Acute-on-Chronic Lithium Toxicity: A Simulation Case for Emergency Medicine Residents.

Introduction: Simulation-based education has become standard within emergency medicine training. Toxicological clinical presentations are challenging to identify and treat in the emergency department. Recognizing that active teaching methods are superior to standard lecture for learner retention, we created an experiential simulation case for education on lithium toxicity. The case was written after an extensive literature review followed by consultation with a medical toxicologist and an expert in simulation-based education. Methods: Fifty-three residents participated in a simulation scenario involving a lithium-poisoned patient over the course of eight simulation sessions. The scenario ran approximately 10 minutes and was followed by postevent debriefing. Debriefing was facilitated by an emergency medicine attending with specialized training in simulation-based education. Following the completion of the scenario, residents received an anonymous educational quality improvement survey assessing residents' perception of their ability to recognize and manage lithium toxicity as well as their comfort level with the lithium-poisoned patient. Results: After the simulation, residents reported an increased comfort level with managing lithium-poisoned patients. Residents also self-reported an increased ability to recognize the signs and symptoms of lithium toxicity. Additionally, residents cited the case's educational importance and a desire to include this specific scenario in future simulation sessions. Discussion: Compared to other disease processes, toxicological overdoses are infrequently seen in the emergency department. Health care simulation can effectively portray lithium toxicity for emergency medicine resident education in a safe, controlled environment to increase repetitive practice in caring for this challenging population.

Unifying Resident Education: 12 Interdisciplinary Critical Care Simulation Scenarios.

Introduction: Unified critical care training within residency education is a necessity. We created a simulation-based curriculum designed to educate residents on core topics and procedural skills, which crossed all adult disciplines caring for critically ill patients. Methods: Residents from seven adult disciplines participated in this annual program during intern year. Learners were grouped into mixed discipline cohorts. Each cohort attended three distinct 4-hour simulation-based sessions, each consisting of four scenarios followed by postevent debriefing. The curriculum included 12 total clinical scenarios. Scenarios covered a broad array of complex critical care topics facing all adult specialties and reinforced important system-specific initiatives. Assessments evaluated clinical performance metrics, self-reported confidence in curricular topics, procedural and communication skills, resident satisfaction, and interdisciplinary attitudes. Results: Quantitative and qualitative data analyzed in three published works over the past 9 years of curricular programming has demonstrated highly satisfied learners along with improved: clinical performance; self-reported confidence in clinical topics, procedural, and communication skills; and interdisciplinary collegiality. Discussion: Purposeful focus on curricular development that integrates basic, clinical, and procedural content, while promoting the development of interdisciplinary relationships and the practice of critical thinking skills, is vital for successful education and patient care. This curriculum was well received by interns, covered difficult to obtain GME milestones, and provided an opportunity for interdisciplinary education. In an era of limited time for devoted bedside teaching and variable training exposures to certain disease processes, the development and implementation of this curriculum has filled a void within our system for unified resident education.

Simulation-based interdisciplinary education improves intern attitudes and outlook toward colleagues in other disciplines.

BACKGROUND: Cooperative interdisciplinary patient care is a modern healthcare necessity. While various medical and surgical disciplines have independent educational requirements, a system-wide simulation-based curriculum composed of different disciplines provides a unique forum to observe the effect of interdisciplinary simulation-based education (IDSE). Our hypothesis: IDSE positively affects intern outlook and attitudes towards other medical disciplines. METHODS: Using an established interdisciplinary simulation curriculum designed for first year interns, we explored the relative effect of IDSE on between-discipline intern attitudes in a convergent, parallel, mixed-methods study. Data sources included novel pre-post anonymous survey measurements (10-point Likert scale), focus groups, direct observations, and reflective field notes. This quasi-experimental pilot study was conducted at an academic, tertiary care medical center with two cohorts of interns: one exposed to IDSE and one exposed to an independent within-discipline simulation curriculum. RESULTS: IDSE exposed interns demonstrated statistically significant improvements when comparing mean pre-test and post-test score differences in five of seven areas: perceived interdisciplinary collegiality ([Formula: see text] = 0.855; p = 0.0002), respect (x̅ = 0.436; p = 0.0312), work interactions ([Formula: see text] = 0.691; p = 0.0069), perceived interdisciplinary attitudes (x̅ = 0.764; p = 0.0031), and comfort in interdisciplinary learning (x̅ = 1.164; p < 0.0001). There were no changes in interdisciplinary viewpoints observed among non-IDSE interns. IDSE interns were comfortable when learning with interns of different disciplines and believed others viewed their discipline positively compared to non-IDSE interns. Qualitative data uncovered the following themes related to the impact of IDSE including: 1) Relationship building, 2) Communication openness, 3) Attitude shifting, and 4) Enhanced learner experience. CONCLUSIONS: IDSE positively influenced intern outlook on and attitudes towards other medical disciplines. This unique learning environment provided interns an opportunity to learn clinical case management while learning about, from, and with each other; subsequently breaking traditional discipline-specific stereotypes and improving interdisciplinary relations. Future explicit focus on IDSE offers opportunity to improve interdisciplinary interactions and patient care.

A Mixed-methods Comparison of Participant and Observer Learner Roles in Simulation Education.

BACKGROUND: Traditional simulation-based education prioritizes participation in simulated scenarios. The educational impact of observation in simulation-based education compared with participation remains uncertain. Our objective was to compare the performances of observers and participants in a standardized simulation scenario. METHODS: We assessed learning differences between simulation-based scenario participation and observation using a convergent, parallel, quasi-experimental, mixed-methods study of 15 participants and 15 observers (N = 30). Fifteen first-year residents from six medical specialties were evaluated during a simulated scenario (cardiac arrest due to critical hyperkalemia). Evaluation included predefined critical actions and performance assessments. In the first exposure to the simulation scenario, participants and observers underwent a shared postevent debriefing with predetermined learning objectives. Three months later, a follow-up assessment using the same case scenario evaluated all 30 learners as participants. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare participants and observers at 3-month follow-up. In addition, we used case study methodology to explore the nature of learning for participants and observers. Data were triangulated using direct observations, reflective field notes, and a focus group. RESULTS: Quantitative data analysis comparing the learners' first and second exposure to the investigation scenario demonstrated participants' time to calcium administration as the only statistically significant difference between participant and observer roles (316 seconds vs. 200 seconds, p = 0.0004). Qualitative analysis revealed that both participation and observation improved learning, debriefing was an important component to learning, and debriefing closed the learning gap between observers and participants. CONCLUSIONS: Participants and observers had similar performances in simulation-based learning in an isolated scenario of cardiac arrest due to hyperkalemia. Findings support current limited literature that observation should not be underestimated as an important opportunity to enhance simulation-based education. When paired with postevent debriefing, scenario observers and participants may reap similar educational benefits.

Factors Associated with Delayed Cooling in Cardiac Arrest Patients.

Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.

Early neurologic examination is not reliable for prognostication in post-cardiac arrest patients who undergo therapeutic hypothermia.

BACKGROUND: Recent advances in post-cardiac arrest (CA) care including therapeutic hypothermia (TH) have improved survival and favorable neurologic outcomes for survivors of CA. Survivors often present with deep coma and lack of brainstem reflexes, which are generally associated with adverse outcomes in many disease processes. Little is known regarding the role of initial emergency department (ED) neurological examination and its potential for prognostication. OBJECTIVES: The purpose of this study is to determine if components of a standardized neurologic examination are reliable prognosticators in patients recently resuscitated from CA. We hypothesize that lack of neurologic function does not reliably predict an adverse outcome and, therefore, should not be used to determine eligibility for TH. METHODS: A standardized neurologic examination was performed in the ED on a prospective, convenience cohort of post-CA patients presenting to a CA resuscitation center who would undergo a comprehensive postarrest care pathway that included TH. Data such as prior sedation or active neuromuscular blockade were documented to evaluate for the presence of possible confounders. Examination findings were then compared with hospital survival and neurologic outcome at discharge as defined by the cerebral performance category (CPC) score as documented in the institutional TH registry. RESULTS: Forty-nine subjects were enrolled, most of whom presented comatose with a Glasgow Coma Scale of 3 (n=41, 83.7%). Nineteen subjects (38.8%) had absence of all examination findings, of which 4 of 19 (21.1%) survived to hospital discharge. Of those with at least 1 positive examination finding, 13 of 30 subjects (43.3%) survived to hospital discharge. Subgroup analysis showed that 9 of the 19 patients with absence of brainstem reflexes did not have evidence of active neuromuscular blockade at the time of the examination; 2 of 9 (22.1%) survived to hospital discharge. Eight of these subjects in this group had not received any prior sedation; 1 of 8 (12.5%) survived to hospital discharge. Only 1 of the 17 subjects who survived was discharged with poor neurologic function with a CPC score=3, whereas all others who survived had good neurologic function, CPC score=1. CONCLUSION: In this cohort of patients treated in a comprehensive postarrest care pathway that included TH, absence of neurologic function on initial ED presentation was not reliable for prognostication. Given these findings, clinicians should refrain from using the initial ED neurological examination to guide the aggressiveness of care or in counseling of family members regarding anticipated outcome.

ED prognostication of comatose cardiac arrest patients undergoing therapeutic hypothermia is unreliable.

BACKGROUND: Therapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population. OBJECTIVE: To determine if physicians can accurately predict survival and neurologic outcome at hospital discharge of resuscitated, comatose out-of-hospital cardiac arrest (OHCA) patients treated in a post-cardiac arrest clinical pathway that included TH. METHODS: This was a prospective, observational study conducted at a tertiary referral center. Participants were physicians involved in the resuscitation of OHCA patients treated with a clinical pathway that included TH. Immediately after patient resuscitation in the ED, physicians recorded their prediction of patient survival and neurologic outcome on a standardized questionnaire. Neurologic outcome was assessed by the cerebral performance category. RESULTS: Forty-two physicians completed questionnaires on 17 patients enrolled from October 2009 to March 2010. Sensitivity and specificity of physician prediction of patient survival were 0.67 (95% confidence interval [CI], 0.45-0.83) and 0.82 (95% CI, 0.59-0.94), respectively, with an area under the curve of 0.74 (95% CI, 0.61-0.88), a positive likelihood ratio (+LR) of 3.72 (95% CI, 1.30-11.02), and a -LR of 0.40 (95% CI, 0.21-0.77). Sensitivity and specificity of physician prediction of good neurologic outcome were 0.40 (95% CI, 0.20-0.64) and 0.69 (95% CI, 0.50-0.84), respectively, with an area under the curve of 0.55 (95% CI, 0.39-0.70), a +LR of 1.29 (95% CI, 0.56-3.03), and a -LR of 0.87 (95% CI, 0.53-1.41). CONCLUSIONS: Physicians poorly prognosticate both survival and neurologic outcome in comatose OHCA patients undergoing TH. Premature prognostication in the ED is unreliable and should be avoided.

Troponin Marker for Acute Coronary Occlusion and Patient Outcome Following Cardiac Arrest.

INTRODUCTION: The utility of troponin as a marker for acute coronary occlusion and patient outcome after out-of-hospital cardiac arrest (OHCA) is unclear. We sought to determine whether initial or peak troponin was associated with percutaneous coronary intervention (PCI), OHCA survival or neurological outcome. METHODS: Single-center retrospective-cohort study of OHCA patients treated in a comprehensive clinical pathway from November 2007 to October 2012. Troponin I levels were acquired at presentation, four and eight hours after arrest, and then per physician discretion. Cardiac catheterization was at the cardiologist's discretion. Survival and outcome were determined at hospital discharge, with cerebral performance category score 1-2 defined as a good neurological outcome. RESULTS: We enrolled 277 patients; 58% had a shockable rhythm, 44% survived, 41% good neurological outcome. Of the 107 (38%) patients who underwent cardiac catheterization, 30 (28%) had PCI. Initial ED troponin (median, ng/mL) was not different in patients requiring PCI vs no PCI (0.32 vs 0.09, p=0.06), although peak troponin was higher (4.19 versus 1.57, p=0.02). Of the 85 patients who underwent cardiac catheterization without STEMI (n=85), there was no difference in those who received PCI vs no PCI in initial troponin (0.22 vs 0.06, p=0.40) or peak troponin (2.58 vs 1.43, p=0.27). Regarding outcomes, there was no difference in initial troponin in survivors versus non-survivors (0.09 vs 0.22, p=0.11), or those with a good versus poor neurological outcome (0.09 vs 0.20, p=0.11). Likewise, there was no difference in peak troponin in survivors versus non-survivors (1.64 vs 1.23, p=0.07), or in those with a good versus poor neurological outcome (1.57 vs 1.26, p=0.14). CONCLUSION: In our single-center patient cohort, peak troponin, but not initial troponin, was associated with higher likelihood of PCI, while neither initial nor peak troponin were associated with survival or neurological outcome in OHCA patients.