ABSTRACT
TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Internal Medicine (IM) resident physicians lack confidence and knowledge on how to manage basic and emergent clinical situations involving tracheostomy. High fidelity simulation is an effective training medium to address such deficiencies but is under-researched and under-utilized. This prospective, quantitative pilot educational and quality improvement study sought to answer if high fidelity simulation training on tracheostomy improves IM resident knowledge, confidence, and team skill performance. METHODS: Over 4 months (January - April 2021), 31 post-graduate year (PGY) 2 and PGY3 IM residents at a large academic hospital participated in this study. Participants were scored on baseline skill performance as a team in a high fidelity simulation of desaturation in a tracheostomy patient using a validated checklist. Thereafter, participants underwent a 3 hour educational intervention comprised of lecture, skills stations, and several simulations of emergent tracheostomy clinical situations. Final team performance on the same simulation initially used to assess baseline performance was scored. Pre and post intervention confidence and knowledge were assessed and compared to PGY2 and PGY3 IM residents who did not take the course. RESULTS: 20 PGY2 IM residents underwent the course. Confidence (P<0.0001) and knowledge (P<0.0001) significantly improved from pre-intervention to post-intervention. Confidence for residents post-intervention was greater than for PGY2 and PGY3’s who did not take the course (P<0.0001). Knowledge for residents post-intervention was greater than for PGY2 and PGY3’s who did not take the course (P<0.0001). In general, team skill performance in simulation improved from pre-intervention to post-intervention, though findings are limited by power and are not statistically significant. CONCLUSIONS: Our study demonstrates PGY2 IM resident confidence and knowledge on basic and emergent tracheostomy clinical situations improves significantly following educational intervention with hands-on instruction and high fidelity simulation. Confidence and knowledge in PGY2 IM residents following the course was significantly greater than for PGY2 and PGY3 IM residents who did not take the course. Our study also suggests team skill performance may be improved by the intervention. CLINICAL IMPLICATIONS: This study demonstrates that high fidelity simulation is an effective method of teaching IM resident physicians the knowledge necessary to manage basic and emergent tracheostomy clinical situations and also improves confidence. Given that many patients with acute respiratory failure from COVID-19 and other causes are frequently treated with tracheostomy and cared for by IM residents, this intervention may improve clinical outcomes for patients with tracheostomies. DISCLOSURES: No relevant relationships by Paul Christos, source=Web Response No relevant relationships by Timothy Clapper, source=Web Response No relevant relationships by Kelly Crane, source=Web Response No relevant relationships by Kapil Rajwani, source=Web Response
ABSTRACT
Background:The coronavirus disease 2019 (COVID-19) pandemic reached NewYork City in March 2020 leading to a state of emergency. Patients who contracted the disease presented with different phenotypes.Multiple reports have described the findings of pneumothoraces, pneumomediastinum and subcutaneous emphysema on computed tomography (CT) scans of these patient. Research Question:To describe the incidence and management of pneumothorax, pneumomediastinum and subcutaneous emphysema related to COVID-19 found on radiologic imaging. Methods: A retrospective chart review was conducted of all confirmed Covid-19 patients admitted between early March to mid May to two hospitals in New York City. Patient demographics, radiological imaging and clinical courses, were documented. Results:Between early March and mid May, a total of 1970 patients were diagnosed with COVID-19 in the two hospitals included in the study. 65/386 intubated patients developed the study specific complications, for an overall incidence of 16.8%;36 developed pneumothorax, 2 patients developed pneumomediastinum, 1 had subcutaneous emphysema and 26 had a combination of both. 87.5% were men and (age 28 to 81). Distribution of comorbidities included: hypertension (55.2%), diabetes(35.7%) , morbid obesity (21.5%) , underlying respiratory disease (12.5%) while 14.3% had no comorbidities. Average duration of intubation was 14 days (0-46). Mean highest PEEP within 72 hours of complication was 11 cmH220 (5-24). Mean highest peak inspiratory pressure within 72 hours of complication was 35.3 cmH2O (17-52). Incidence of spontaneous pneumothorax was 0.45%. Discussion:To our knowledge, this is the largest series of patients documenting these complications in the COVID-19 population. Given a mean duration of 14 days, it is theorized that it is the progression of the inflammation and lung destruction results in cyst development that are prone to rupture. Low lung compliance and high BMI leading to restrictive lung disease and higher peak airway pressures, and the need for high PEEP due to severe hypoxia, likely contributed to a higher incidence of these complications. In comparison to our intubated patients, there were no identifiable risk factors in our patients with spontaneous complications. Most of our patients had a pigtail catheter placed, however patients with small pneumothoraces with no hemodynamically instability were managed conservatively with a higher FiO2 concentration to help with re-absorption. Conclusions:Patients with COVID-19 pneumonia are high risk for pneumothorax, pneumomediastinum and subcutaneous emphysema both while intubated and spontaneously. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with new diagnosis COVID-19 or worsening hemodynamics in an ICU setting.