Stakeholder engagement as a strategy to enhance palliative care involvement in intensive care units: A theory of change approach.

BACKGROUND: Adult patients admitted to intensive care units in the terminal phase experience high symptom burden, increased costs, and diminished quality of dying. There is limited literature on palliative care engagement in ICU, especially in lower-middle-income countries. This study explores a strategy to enhance palliative care engagement in ICU through a stakeholder participatory approach. METHODS: Theory of Change approach was used to develop a hypothetical causal pathway for palliative care integration into ICUs in India. Four facilitated workshops and fifteen research team meetings were conducted virtually over three months. Thirteen stakeholders were purposively chosen, and three facilitators conducted the workshops. Data included workshop discussion transcripts, online chat box comments, and team meeting minutes. These were collected, analysed and represented as theory of change map. RESULTS: The desired impact of palliative care integration was good death. Potential long-term outcomes identified were fewer deaths in ICUs, discharge against medical advice, and inappropriate admissions; increased referrals to palliative care; and improved patient and family satisfaction. Twelve preconditions were identified, and eleven key interventions were developed. Five overarching assumptions related to contextual factors influencing the outcomes of interventions. CONCLUSION: Theory of change framework facilitated the identification of proposed mechanisms and interventions underpinning palliative care integration in ICUs.

Newer teaching-learning methods and assessment modules in anaesthesia education.

The National Medical Commission in its recent guidelines has stated that postgraduate training in anaesthesiology should have clear objectives and be competency based. This means that the existing teaching-learning (TL) methods need a major face-lift. E-learning and blended learning including learning management systems, virtual classrooms, app-based learning, flipped classroom, podcasts, webinars, web-based collaborative education, reflective feedback, problem-based discussions and mentorship are some newer TL methods that can be adopted. Simulation can help teach technical and non-technical skills such as leadership, teamwork and communication. In line with TL methods, newer assessment methods have to be applied to revolutionise postgraduate anaesthesia education. Formative assessment and assessment of clinical skills are important and to do this, workplace-based assessment methods such as mini-clinical evaluation exercise, direct observation of procedural skills, multisource feedback, logbook and E-portfolio can be applied. Objective structured clinical examination, simulation-based assessment and E-assessment are other useful evaluation methods.

Competency-based undergraduate curriculum implementation in anesthesiology-A survey-based comparison of two models of training.

BACKGROUND AND AIM: Imparting the knowledge and skills of Anesthesiology to undergraduates can be challenging. Competency Based Undergraduate (CBUG) Curriculum for the Undergraduate medical students introduced by the Medical Council of India (MCI) aims to improve the quality of the Indian Medical Graduate (IMG). The Department of Anesthesiology and Critical Care of our college redrafted the training program and brought it in-line with the CBUG Curriculum beginning February 2019. A questionnaire based survey was conducted to assess the efficacy, satisfaction levels and the perception of the students towards the new competency based curriculum. The aim was to assess the students perception of the competency based curriculum and to evaluate two slightly different approaches to the implementation of the curriculum. MATERIAL AND METHODS: Two groups of undergraduate medical students belonging to the 6th and 8th term, underwent two different models of teaching. The 8th term students had already completed their theory classes based on the older curriculum a year ago when they were in 6th term. However, their clinics and tutorials were modelled as per the new CBUG Curriculum. The current 6th term students had their first exposure to Anesthesiology and their theory, tutorials and clinics were scheduled in the same term, simulation based training was added, the operation theatre rotation was held in the mornings at 0730hrs and the intensive care unit rounds were held in the evenings. There was no difference in the theory classes taken for the two batches, however the clinics were different. After both the batches finished their rotation, they were given the survey questionnaire to assess their perception of the model of CBUG Curriculum that they were exposed to. RESULTS: The results of the survey revealed that about 80% of the students in both groups preferred that theory classes and practical training should be conducted in parallel in 6th term. About 60% students in both groups felt that early morning clinics 0800hrs were better than mid-morning clinics at 1100hrs as they get to see and do more procedures. 66%-82% students in both groups felt that the practical training in the OT, ICU and skills lab were very helpful or extremely helpful. The most important aspect of Anesthesiology rotation was "learning basic life saving skills and simulation based learning" according to 85% students in both groups. Nearly 80% students in both groups felt that the training in Anesthesiology should be allotted more time and more weightage in undergraduate training. 72% students in 6th term and 63% students in 8th term felt more confident of handling emergencies after their Anesthesiology rotation. CONCLUSION: The new curriculum was extremely well received by the students of both groups. The model used for 6th term students comprising of teaching theory and practical in the same term and having early morning clinics, was found to be superior as compared to the model used to teach 8th term students where there was a gap of one year between theory and practical teaching and the clinics were held midmorning.

Preventing exposure to COVID-19 in the operation theatre and intensive care unit.

The COVID-19 pandemic has gripped the world since January 2020 and has changed our lives in unprecedented ways. It has changed the way we work in the Operation Theatres and Intensive Care Units mainly because of the high risk of disease transmission to the healthcare workers. In order to reduce the risk of disease transmission, an understanding of the means of transmission of the virus is essential to develop a rational strategy that allows patients to receive treatment without placing either the patient or healthcare workers at risk. It should be cautioned that this is a rapidly changing field and there is a paucity of randomised controlled trials related to various aspects of the disease. It is therefore advisable to revise any recommendations in this article, as and when new evidence emerges.

Adjunctive dexmedetomidine for treatment of delirium tremens: Case report and brief review.

Alcohol withdrawal delirium (delirium tremens [DT]) is a medical emergency. Gamma-aminobutyric acid type A agonists (benzodiazepines [BZDs]) are the mainstay of treatment. Resistant alcohol withdrawal requires adjunctive medications along with BZDs and supportive care. DT is associated with significant autonomic dysfunction (sympathetic hyperactivity). Dexmedetomidine is a selective a2-adrenergic receptor agonist which reduces sympathetic over-activity and agitation in delirious patients. We present a case of alcohol withdrawal delirium (DT) who responded well to adjunctive dexmedetomidine infusion resulting in reduced sympathetic activity and reduced dose requirement of BZDs.

Isolated inhalational injury: Clinical course and outcomes in a multidisciplinary intensive care unit.

BACKGROUND AND AIMS: Although smoke inhalation is well known to cause acute lung injury, there are few reports in literature that study the evolution, clinical course and outcomes of isolated inhalational lung injury in a modern intensive care setting. A major fire disaster provided us the opportunity to study victims of isolated inhalational injury admitted to our Multidisciplinary Intensive Care Unit (MICU). MATERIALS AND METHODS: We studied the clinical course, ICU and hospital outcomes of 13 victims of a fire disaster who required mechanical ventilation for isolated inhalational lung injury. All patients were followed up at regular intervals, and their functional status was assessed at 8 months after hospital discharge. RESULTS: The Lung Injury Scores (LIS) worsened to reach a nadir on Day 3 of injury. There was a significant correlation between the LIS on Day 3 and duration of mechanical ventilation (r = 0.8; P = 0.003), ICU (r = 0.8; P = 0.002) and hospital (r = 0.6; P = 0.02) days. Late-onset airway complications were encountered in four patients. Three of them required long-term artificial airways - two with a tracheostomy while the third patient required surgical insertion of a "T" tube. Persistent problems with phonation occurred in two patients. At 8 months postdischarge, all patients were independent with activities of daily living; all were back to work, except for two who continued to need artificial airways. CONCLUSIONS: Inhalational lung injury progresses over the first few days and is worst after 72 h. Late-onset airway complications may manifest after several weeks and require repeated intervention.