Preparing interns for clinical practice through an institution-wide simulation-based mastery learning program for teaching central venous catheter placement.

Central venous catheter (CVC) placement is a challenging procedure with known iatrogenic risks. However, there are no residency program requirements to demonstrate baseline CVC procedural competency. Competency-based procedural education has been shown to decrease CVC-associated morbidity, but there has been limited literature about institution-wide efforts to ensure initial trainee competency for CVC placement. This study describes the implementation of a competency-based CVC curriculum for first-year interns across an institution before supervised clinical care. An institution-wide, simulation-based mastery training curriculum was designed to assess initial competency in CVC placement in first-year residents during 2021 and 2022. A checklist was internally developed with a multidisciplinary team. Using the Mastery-Angoff technique, minimum passing standards were derived to define competency levels considered appropriate for intern participation in supervised clinical care. Interns were trained through the competency-based program with faculty assessing intern performance using the CVC checklist to verify procedural competency. Over 2 academic cycles, 229 interns from 20 specialties/subspecialties participated. Overall, 83% of interns met performance standards on their first posttest attempt, 14% on the second attempt, and 3% on the third attempt. Interns from both cycles demonstrated significant improvement from baseline to posttest scores (P < .001). Overall, 10.5% of interns performed dangerous actions during assessment (malpositioning, retained guidewire, or carotid dilation). All interns ultimately achieved the passing standard to demonstrate initial competency in the simulation assessment. All participating interns demonstrated simulation-based competency allowing them to place CVCs under supervised clinical care. Dangerous actions, however, were not uncommon. Simulation-based teaching and learning frameworks were a feasible method to promote patient safety through an institutional-wide verification of preliminary procedural competency.

Difficult Airway Response Team (DART) and Airway Emergency Outcomes: A Retrospective Quality Improvement Study.

OBJECTIVE: Difficult airways can be associated with significant morbidity and mortality, particularly in the event of a delay in securing the airway. To improve the airway metrics at our institution, we implemented a multidisciplinary team of airway providers to respond to difficult and emergent airways, or the Difficult Airway Response Team (DART). The purpose of the present study is to assess the feasibility of a DART program at a tertiary care center. STUDY DESIGN: A retrospective study evaluating the outcomes of emergent airway cases using the DART protocol. SETTING: Single tertiary academic care center. METHODS: In August 2019, a DART program was implemented at a tertiary academic medical center. In order to assess the feasibility and effectiveness of this system, data were collected to assess DART outcomes through chart review and surveys following each event, and analyzed in Microsoft Excel. RESULTS: A total of 161 DART events (average 4.6/month) took place from August 2019 to June 2022. Anesthesiologists secured the airway in 71 events (51%), otolaryngologists in 38 (27%), and pulmonary/critical care in 12 (9%). Seventy-three activations were not labeled as a difficult airway. Pre-DART, 19 cases required more than 3 attempts to secure the airway compared to 11 cases after DART. Transoral intubation was the most common intervention. Thirteen cases required surgical intervention. CONCLUSION: Implementing a multidisciplinary team-based approach for managing emergent difficult airways at a tertiary care institution was feasible and resulted in a decreased number of airway attempts in difficult airway patients. Continuous process improvement is essential for the ongoing enhancement of DART systems.

An Unusual Source of Tension.

CASE PRESENTATION: A 67-year-old man with a history of hypertension, type 2 diabetes, and COPD requiring supplemental oxygen at baseline (4 L by nasal cannula) was admitted to the hospital for progressive dyspnea and dysphagia in the context of a newly diagnosed supraglottic mass.

Going Silent: Redesigning the Activation Process for In-Hospital Cardiopulmonary Arrests.

INTRODUCTION: Reducing environmental noise has become a priority for many health systems. Following a 10-week preparation period, our health system transitioned from an overhead-activated to a silently activated in-hospital code team notification system. The goal of this initiative was to reduce environmental noise and support code team communication and function without adversely affecting response time, provider availability, or key quality metrics. METHODS: Transitioning from overhead to silently activated events involved a three-step quality improvement approach. Input from key stakeholders and preimplementation education were of key importance. Multiple timed trials and a full in situ simulation were completed before going live with the new process. RESULTS: Evaluation of 6-month pre- and postimplementation quality metrics showed no significant difference in compliance with defibrillating shockable rhythms within two minutes, event survival, or survival to discharge. Provider survey data and Hospital Consumer Assessment of Healthcare Providers and Systems "quiet at night" scores were not significantly different. CONCLUSION: By utilizing a multistep implementation approach, transitioning from overhead pages to a silently activated system for in-hospital code team activation was feasible and safe. Abandoning the overhead paging system did not lead to a decrease in key quality metrics nor impair team perception of code function.

Pulmonary Critical Care Fellows' Use of and Self-reported Barriers to Learning Bedside Ultrasound During Training: Results of a National Survey.

BACKGROUND: Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. RESEARCH QUESTION: How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? STUDY DESIGN AND METHODS: A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors' discretion. RESULTS: Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. INTERPRETATION: Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

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.

Nanoparticle delivery of microRNA-146a regulates mechanotransduction in lung macrophages and mitigates injury during mechanical ventilation.

Mechanical ventilation generates injurious forces that exacerbate lung injury. These forces disrupt lung barrier integrity, trigger proinflammatory mediator release, and differentially regulate genes and non-coding oligonucleotides including microRNAs. In this study, we identify miR-146a as a mechanosensitive microRNA in alveolar macrophages that has therapeutic potential to mitigate lung injury during mechanical ventilation. We use humanized in-vitro systems, mouse models, and biospecimens from patients to elucidate the expression dynamics of miR-146a needed to decrease lung injury during mechanical ventilation. We find that the endogenous increase in miR-146a following injurious ventilation is not sufficient to prevent lung injury. However, when miR-146a is highly overexpressed using a nanoparticle delivery platform it is sufficient to prevent injury. These data indicate that the endogenous increase in microRNA-146a during mechanical ventilation is a compensatory response that partially limits injury and that nanoparticle delivery of miR-146a is an effective strategy for mitigating lung injury during mechanical ventilation.

Inflammasome Adaptor ASC Is Highly Elevated in Lung Over Plasma and Relates to Inflammation and Lung Diffusion in the Absence of Speck Formation.

Rationale: Caspase-1 is a zymogen whose activation predominantly depends upon the assembly of ASC monomers into insoluble prion-like polymers (specks). ASC polymers support caspase-1 dimer formation inducing a proximity mediated auto-activation of caspase-1. Therefore, the amount and nature of ASC monomers and polymers in lung bronchoalveolar lavage fluid (BALF) might serve as a marker of lung inflammasome activity. Objectives: To determine whether lung ASC concentrations or oligomerization status predicts lung function or activity of lung inflammation. Methods: BALF ASC amount and oligomerization status was studied in three distinct cohorts: (1) young healthy non-smokers, vapers and smokers; (2) healthy HIV+ smokers who underwent detailed lung function studies; and (3) hospitalized patients with suspected pneumonia. We quantified cell free BALF ASC levels by ELISA and immunoblot. Oligomers (i.e., ASC specks) were identified by chemical crosslinking and ability to sediment with centrifugation. Measurement and Main Results: ASC levels are significantly higher in lung lining fluid than in plasma as well as higher in smoker lungs compared to non-smoker lungs. In this context, ASC levels correlate with macrophage numbers, smoking intensity and loss of lung diffusion capacity in a well-characterized cohort of healthy HIV+ smokers. However, only monomeric ASC was found in our BALF samples from all subjects, including patients with lung infections. Conclusions: Even though, most, if not all, extracellular ASC in BALF exists in the soluble, monomeric form, monomeric ASC concentrations still reflect the inflammatory status of the lung microenvironment and correlate with loss of lung function.

Tips for pandemic response planning for Internal Medicine training programs.

This article was migrated. The article was marked as recommended. The current Coronavirus Disease 2019 (COVID-19) pandemic has strained hospital systems and training programs across the world. As capacity issues mount and trainees are called upon to provide frontline medical care, programs and institutions have had to rapidly evolve to redefine the trainee experience. To that end, there is a paucity of literature regarding how healthcare training programs should operate during a global pandemic. Here, we aim to describe twelve evidence-based recommendations for coordinating a cohesive, systematic approach to pandemic response planning for Internal Medicine residency training programs. These tips encompass inpatient and outpatient practices, provider safety, resuscitation, virtual education programming and resident wellbeing. Though many of these considerations or recommendations were not described during the COVID-19 pandemic, these tips have been described previously in the literature, are applicable to the current pandemic and could be easily extrapolated to future crises.

Incorporating Retrieval Practice Into Intensive Care Unit Teaching Rounds: A Feasibility Study.

BACKGROUND: Teaching rounds are an important component of the learning environment for residents in the intensive care unit (ICU). Retrieval practice is a cognitive learning tool that helps learners consolidate information and might improve the quality and culture of teaching rounds. OBJECTIVE: We performed a feasibility study from October 2018 to June 2019 to investigate the incorporation of retrieval practice into ICU rounds. METHODS: Participants included internal medicine and family medicine residents and pulmonary and critical care medicine fellows and faculty on medical ICU (MICU) teams at a tertiary care academic medical center. For 1-week periods, residents were asked to use retrieval practice after rounds, sharing one learning point. Participants were anonymously surveyed about the feasibility and acceptability of this strategy and perceptions of the educational value of ICU rounds before and after incorporating retrieval practice. RESULTS: We enrolled 9 MICU teams, including 31 residents, 8 fellows, and 8 attendings. Pre- and postsurvey response rates were 89% and 91% (42 and 43 of 47, respectively). Sixty-nine percent of respondents (30 of 43) reported sharing learning points on at least 3 days of the intervention week. Eighty-six percent of respondents (37 of 43) said retrieval practice did not adversely affect the workflow at the end of rounds. The perception that teaching on rounds was a priority increased after the intervention (3.93 versus 4.28 on 1-5 Likert scale, P = .047). CONCLUSIONS: Using retrieval practice on MICU rounds was feasible and acceptable and was associated with an increase in the perceived priority given to teaching on rounds.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

BACKGROUND AND AIM: Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS: A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS: Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION: When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI.

BACKGROUND: The causative agents for the current national outbreak of electronic-cigarette, or vaping, product use-associated lung injury (EVALI) have not been established. Detection of toxicants in bronchoalveolar-lavage (BAL) fluid from patients with EVALI can provide direct information on exposure within the lung. METHODS: BAL fluids were collected from 51 patients with EVALI in 16 states and from 99 healthy participants who were part of an ongoing study of smoking involving nonsmokers, exclusive users of e-cigarettes or vaping products, and exclusive cigarette smokers that was initiated in 2015. Using the BAL fluid, we performed isotope dilution mass spectrometry to measure several priority toxicants: vitamin E acetate, plant oils, medium-chain triglyceride oil, coconut oil, petroleum distillates, and diluent terpenes. RESULTS: State and local health departments assigned EVALI case status as confirmed for 25 patients and as probable for 26 patients. Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group. No other priority toxicants were found in BAL fluid from the case patients or the comparator group, except for coconut oil and limonene, which were found in 1 patient each. Among the case patients for whom laboratory or epidemiologic data were available, 47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products in the 90 days before the onset of illness. Nicotine or its metabolites were detected in 30 of 47 of the case patients (64%). CONCLUSIONS: Vitamin E acetate was associated with EVALI in a convenience sample of 51 patients in 16 states across the United States. (Funded by the National Cancer Institute and others.).

Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation.

BACKGROUND: Mortality from in-hospital cardiac arrests remains a large problem world-wide. In an effort to improve in-hospital cardiac arrest mortality, there is a renewed focus on team training and operations. Here, we describe the implementation of a "pit crew" model to provide in-hospital resuscitation care. METHODS: In order to improve our institution's code team organization, we implemented a pit crew resuscitation model. The model was introduced through computer-based modules and lectures and was reemphasized at our institution-based ACLS training and mock code events. To assess the effect of our model, we reviewed pre- and post-pit crew implementation data from five sources: defibrillator downloads, a centralized hospital database, mock codes, expert-led debriefings, and confidential surveys. Data with continuous variables and normal distribution were analyzed using a standard two-sample t-test. For yes/no categorical data either a Z-test for difference between proportions or Chi-square test was used. RESULTS: There were statistically significant improvements in compression rates post-intervention (mean rate 133.5 pre vs. 127.9 post, two-tailed, p = 0.02) and in adequate team communication (33% pre vs. 100% post; p = 0.05). There were also trends toward a reduction in the number of shockable rhythms that were not defibrillated (32.7% pre vs. 18.4% post), average time to shock (mean 1.96 min pre vs. 1.69 min post), and overall survival to discharge (31% pre vs. 37% post), though these did not reach statistical significance. CONCLUSION: Implementation of an in-hospital, pit crew resuscitation model is feasible and can improve both code team communication as well as key ACLS metrics.