Adam Keene

The use of a critical care consult team to identify risk for methicillin-resistant Staphylococcus aureus infection and the potential for early intervention: A pilot study

Objective:To test whether a critical care consult team can be used to identify patients who have methicillin-resistant Staphylococcus aureus nasal colonization during a window period at which they are at highest risk for methicillin-resistant S. aureus infection and can most benefit from topical decolonization strategies. Design:Prospective cohort study. Setting:Two adult tertiary care hospitals. Patients:Patients with at least one risk factor for methicillin-resistant S. aureus nasal colonization who were seen by a critical care consult team for potential intensive care unit admission were enrolled. Interventions:Nasal cultures for methicillin-resistant S. aureus were performed on all subjects. All subjects were followed for the development of a methicillin-resistant S. aureus infection for 60 days or until hospital discharge. Demographic and outcome data were recorded on all subjects. Measurements and Main Results:Two hundred subjects were enrolled. Overall 29 of 200 (14.5%) were found to have methicillin-resistant S. aureus nasal colonization. Methicillin-resistant S. aureus infections occurred in seven of 29 (24.1%) subjects with methicillin-resistant S. aureus nasal colonization vs. one of 171 (0.6%) subjects without methicillin-resistant S. aureus nasal colonization (p < .001). Methicillin-resistant S. aureus clinical specimens were recovered in 15 of 29 (51.7%) subjects with methicillin-resistant S. aureus nasal colonization vs. two of 171 (1.2%) without methicillin-resistant S. aureus nasal colonization. Conclusions:A critical care consult team can be used to rapidly recognize patients with methicillin-resistant S. aureus nasal colonization who are at very elevated risk for methicillin-resistant S. aureus infection. The use of such a team to recognize patients who have greatest potential benefit from decolonization techniques might reduce the burden of severe methicillin-resistant S. aureus infections.

Increased bleeding risk associated with the use of recombinant human activated protein C in patients with advanced liver disease

Advanced liver disease (ALD) was an exclusion criteria from enrollment in the major clinical trials of recombinant human activated protein C (APC), but is listed on the package insert as a relative contraindication rather than an absolute contra-indication to APC administration [1]. There are recent reports of elevated rates of bleeding due to APC in clinical practice, particularly in patients with relative contraindications to the drug [2,3]. Since many patients who develop septic shock at Montefiore Medical Center in the Bronx, New York have ALD, we decided to evaluate whether such patients have an increased risk for bleeding during APC administration. We retrospectively reviewed a database of all adult patients who have received APC at Montefiore Medical Center since the drugs approval. All patients at Montefiore Medical Center with severe sepsis at high risk for death and without absolute contraindications are considered eligible for APC at the discretion of the attending intensivist. Overall, 41 patients received APC at our hospital, seven of whom were not evaluable because of death soon after initiation of APC. Of the 34 remaining patients, nine had major bleeding episodes. The clinical characteristics of these 34 patients are presented in Table ​Table1.1. Five out of 10 patients (50%) with ALD had major bleeding episodes, as opposed to four out of 24 patients without episodes (16.7%) (P = 0.04). The bleeding events experienced by the patients with ALD included two gastrointestinal hemorrhages, one intracranial hemorrhage, one major vaginal bleed, and one massive epistaxis. In a multivariate regression model that included race, sex, and Acute Physiology and Chronic Health Evaluation II score, cirrhosis remained independently associated with the risk of a bleeding event (P = 0.02, odds ratio = 23.5, 95% confidence interval = 1.75–315). Of the five patients with ALD who had bleeding episodes, four died within 28 days of drug administration. Interestingly, only one out of 12 patients who had undergone major surgery during their hospitalization experienced a bleeding episode (this patient did not have ALD). Table 1 Patient characteristics and outcomes Patients with ALD are at increased risk both for severe sepsis and for bleeding. These data suggest that they may be at greatly increased risk for bleeding while receiving APC. Because such patients were excluded from the major clinical trials of APC, it may be prudent to withhold therapy with APC from all patients with ALD until data from trials that include these patients, or further postmarketing data, are available.

Vasospasm Risk in Surgical ICU Patients With Grade I Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality. The initial hemorrhage causes death in approximately 25% of patients, with most subsequent mortality being attributable to delayed cerebral ischemia (DCI). Delayed cerebral ischemia generally occurs on post-bleed days 4 through 20, with the incidence peaking at day 8. Because of the risks of DCI, patients with SAH are usually monitored in an intensive care unit (ICU) for 14 to 21 days. Unfortunately, prolonged ICU admissions are expensive and are associated with well-documented risks to patients. We hypothesized that a subset of patients who are at low risk of DCI should be safe to transfer out of the ICU early. All patients admitted to Montefiore Medical Center from 2008 to 2013 with grade I SAH who had their aneurysms successfully protected, had an uncomplicated postoperative course, and had no clinical or ultrasonographic evidence of DCI after day 8 were retrospectively studied. The primary outcome was clinical or ultrasonographic evidence of the development of DCI after day 8. Secondary outcomes included length of ICU and hospital stay and hospital mortality. Forty patients who met the above-mentioned criteria were identified. Of these, only 1 (2.5%) developed ultrasonographic evidence of DCI after day 8 but required no intervention. The mean length of stay in the ICU was until post-bleed day 13, and the mean hospital length of stay was until post-bleed day 14. The in-hospital mortality was 0 of 40. Thus, we identified a low-risk subset of patients with grade I SAH who may be candidates for early transfer out of the ICU.

392: NUMBERED JERSEYS IMPROVE TEAMWORK DURING SIMULATED EMERGENCIES

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Teamwork and leadership skills in Cardiac Arrest/Rapid Response (CA/RR) scenarios have been shown to correlate with clinical outcomes such as mortality. During these high stress and high acuity events, leaders must be able to rapidly assign roles and tasks, as well as give effective commands to each team member to optimize teamwork. We hypothesize that the use of individual numbered jerseys for each code team member improves overall teamwork performance during simulated CA/ RR scenarios. Methods: Internal Medicine Residents PGY-1 (n = 48) were randomized into two groups. In the experimental group, the team leader received a yellow jersey with the number 1 printed on it and each team member received white numbered jerseys (2 through 8). The control team leader and members wore their regular work clothes. Each group participated in 8 simulated CA/RR cases using high-fidelity simulation, and participants alternated between team leader and team member roles for each case. The 16-item validated Mayo High Performance Teamwork Scale (MHPTS) was independently completed by an experienced faculty member observer. Results: A total of 64 simulated cases and 64 Mayo scales were completed. In the experimental jersey group, the overall teamwork score was significantly higher as compared to the control group (24.8 vs 18.2, p < 0.01). In addition, team leaders in the experimental group were better recognized by the other team members (2.0 vs 1.8, p < 0.01) and were better at finding balance between command authority and team member participation (1.7 vs 1.2, p < 0.01). Furthermore, team members in the experimental group had a clearer understanding of their assigned team role (1.6 vs 1.1, p < 0.01) and had improved team communication and recognition of errors (1.4 vs 0.8, p < 0.01). Conclusions: The use of numbered jerseys to identify each member of the CA/RR team is an effective method of improving overall teamwork as well as many specific critical team components during CA/RR scenarios. Further research is needed to evaluate the feasibility of using these jerseys during real in-hospital events 392

Comparison between Simulation-based Training and Lecture-based Education in Teaching Situation Awareness. A Randomized Controlled Study

Rationale: Situation awareness has been defined as the perception of the elements in the environment within volumes of time and space, the comprehension of their meaning, and the projection of their status in the near future. Intensivists often make time‐sensitive critical decisions, and loss of situation awareness can lead to errors. It has been shown that simulation‐based training is superior to lecture‐based training for some critical scenarios. Because the methods of training to improve situation awareness have not been well studied in the medical field, we compared the impact of simulation vs. lecture training using the Situation Awareness Global Assessment Technique (SAGAT) score. Objectives: To identify an effective method for teaching situation awareness. Methods: We randomly assigned 17 critical care fellows to simulation vs. lecture training. Training consisted of eight cases on airway management, including topics such as elevated intracranial pressure, difficult airway, arrhythmia, and shock. During the testing scenario, at random times between 4 and 6 minutes into the simulation, the scenario was frozen, and the screens were blanked. Respondents then completed the 28 questions on the SAGAT scale. Sample items were categorized as Perception, Projection, and Comprehension of the situation. Results were analyzed using SPSS Version 21. Results: Eight fellows from the simulation group and nine from the lecture group underwent simulation testing. Sixty‐four SAGAT scores were recorded for the simulation group and 48 scores were recorded for the lecture group. The mean simulation vs. lecture group SAGAT score was 64.3 ± 10.1 (SD) vs. 59.7 ± 10.8 (SD) (P = 0.02). There was also a difference in the median Perception ability between the simulation vs. lecture groups (61.1 vs. 55.5, P = 0.01). There was no difference in the median Projection and Comprehension scores between the two groups (50.0 vs. 50.0, P = 0.92, and 83.3 vs. 83.3, P = 0.27). Conclusions: We found a significant, albeit modest, difference between simulation training and lecture training on the total SAGAT score of situation awareness mainly because of the improvement in perception ability. Simulation may be a superior method of teaching situation awareness.

13: TEACHING SITUATION AWARENESS DURING CARDIAC ARRESTS AND RAPID RESPONSES - A SIMULATION STUDY

Learning Objectives: During rapid responses (RR) and cardiac arrests (CA), team leaders must be aware of multiple factors simultaneously in order to successfully manage them. Situation awareness (SA) is a necessary skill for leaders to optimize patient outcomes. SA can be divided into 3 components: facts, comprehension, and projection. SA involves understanding the current situation, having the ability to look at all the data, synthesizing the information and determining its relevance. We hypothesized that residents’ SA and ability to manage RR/CA scenarios can be improved with simulation training. Methods: Internal Medicine residents (n=48) participated in 8 RR/CA scenarios using High Fidelity Simulation (HFS). They were scored in 2 pre-training cases, then received feedback and education about SA and RR/CA management, participated in 4 more cases for education penetrance, and scored again in 2 cases as post-training evaluation. A modified SABAR (Situation Awareness Behaviorally Anchored Rating) scale was used, ranging from 1 (very poor) to 5 (very good). Scoring was performed by a trained observer. Results: After training the residents’ SA during RR/CA scenarios improved from 2.4+0.6 to 4.4+0.4 (p< 0.01). All 20 evaluated items showed statistically significant improvement (p<0.01) The greatest improvements were in: employ team members appropriately to perform needed tasks (2.1 to 5.0); use team members to effectively assess the situation (1.8 to 4.4) and ask for pertinent information (2.4 to 4.7). After training the lowest scores were in: gather follow up information when needed (3.4); perform a team leader’s overview (3.5); project future possibilities and create contingency plans (3.5). Conclusions: Novice code leaders often struggle with maintaining awareness of the dozens of inputs they may receive during a RR/CA situation. HFS training improves SA of medical residents markedly and rapidly. Although improved, residents still had some difficulty with items related to taking a general overview and projection of the future patient course.

Board 304 - Research Abstract Leadership Skills and Clinical Performance of Internal Medicine Residents in Cardiac Arrests and Rapid Responses - A Simulation Study (Submission #504)

Introduction/Background Internal Medicine residents are expected to lead and participate in rapid responses (RA) and cardiac arrests (CA) throughout their residency training. While the American Heart Association Advance Cardiac Life Support course provides education in resuscitative protocols, not all residents have the same confidence level and skills to run RR/CA scenarios. Scenario-based training (SBT) with a high-fidelity simulator (HFS) allows trainees to experience high-risk, low-frequency events that are typical of inpatient medicine without exposing patients to the risks inherent in trainee learning. We hypothesized that simulation training offered during residency training is an effective teaching modality that can improve residents’ self-confidence, teamwork, leadership and ability to manage RR/CA scenarios. Methods A prospective, before and after study design was used. All first and second year Internal Medicine residents at Montefiore Medical Center (n=126) were divided into small groups to replicate RR/CA teams. Each group participated in 8 RR/CA scenarios in random order using a HFS (SimMan - Laerdal). First, the residents participated in two pre-training cases with evaluation scores and without feedback. Then they received teaching feedback, as well as a brief talk focusing on team performance and crew resource management techniques. They then participated in two more cases to allow for education penetrance. Their performance in these cases were not evaluated. Finally, they participated in four more cases that were evaluated and scored as post-training cases. The pre and post-training case scores were compared. Cases were designed by a teaching committee to anonymously replicate actual RR/CA cases that had been observed in the hospital. The clinical component was evaluated through pertinent checklists divided by levels of difficulty (level A being the easiest and level D the most difficult). The teamwork performance was evaluated with the validated Mayo Clinic Teamwork Scale. Analysis was performed using STATA/IC 11.2. Results After each scenario all groups showed improvement in their RR/CA clinical performance. The pre vs. post-training combined score improved from 41.8 % + 15% to 68% + 18% (delta +26.2%, p<0.00). Level A (basic) performance on checklists improved from 54.4% + 10% to 95% + 16% (+40.6%p<0.00); Level B (intermediate) from 65.4% + 9% to 87.6% + 18% (+22.2% p<0.00); Level C (advanced) from 38.5% + 6 to 63.6% + 6 (+25.1% p<0.00); and Level D (expert) from 8.84% + 17 to 25.9% + 9 (+17.1%p<0.00). Leadership and teamwork skills improved from 26.5% +30% to 84.5% + 30% (+58% p<0.00). The greatest improvements were in the team’s ability to:understand their role (+68.3% p<0.00), appropriately manage disagreements (+69.3% p<0.00) and ask for clarifications when instructions were unclear(+76.5% p<0.00). Conclusion Training residents with a HFS provides instantaneous access to learning modules without compromising patient safety. Both clinical performance and teamwork skills improved significantly among all groups of residents and at all levels of complexity. Simulation training offered during residency training is an effective teaching modality that can improve resident’s self-confidence, teamwork, leadership and ability to manage rapid response/cardiac arrest scenarios. References 1. Stefan MS, et al: A simulation-based program to train medical residents to lead and perform advanced cardiovascular life support. Hosp Pract (Minneap) 2011 Oct; 39(4):63-9. 2. Langhan TS, et al: Simulation-based training in critical resuscitation procedures improves residents’ competence. CJEM 2009 Nov; 11(6):535-9. 3. Schroedl CJ, et al: Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care 2012 April; 27(2):219.e7-13. 4. Malec JF, Torsher LC, Dunn WF, et at: The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills. Simul Healthc 2007 Spring; 2(1):4-10. Disclosures 12.5% salary support for grant from Center for Medicare Services for study of new electronic dashboard to view ICU data.