Anna Newcomb

Talk the Talk: Implementing a Communication Curriculum for Surgical Residents.

OBJECTIVES The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. DESIGN The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. SETTING Surgical simulation center in a 900-bed tertiary care hospital. PARTICIPANTS Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. RESULTS We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. CONCLUSIONS Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance patient care for institutions providing such education as well as for institutions where residents continue on in fellowships or begin their surgical practice.

Reducing Transfusions in Critically Injured Patients Using a Restricted-Criteria Order Set.

BACKGROUND We sought to examine the effect on blood usage of a new electronic order set restricting transfusion orders to specific evidence-based criteria for each unit (U) of red blood cells (RBC), plasma, and platelets. METHODS Prospectively collected transfusion data for Trauma ICU patients were compared for the 12 months before (PRE) and 8 months after (POST) order set implementation. Criteria for RBC transfusion were 1 U only for hemoglobin <7 g/dL in stable patients or <8 g/dL with angina, myocardial infarction, or cardiogenic shock; 2 U for hemoglobin <5 g/dL; and multiple U in the presence of shock, hypotension, or bleeding. Restrictive ordering criteria were also applied to plasma and platelets. Massive transfusion patients were excluded. Differences in demographics and outcomes were assessed with Wilcoxon–Mann–Whitney test or Wilcoxon rank sum test for continuous variables, and &khgr;2 test for categorical variables. The percentage of patients receiving transfusions over time was compared with trend tests. Severity of illness (SOI) was graded from 1 (minor) to 4 (extreme). RESULTS Of 1,038 Trauma ICU patients (583 PRE, 455 POST), 228 (22%) were transfused. Median SOI [IQR] (4 [3–4] vs. 4 [3–4]) and mortality (24.3% vs. 22.5%, p = 0.757) were similar for PRE and POST transfused patients, respectively. The percentage of patients getting transfused decreased for all transfusions (25.4% vs. 17.6%, p = 0.003), RBC (19.9% vs. 11.2%, p < 0.001), and plasma (9.3% vs. 5.9%, p = 0.047) in PRE and POST, respectively. After adjusting for age, Injury Severity Score, admission hypotension, and other variables, there was a lower odds of receiving any transfusion (OR 0.67 [0.49–0.92], p = 0.015), and RBCs specifically (OR 0.60 [0.41–0.86], p = 0.006), in the POST period. The frequency of pre-transfusion hemoglobin ≥7 g/dL decreased by 27%, and mean direct costs of transfusion decreased by approximately 28%, after the intervention. CONCLUSIONS A significant reduction in transfusions was achieved after introduction of an order set restricting orders to predefined evidence-based criteria. LEVEL OF EVIDENCE Therapeutic study, level III.

FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients

BACKGROUND A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk. METHODS FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation. RESULTS There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]). CONCLUSIONS Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Supine position and nonmodifiable risk factors for ventilator-associated pneumonia in trauma patients.

BACKGROUND We studied trauma-specific conditions precluding semiupright positioning and other nonmodifiable risk factors for their influence on ventilator-associated pneumonia (VAP). METHODS We performed a retrospective study at a Level I trauma center from 2008 to 2012 on ICU patients aged ≥15, who were intubated for more than 2 days. Using backward logistic regression, a composite of 4 factors (open abdomen, acute spinal cord injury, spine fracture, spine surgery) that preclude semiupright positioning (supine composite) and other variables were analyzed. RESULTS In total, 77 of 374 (21%) patients had VAP. Abbreviated Injury Score head/neck greater than 2 (odds ratio [OR] 2.79, P = .006), esophageal obturator airway (OR 4.25, P = .015), red cell/plasma transfusion in the first 2 intensive care unit days (OR 2.59, P = .003), and 11 or more ventilator days (OR 17.38, P < .0001) were significant VAP risk factors, whereas supine composite, scene vs emergency department airway intervention, brain injury, and coma were not. CONCLUSION Factors that may temporarily preclude semiupright positioning in intubated trauma patients were not associated with a higher risk for VAP.