Multiinstitutional Evaluation of a Debate-Style Journal Club for Cardiothoracic Surgery Trainees.

BACKGROUND: Traditional journal clubs address individual articles and are limited in terms of breadth and depth of content covered. The present study describes the outcomes of a novel debate-style journal club in a multiinstitutional setting. METHODS: Participating institutions were recruited through the Thoracic Education Cooperative Group. The distributed curriculum included instructions, debate scenarios, suggested article lists, moderator slides, debate scoresheets, exams, and feedback surveys. RESULTS: Six institutions participated in the study (2015-2019), consisting of a total of 10 years' worth of cumulative debates. Cardiothoracic surgery trainees participated in 10 monthly debates over each academic year. Trainee performance on the written examination in the realm of evidence-based medicine and critical appraisal improved over the course of the academic year (beginning 55.2% vs end 76.3%; P = .040). Importantly, written examination after debates revealed a significant improvement in scores on questions relating to topics that were debated as compared with those that were not (+27.1% vs +2.5%; P = .006), emphasizing the importance of the debates as compared with other sources of knowledge gain. Surveys completed by trainees and faculty overall favored the debate-style journal club as compared with the traditional journal club in gaining familiarity with seminal literature in the field, improving on oral presentation skills, and applying published literature to questions encountered clinically. CONCLUSIONS: In this multiinstitutional prospective study, we demonstrate that the novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to acquire, retain, and gain practice in applying literature-based evidence to case-based scenarios.

Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis.

PURPOSE: To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. METHODS: We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. RESULTS: Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle-Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59-100% were mechanically ventilated, and 47-100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48-71%)] and midazolam [utilization rate 28% (95% CI 23-32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2-4). CONCLUSIONS: Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care.

Clinical Practice Guidelines and Consensus Statements About Pain Management in Critically Ill End-of-Life Patients: A Systematic Review.

OBJECTIVES: To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU. DATA SOURCES: We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019. STUDY SELECTION: We included all clinical practice guidelines, consensus statements, and benchmarks for quality. DATA EXTRACTION: Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized. DATA SYNTHESIS: Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU. CONCLUSIONS: In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.

Novel Debate-Style Cardiothoracic Surgery Journal Club: Results of a Pilot Curriculum.

BACKGROUND: Traditional journal clubs addressing single articles are limited by the lack of a standardized process for conduct and evaluation. We developed a novel, debate-style journal club for trainees to use best available evidence to address controversial topics in cardiothoracic surgery through discussion of realistic patient scenarios. METHODS: After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys. RESULTS: Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus -4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature (r = 0.853), moderately correlated with persuasiveness (r = 0.465), and overall effect of the debate (r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically. CONCLUSIONS: Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort.

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

OBJECTIVES: To update the Society of Critical Care Medicine's guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. DESIGN: An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. MEASUREMENTS AND MAIN RESULTS: The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. CONCLUSION: Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

A Structured, Debate-Style Cardiothoracic Surgery Journal Club for Trainee Acquisition and Application of Seminal Literature.

INTRODUCTION: The acquisition of specialty-specific seminal literature and its application to daily, clinical patient-care decisions are critical components of clinical training. This structured, debate-style cardiothoracic surgery journal club module engages trainees in discussion of realistic patient scenarios, incorporating an extensive body of literature identified as the best evidence for the practice of cardiothoracic surgery. METHODS: We designed the structured, debate-style cardiothoracic surgery journal club and delivered it to University of Texas MD Anderson Cancer Center cardiothoracic surgery trainees. Overall assessment of knowledge acquisition consisted of both direct judging of debates by faculty facilitators and a year-end written test of trainee knowledge. Associated materials include guidelines and resources for faculty facilitators and trainees to prepare them for the journal club debate. Also included are cardiothoracic surgery patient cases, PowerPoint presentation slides, a debate score sheet, and multiple-choice knowledge tests with answer keys. RESULTS: Our structured, debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to gain practice in applying specialty-specific, literature-based evidence to particular patient problems. DISCUSSION: This resource may be used by course directors for surgery, for independent study by individuals planning to matriculate into surgical residencies, or as a review for those already in surgical training. Moreover, this curriculum can be delivered at other clinical training programs.

Clinical librarian support for rapid review of clinical utility of cancer molecular biomarkers.

The clinical librarian used a restricted literature searching and quality-filtering approach to provide relevant clinical evidence for the use of cancer molecular biomarkers by institutional policy makers and clinicians in the rapid review process. The librarian-provided evidence was compared with the cited references in the institutional molecular biomarker algorithm. The overall incorporation rate of the librarian-provided references into the algorithm was above 80%. This study suggests the usefulness of clinical librarian expertise for clinical practice. The searching and filtering methods for high-level evidence can be adopted by information professionals who are involved in the rapid literature review.

End-of-life decision making in hematopoietic cell transplantation recipients.

Discussions about futile treatment options for patients undergoing hematopoietic cell transplantation (HCT) can be difficult for healthcare providers. These discussions often are not initiated before transplantation, but only after a patient's healthcare status deteriorates. Nurses are in a key position to provide support and advocate for patients and their families in end-of-life (EOL) decisions. A need exists for increased autonomy for nurses as patient advocates. Implementation of multidisciplinary nursing education, both in schools and in the workplace, will support these new responsibilities. This article will provide a review of the literature related to the nurse role in the transition from active treatment (aggressive care) to EOL care in the HCT population.

Follow-up of patients with resected thoracic malignancies.

The authors have systematically performed a literature search using 8 databases identifying established guidelines for follow-up after resected thoracic malignancies. Seven different societies' (found to have published recommendations for non-small cell lung cancer, esophageal cancer, thymoma, or mesothelioma) guidelines are reviewed in this article. High-quality evidence leading to consistent, strong recommendations among societies has not been found. With the subsequent advancements in surgical treatment and other curative modalities, the ability to detect and intervene with curative therapy at earlier stages of disease in a growing portion of the current patient population will benefit from higher-quality evidence.