Using simulation to support doctors in difficulty.

BACKGROUND: A small percentage of medical trainees will have performance concerns identified within their clinical practice. These trainees require specific interventions to address these concerns. The Postgraduate Ward Simulation Exercise (PgWSE) was developed as a joint collaboration between the University of Dundee and NHS Education for Scotland (NES). CONTEXT: The PgWSE takes around 90 minutes to complete. It allows assessors to directly observe the performance of trainees within a simulated ward environment. Trainees are assessed individually on their ability to prioritise competing demands, work as part of a team and make safe informed clinical decisions. INNOVATION: The PgWSE is the first specific national intervention to support the assessment and remediation of trainee doctors in difficulty. Nine PgWSE scenarios have been developed to reflect clinical practice: three in general surgery, four in general medicine and two in medicine for the elderly. To enhance realism, simulated patients (SPs) are recruited and trained for each exercise. Standardised assessment tools were developed and validated for assessors to make individual and consensus judgements regarding a trainee's performance. Self-assessment of performance is used to disengage trainees from the simulated activity and to prepare them for constructive feedback. IMPLICATIONS: The PgWSE has been shown to be a valuable tool for the management of trainee doctors in difficulty in Scotland. Although the PgWSE is time and resource intensive, it has been shown to have a positive impact on the remediation of trainees and in the provision of objective, detailed and comprehensive feedback to the referring deanery. Within NES there are four geographical centres led by a postgraduate dean with responsibility for supervision of postgraduate medical education.

Trends in function and postdischarge mortality in a medicine for the elderly rehabilitation center over a 10-year period.

OBJECTIVES: To ascertain trends in function and mortality after admission to a medicine for the elderly rehabilitation unit, and to analyze factors associated with these outcomes. DESIGN: Retrospective cohort analysis of routinely collected clinical data during the period from January 1, 1999, to December 31, 2008. SETTING: Hospital-based medicine for the elderly rehabilitation unit. PARTICIPANTS: Patients (N=4449) admitted for rehabilitation after medical and surgical illness, stroke, and fractured neck of the femur. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Analysis of routinely collected clinical data: admission and discharge Barthel scores; indices of cognitive impairment, mental illness, swallowing and feeding difficulties. Discharge diagnoses, place of discharge, date of death, and discharge medications were analyzed, along with length of stay. Regression analysis of factors associated with improvement in Barthel score, place of discharge, and postdischarge mortality. RESULTS: Length of stay and admission Barthel scores were unchanged over the study period, but discharge Barthel scores improved from 13.5 (maximum score, 20) in 2002 to 14.8 in 2008 (P=.002 for trend). Discharge to home increased from 290 (61%) of 472 patients in 2001 to 290 (76%) of 382 patients in 2007 (P<.001 for trend). Age, admission Barthel score, cognitive impairment, problems with understanding, and problems with expression were independent predictors of the change in Barthel score between admission and discharge. The adjusted hazard ratio for postdischarge mortality in 2007 to 2008 compared with 1999 to 2000 was .76 (95% confidence interval, .63-.93). CONCLUSIONS: Functional and mortality outcomes improved over a 10-year period in this rehabilitation unit, despite similar Barthel scores on admission and equivalent lengths of stay.