Danielle Hart

Entrustment Decision Making in Clinical Training

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee’s development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis. Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article. The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors’ aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.

Point-of-care ultrasound to estimate central venous pressure: A comparison of three techniques

Objective:To determine the most accurate predictor of central venous pressure among three point-of-care venous ultrasound techniques. Design:Cross-sectional study. Setting:Medical ICU in an academic medical center. Patients:Convenience sample of 67 spontaneously breathing patients who had an intrathoracic central venous catheter to allow measurement of central venous pressure. Intervention:Measurement of the internal jugular vein height to width ratio (aspect ratio), the inferior vena cava diameter, and the percent collapse of the inferior vena cava with inspiration (collapsibility index) by ultrasound. Measurements and Main Results:Complete data for analysis were available in 65 patients, as the inferior vena cava could not be visualized in two patients. A central venous pressure of 10 mm Hg was chosen a priori as a clinically significant cutoff. The range of central venous pressure values was 1–23 mm Hg with a median value of 7 mm Hg. The maximal inferior vena cava diameter correlated moderately with central venous pressure (R2 = 0.58), whereas the inferior vena cava collapsibility index and the internal jugular vein aspect ratio showed poor correlation (R2 = 0.16 and 0.21, respectively). The area under the receiver operating characteristics curve (area under the curve) to discriminate a low central venous pressure (< 10 mm Hg) was 0.91 for inferior vena cava diameter (95% confidence interval 0.84–0.98), which was significantly higher than the internal jugular vein aspect ratio (area under the curve 0.76; 95% confidence interval 0.65–0.89) or the inferior vena cava collapsibility index (area under the curve 0.66; 95% confidence interval 0.51–0.80) (p = 0.0001). An inferior vena cava diameter < 2 cm predicted a central venous pressure < 10 mm Hg with a sensitivity of 85% (95% confidence interval 69% to 94%), specificity of 81% (95% confidence interval 60% to 93%), and positive predictive value of 87% (95% confidence interval 71% to 95%). Inferior vena cava collapsibility index was not an independent predictor of central venous pressure after adjusting for inferior vena cava diameter in a multiple linear regression model. Conclusion:Among spontaneously breathing patients largely without vasopressor support, the maximal inferior vena cava diameter is a more robust estimate of central venous pressure than the inferior vena cava collapsibility index or the internal jugular vein aspect ratio.

Core principles of assessment in competency-based medical education

Abstract The meaningful assessment of competence is critical for the implementation of effective competency-based medical education (CBME). Timely ongoing assessments are needed along with comprehensive periodic reviews to ensure that trainees continue to progress. New approaches are needed to optimize the use of multiple assessors and assessments; to synthesize the data collected from multiple assessors and multiple types of assessments; to develop faculty competence in assessment; and to ensure that relationships between the givers and receivers of feedback are appropriate. This paper describes the core principles of assessment for learning and assessment of learning. It addresses several ways to ensure the effectiveness of assessment programs, including using the right combination of assessment methods and conducting careful assessor selection and training. It provides a reconceptualization of the role of psychometrics and articulates the importance of a group process in determining trainees’ progress. In addition, it notes that, to reach its potential as a driver in trainee development, quality care, and patient safety, CBME requires effective information management and documentation as well as ongoing consideration of ways to improve the assessment system.

The Millennial Generation and “The Lecture”

This lecture can be viewed in its entirety online by visiting http://vimeo.com/24148123.

Face Mask Ventilation: A Comparison of Three Techniques

BACKGROUND There are multiple techniques for face-mask (FM) ventilation. To our knowledge, the one-handed vs. two-handed C-E technique has been compared in children and adults, but no studies have compared the various two-handed methods. OBJECTIVE To compare the effectiveness of mask seal using three different FM techniques on a model intended to simulate difficult FM ventilation and measure ventilation performance. METHODS This was a prospective randomized study of health care providers. A standard airway-training mannequin was modified to produce variable airway resistance and allow measurements of ventilation volume and pressure. Each subject performed FM ventilation for 3 min per technique (30 breaths) in a randomized order. Median exhaled tidal volume and proximal peak flow pressure were determined and compared. RESULTS Seventy subjects were enrolled. Both two-handed ventilation techniques were more effective than the one-handed technique by both volume and pressure measurements. The one-handed C-E technique yielded a median volume of 428.4 mL, vs. the two-handed C-E technique with 550.8 mL, and the two-handed V-E technique with 538 mL (p < 0.001). Peak pressure measurements revealed a median of 54.6 cm H2O for the one-handed C-E technique, 66 cm H2O for the two-handed C-E technique, and 66.6 cm H2O for the two-handed V-E technique (p < 0.001). There was not a difference between the various two-handed techniques. CONCLUSIONS This model for FM ventilation is able to differentiate the efficacy of FM techniques. Both two-handed ventilation methods were superior to one-handed ventilation, both of which should perhaps be included in airway training for health care providers.

Entrustable professional activities: making sense of the emergency medicine milestones.

BACKGROUND The Next Accreditation System (NAS) is being implemented by the Accreditation Council for Graduate Medical Education with seven specialties, including Emergency Medicine (EM), which began in July 2013. The NAS represents a more structured method of accreditation, with dependence on outcomes and less emphasis on educational process. A key component of the NAS is the individual resident semiannual reporting of the Milestone proficiency levels for all sub-competencies, which are more specific areas of domain for the general competencies. All specialties are struggling to some extent with developing assessment mechanisms for the Milestones. At the heart of this struggle is the conceptualization of the Milestones themselves-descriptors of the individual. In practice, faculty assess clinical care provided to the patient by the resident. This creates difficulty for faculty to assign a resident to a specific sub-competency proficiency level when their focus has been on assessment of clinical care. OBJECTIVES The objectives of this article include the discussion of whether Entrustable Professional Activities (EPAs) could be defined and linked to milestones in a way that, once implemented, could inform Clinical Competency Committees of the Milestone proficiency reporting. DISCUSSION EPAs are units of professional work, or clinical care that may help translate aspects of clinical care into Milestone proficiencies. This article explores EPAs in depth, and discusses how EPAs may be used within EM as one method of assigning proficiency levels to residents. CONCLUSIONS EPAs may be a useful tool to inform Milestone proficiency placement of residents. Because EPAs are based on clinical descriptions rather than individual physician descriptions, there may be less faculty development needed for Milestone sub-competency assessment.

Feasibility of a perfused and ventilated cadaveric model for assessment of lifesaving traumatic hemorrhage and airway management skills.

BACKGROUND Training health care providers to manage common life-threatening traumatic injuries is an important endeavor. A fresh perfused cadaveric model with high anatomic and tissue fidelity was developed to assess performance of hemorrhage and airway management skills during a simulated polytrauma scenario. METHODS Fresh human cadavers were obtained within 96 hours of death. Hemorrhage from a right traumatic amputation and left inguinal wound was simulated using cannulation of the right popliteal and left femoral artery, respectively. The thoracic aorta (thoracotomy method) or external iliac arteries (Pfannenstiel method) were used for catheter access points. Lung ventilation to simulate chest rise and fall was achieved using bilateral chest tubes connected to a bag valve mask. Participants underwent a simulated nighttime field care scenario in which they attempted tourniquet placement, direct wound pressure and packing, and endotracheal intubation. RESULTS Twenty-four donors were obtained (58–95 years old; mean, 77). There were 305 total scenarios completed using 23 cadavers (mean, approximately 13 scenarios per cadaver). The cost for acquisition and preparation of donors can be estimated at

A Novel Technique for a Difficult Breech Delivery

3,611 to

Emergency Medicine Resident Shift Work Preferences: A Comparison of Resident Scheduling Preferences and Recommended Schedule Design for Shift Workers

9,399. CONCLUSION This model successfully allowed for the demonstration of hemorrhage and airway management skills with high anatomic and tissue fidelity. For the assessment of critical lifesaving skills that are nondestructive in nature, the use of a fresh perfused cadaveric model is feasible and suitable for evaluation of these procedures.

Development of an Emergency Medicine Simulation Fellowship Consensus Curriculum: Initiative of the Society for Academic Emergency Medicine Simulation Academy

BACKGROUND Breech presentation and delivery are important complications of labor and delivery, which, although dealt with by the emergency physician infrequently, can represent major morbidity and mortality to both the mother and fetus if techniques are not performed correctly. OBJECTIVES We aim to describe a technique for breech delivery that was used successfully when all conventional techniques had failed. To our knowledge, this technique has not been described in previous literature. CASE REPORT A 36-year-old woman presented to an urban emergency department in active labor. The physicians were called to the triage area, and found the patient lying on the floor with a limp, cyanotic-appearing fetus delivered to the level of the mid thorax. The arms and shoulders were delivered successfully, but after all traditional maneuvers to deliver the head were unsuccessful, a novel approach was used successfully and is described in this report. CONCLUSION We have described a novel, seemingly safe, and effective technique to use in breech delivery when traditional techniques have failed.