern's six step approach (1) There was clear need due to the sheer volume of critically ill patients at our institution. (2) We developed areas of content focus through a needs-assessment directed at residents who had already begun managing critical COVID patients. (3) Objectives described above. (4) The curriculum included three lectures and three corresponding study guides for reference. The lectures were led by senior residents focused on creating a relaxed discussion-based learning environment. A critical care pharmacist collaborated on the module on sedative, paralytic, and vasopressor selection. (5) The curriculum was launched on April 10th and concluded April 23rd 2020. A virtual meeting platform was selected given the necessity of socially distant learning, and for ease of recording and re-distribution. (6) We will judge effectiveness with a knowledge based survey to measure understanding and retention. Impact: 100% of interns attended at least one lecture. 13 of 16 interns provided feedback, giving an average rating of 4.77 (on a 5-point Likert scale) for how well the curriculum prepared them for the COVID ICU. We plan to administer a knowledge based survey 6-8 months post intervention, with completed results by CORD 2021.

Randomized Study of Digital Life Coaching during Autologous Stem Cell Transplantation

BACKGROUND: Autologous stem cell transplantation (ASCT) for multiple myeloma (MM) entails sudden life changes including acute symptom burden, changes in physical function, and shifting caregiver dynamics. Several studies have shown that anxiety, insomnia, and distress rise in the initial weeks following ASCT before slowly recovering. Long-term consequences of these acute exacerbations include persistent quality of life (QOL) impairments (El-Jawahri 2016), post-traumatic stress disorder (Griffith 2020), and the usage of potentially inappropriate medications (PIMs) for symptom management (Banerjee 2021). We have recently completed a pilot study of digital life coaching (DLC), whereby life coaches work with patients via phone calls and text messages to provide longitudinal support, education, and accountability to meet wellbeing-related goals. Our pilot study of 15 patients demonstrated the feasibility of DLC during this period, with bidirectional patient-coach engagement occurring every 5-7 days even during index hospitalizations for ASCT (Banerjee 2021). Based on these positive results, we have now launched a randomized Phase 2 study of DLC versus usual care among patients with MM undergoing ASCT. STUDY DESIGN: Our study is registered at clinicaltrials.gov as NCT04589286. We plan to enroll 60 adult patients with MM undergoing first ASCT at our institution. Inclusion criteria include English language proficiency and ownership of a personal cellphone. However, neither smartphones nor specific mobile apps are required for study participation. All patients, including those in the control arm, receive brief wellness-related tips with each request for PRO data as outlined below. As shown in the Figure, patients in the DLC arm are paired with a trained life coach beginning at Day -10 before ASCT. Coaches use structured frameworks to assist patients longitudinally with identifying and accomplishing wellbeing-related goals. Specific coaching topics can vary from week to week and are set by each patient. In addition to weekly coach-led phone calls, patients are encouraged to maintain bidirectional communication via phone/text/email as often as desired. Patients in the control arm do not receive access to DLC. Our primary endpoint is the total usage of sedative-class PIMs - including lorazepam, temazepam, zolpidem, and other similar medications - prescribed for anxiety or insomnia during each of 4 four-week study subperiods identified in the Figure. Secondary endpoints include patient-reported outcome (PRO) assessments of QOL (PROMIS Global Health), distress (NCCN Distress Thermometer), and insomnia (PROMIS Sleep Disturbances 4A). PRO assessments are collected exclusively using automated REDCap emails every 1-2 weeks as shown in the Figure. PROGRESS TO DATE: As of the data cutoff (7/31/21), 19 patients have enrolled onto our study and 5 have completed all follow-up. The median age of enrolled patients is 62 (range: 31-77), with 26% of patients aged 70 or older. As shown in our pilot study (Banerjee 2021), PRO collection via automated REDCap emails is feasible. Specifically, of 93 email-based requests for PRO assessments as of the data cutoff, 92 (99%) have been completed. Analyses of PRO assessment responses and PIM usage will be conducted after study completion. DISCUSSION: Improving patient wellbeing during the acute peri-ASCT period is an unmet need in multiple myeloma. Published supportive strategies during this time include music therapy (Bates 2017), acupuncture (Deng 2018), palliative care (El-Jawahri 2017), and programmed hospital room lighting (Valdimarsdottir 2018). DLC may offer unique advantages given its easy accessibility and unified patient-facing interface across hospital/clinic/home transitions. These strengths may be particularly relevant in light of the COVID-19 pandemic, where home-based follow-up after ASCT has become more common. That being said, broadening the accessibility of DLC to include patients with limited English proficiency or patients without personal cell phones are important priorities for fu ure studies. In summary, our randomized Phase 2 study of DLC versus usual care is ongoing. If shown to reduce PIM prescription rates while improving wellbeing-related PRO trajectories longitudinally, DLC may become a standard of care for patients with hematologic malignancies undergoing ASCT. [Formula presented] Disclosures: Banerjee: Pack Health: Research Funding;SparkCures: Consultancy;Sanofi: Consultancy. Knoche: Amgen: Honoraria. Brassil: Abbvie: Research Funding;Astellas: Research Funding;BMS: Research Funding;Daiichi Sankyo: Research Funding;Genentech: Research Funding;GSK: Research Funding;Sanofi: Research Funding;Pack Health: Current Employment. Jackson: Pack Health: Current Employment. Patel: Pack Health: Current Employment. Lo: Oncopeptides: Consultancy;EUSA Pharma: Consultancy. Chung: Caelum: Research Funding. Wong: Amgen: Consultancy;Genentech: Research Funding;Fortis: Research Funding;Janssen: Research Funding;GloxoSmithKlein: Research Funding;Dren Biosciences: Consultancy;Caelum: Research Funding;BMS: Research Funding;Sanofi: Membership on an entity's Board of Directors or advisory committees. Wolf: Adaptive Biotechnologies: Consultancy;Teneobio: Consultancy;Sanofi: Consultancy;Amgen: Consultancy. Martin: Oncopeptides: Consultancy;Sanofi: Research Funding;Amgen: Research Funding;Janssen: Research Funding;GlaxoSmithKline: Consultancy. Shah: Bluebird Bio: Research Funding;GSK: Consultancy;Janssen: Research Funding;Indapta Therapeutics: Consultancy;BMS/Celgene: Research Funding;CareDx: Consultancy;CSL Behring: Consultancy;Kite: Consultancy;Nektar: Research Funding;Karyopharm: Consultancy;Amgen: Consultancy;Oncopeptides: Consultancy;Poseida: Research Funding;Precision Biosciences: Research Funding;Sanofi: Consultancy;Sutro Biopharma: Research Funding;Teneobio: Research Funding.

Clinical characteristics of COVID-19 patients with pulmonary embolism in 1st and 2nd waves

Introduction and ObjectivesMultiple studies have demonstrated increased risk of pulmonary embolism (PE) in COVID-19. Our study at a major NHS Trust examined the clinical characteristics, attributes and outcomes of PE in COVID-19, which have infrequently been explored in literature.MethodsWe performed a retrospective cohort study of COVID-19 patients with PE diagnosed on CT pulmonary angiogram (CTPA) over 2 months in 1st and 2nd waves (April 2020 and January 2021). Data collected from electronic health and imaging records included patient demographics, D-dimers, oxygen requirements, clinical outcomes, thromboprophylaxis/treatment and PE attributes on CTPA.ResultsWe identified 76 COVID-19 patients with PE (mean age 62.2 years, 69.7% male, 40.8% Caucasian). Patients experienced prolonged periods of COVID-19 symptoms prior to PE diagnosis - 19.6 day symptoms in 1st wave (n = 16, 21.9%) compared to 15.2 days in 2nd wave (n = 57, 78.1%). Average D-dimer was highly elevated (mean = 11576 ng/mL). 43 (56.5%) patients had high oxygen requirements - 21 (27.6%) required ≥10 litres/min via mask, 13 (17.1%) required non-invasive ventilation and 9 (11.8%) were intubated and ventilated. 22 patients (28.9%) were admitted to intensive care and 11 patients (14.5%) died. On admission, 48 patients (63.2%) were started on treatment dose enoxaparin (high PE suspicion) and 12 (15.8%) had intermediate (prophylactic) dose enoxaparin. PEs were largely treated with 3–6 months of rivaroxaban (n = 43, 56.6%) or apixaban (n = 7, 9.2%). 65.5% (n = 49) of patients had bilateral PEs;largest sizes being segmental (n = 32, 42.1%), subsegmental (n = 17, 22.4%), lobar (n = 16, 21.1%), main pulmonary artery (n= 5, 6.6%) and saddle (n = 5, 6.6%). 15 patients (19.7%) had evidence of right heart strain on CTPA.ConclusionsOur study suggests that PE in COVID-19 is more common in males and in those with COVID symptoms greater than 2 weeks, high oxygen requirements and highly elevated D-dimers. There should be a low threshold for investigating such patients for PE. Moreover, we found COVID-19 patients with PE have high likelihood of having a bilateral pulmonary distribution with right heart strain.

Designing information systems to break habits and promote preventive behaviours during large-scale disease outbreaks

Adhering to preventive behaviours, like social distancing and wearing a mask, can help reduce the spread of some transmissible diseases;however, doing so can be a challenge as it requires people to break established habits. This challenge will be most evident for organisations as they need to ensure that all stakeholders adhere to preventive behaviours to resume in-person business operations. While various information systems (IS) have emerged to address this challenge, they remain limited in scope and fall short of helping users navigate the evolving practices and guidelines of a pandemic. To address this shortcoming, we adopt the design science research approach to derive design principles for IS supporting the breaking of established habits and promotion of preventive behaviours. The design principles are rigorously anchored in the habit alteration knowledge base and the Health Belief Model. We demonstrate how the design principles can be applied using an illustrative case. © 2021 IEEE Computer Society. All rights reserved.

A Qualitative Needs Assessment of COVID-19's Impact on Emergency Medicine Interns

Study Objective: The COVID-19 pandemic posed an unprecedented challenge to our learners. Emergency medicine interns this year began their training during a time of great need for skilled medical professionals and with less clinical experience than those of prior years. Methods: We conducted a 60-minute semi-structured focus group with 18 EM interns at a single residency program in July 2020. A recording of the interview was transcribed and de-identified. Using qualitative methods, initial coding was performed independently using an inductive and iterative process by two study authors with experience in qualitative methodology. Once saturation was achieved, final codes were re-applied by an initial coder and a third author. After consensus discussion, agreement reached 100%, and codes were grouped for thematic analysis. Results: We identified two major themes: education and professional identity formation. Interns expressed concerns about the quality and breadth of their medical training during the COVID pandemic. Interns also voiced frustration with the politicization of medicine and uncertainty about their roles as physicians and public health advocates during the pandemic. Minor themes included physical health, mental health, and grief related to COVID-19. Interns reported experiencing several unique challenges to their emotional and mental health, including socially distancing during a period in their training when they traditionally rely on additional support systems and build new relationships. Conclusions: Our analysis suggests that new EM interns have significant concerns about their medical knowledge and the quality of their education as well as their identity as emergency physicians and public health advocates during the COVID pandemic. EM interns also reported unique challenges to their physical and mental health. These results may inform future decisions regarding dedicated support and training necessary for this unique group of learners. [Formula presented]

Towards computer-aided severity assessment via deep neural networks for geographic and opacity extent scoring of SARS-CoV-2 chest X-rays

A critical step in effective care and treatment planning for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause for the coronavirus disease 2019 (COVID-19) pandemic, is the assessment of the severity of disease progression. Chest x-rays (CXRs) are often used to assess SARS-CoV-2 severity, with two important assessment metrics being extent of lung involvement and degree of opacity. In this proof-of-concept study, we assess the feasibility of computer-aided scoring of CXRs of SARS-CoV-2 lung disease severity using a deep learning system. Data consisted of 396 CXRs from SARS-CoV-2 positive patient cases. Geographic extent and opacity extent were scored by two board-certified expert chest radiologists (with 20+ years of experience) and a 2nd-year radiology resident. The deep neural networks used in this study, which we name COVID-Net S, are based on a COVID-Net network architecture. 100 versions of the network were independently learned (50 to perform geographic extent scoring and 50 to perform opacity extent scoring) using random subsets of CXRs from the study, and we evaluated the networks using stratified Monte Carlo cross-validation experiments. The COVID-Net S deep neural networks yielded R[Formula: see text] of [Formula: see text] and [Formula: see text] between predicted scores and radiologist scores for geographic extent and opacity extent, respectively, in stratified Monte Carlo cross-validation experiments. The best performing COVID-Net S networks achieved R[Formula: see text] of 0.739 and 0.741 between predicted scores and radiologist scores for geographic extent and opacity extent, respectively. The results are promising and suggest that the use of deep neural networks on CXRs could be an effective tool for computer-aided assessment of SARS-CoV-2 lung disease severity, although additional studies are needed before adoption for routine clinical use.