Description of web-enhanced virtual character simulation system to standardize patient hand-offs.

INTRODUCTION: The 80-h work week has increased discontinuity of patient care resulting in reports of increased medication errors and preventable adverse events. Graduate medical programs are addressing these shortcomings in a number of ways. METHODS: We have developed a computer simulation platform called the Virtual People Factory (VPF), which allows us to capture and simulate the dialogue between a real user and a virtual character. We have converted the system to reflect a physician in the process of "checking-out" a patient to a covering physician. The responses are tracked and matched to educator-defined information termed "discoveries." Our proof of concept represented a typical post-operative patient with tachycardia. The system is web enabled. RESULTS: So far, 26 resident users at two institutions have completed the module. The critical discovery of tachycardia was identified by 62% of users. Residents spend 85% of the time asking intraoperative, postoperative, and past medical history questions. The system improves over time such that there is a near-doubling of questions that yield appropriate answers between users 13 and 22. Users who identified the virtual patient's underlying tachycardia expressed more concern and were more likely to order further testing for the patient in a post-module questionnaire (P = 0.13 and 0.08, respectively, NS). CONCLUSIONS: The VPF system can capture unique details about the hand-off interchange. The system improves with sequential users such that better matching of questions and answers occurs within the initial 25 users allowing rapid development of new modules. A catalog of hand-off modules could be easily developed. Wide-scale web-based deployment was uncomplicated. Identification of the critical findings appropriately translated to user concern for the patient though our series was too small to reach significance. Performance metrics based on the identification of critical discoveries could be used to assess readiness of the user to carry off a successful hand-off.

Simultaneous fundoplication and gastric stimulation in a lung transplant recipient with gastroparesis and reflux.

BACKGROUND: Gastroparesis following lung transplantation can complicate medical management leading to malnutrition, weight loss, and erratic absorption of immunosuppressive medications, which are all important factors in the success of grafts. Gastric electrical stimulation has been shown to reduce the frequency of nausea and vomiting and lead to weight gain in patients with gastroparesis refractory to standard medical treatment; however, it has not yet been reported as being used for the treatment of gastroparesis in lung transplant recipients. METHODS: We report the case of a female bilateral lung transplant recipient suffering from severe gastric reflux and severe gastroparesis, who was successfully treated with simultaneous creation of a laparoscopic Nissen fundoplication and placement of a gastric stimulator. RESULTS: The patient noted an immediate and sustained decrease in her symptoms of nausea and vomiting, and an increased appetite, and less variability in the serum levels of her immunosuppressive medication. CONCLUSION: Lung transplant recipients with severe gastroparesis and reflux may benefit from Nissen fundoplication and gastric electrical stimulation.

Small case series of gastric stimulation for the management of transplant-induced gastroparesis.

BACKGROUND: Gastroparesis is a recognized complication following organ transplantation with incidences reported between 24 and 83%. Gastroparesis can complicate medical management in these patients leading to the inability to take medications and possibly chronic transplant rejection. Gastric electrical stimulation (GES) has been shown in both controlled and uncontrolled studies to reduce the frequency of nausea and vomiting and lead to weight gain in patients with gastroparesis refractory to standard medical treatment; however, there is little evidence to support the use of GES in transplant recipients. The goal was to evaluate the response of transplant patients with gastroparesis to GES and compare to nontransplant recipients. MATERIALS AND METHODS: A questionnaire consisting of 11 questions was administered to investigate symptoms. Patients were asked to score these symptoms before and after surgery using a 0-5 Likert scale. RESULTS: Thirteen consecutive patients underwent placement of the Enterra (Medtronic, Minneapolis, MN) device with a mean follow-up of 12 +/- 6.1 months. All three transplant patients (100%) reported an improvement in quality of life. Similarly, transplant patients were as likely as the diabetic or idiopathic patients to demonstrate improvements in symptoms of nausea, vomiting, and retching and prandial symptoms following Enterra therapy. In fact, transplant patients reported improvement in appetite and bloating symptoms more frequently than diabetics (P = 0.055 and P = 0.037, respectively). CONCLUSION: Posttransplantation gastroparesis responds to therapy with Enterra GES as well as in patients with idiopathic or diabetic gastroparesis. Enterra therapy should be prospectively investigated in this population of patients.