Darlene R. Nelson

Addressing the Interprofessional Collaboration Competencies of the Association of American Medical Colleges: A Systematic Review of Assessment Instruments in Undergraduate Medical Education.

Purpose To summarize characteristics and validity evidence of tools that assess teamwork in undergraduate medical education (UME), and provide recommendations for addressing the interprofessional collaboration competencies of the Association of American Medical Colleges (AAMC). Method The authors conducted a systematic review, searching MEDLINE, MEDLINE In-process, CINAHL, and PsycINFO from January 1, 1979, through April 1, 2014; they searched reference lists and national meeting abstracts. They included original research reports that described a quantitative tool used to assess teamwork in UME. They abstracted characteristics and validity evidence for the tools, plus study quality, according to established frameworks. Two authors independently abstracted 25% of articles and calculated agreement. Authors then applied predefined criteria to identify tools best suited to address the AAMC’s teamwork competencies. Results Of 13,549 citations, 70 articles describing 64 teamwork assessment tools were included. Of these 64 tools, 27 (42%) assessed teamwork in classroom, 31 (48%) in simulation, and only 7 (11%) in actual clinical settings. The majority (47; 73%) of tools assessed medical students’ teamwork in interprofessional teams. On the basis of content concordance, strength of validity evidence, generalizability of scores, and level of outcomes, four published tools were recommended to assess the AAMC’s teamwork competencies: the Collaborative Healthcare Interdisciplinary Relationship Planning Scale, Readiness for Interprofessional Learning Scale, Communication and Teamwork Skills assessment, and Teamwork Mini-Clinical Evaluation Exercise. Conclusions Substantial validity evidence supports the use of several UME teamwork assessments. Four tools have been appropriately designed and sufficiently studied to constitute appropriate assessments of the AAMC’s teamwork competencies.

A Strategy to Reduce Interruptions at Hospital Morning Report

BACKGROUND The learning atmosphere of hospital morning report is frequently interrupted by nonurgent beeper pages to participating residents. INTERVENTION During 176 consecutive internal medicine morning reports, 1 of the 4 chief residents at a single academic medical center collected and answered house staff pages during the 30-minute conference. RESULTS A total of 884 pages were answered during this period. Of these, 743 could wait until after the end of morning report, resulting in more than 4 interruptions averted per session. Over half of the pages were from nursing personnel. There was no significant decrease in the total number of pages or nurse pages during the observation period. DISCUSSION In summary, our simple system of holding intern pages resulted in a dramatic reduction in interruptions during hospital morning report.

Interprofessional collaboration milestones: advocating for common assessment criteria in graduate medical education.

BackgroundMilestone-based assessments of resident physicians inform critical decisions regarding resident competence and advancement. Thus, it is essential that milestone evaluations are based upon strong validity evidence and that consistent evaluation criteria are used across residency programs. A common approach to assessment of interprofessional collaboration milestones is particularly important since standardized measures of individual resident competence in interprofessional collaboration have not been established.DiscussionWe propose that assessments of interprofessional collaboration in graduate medical education meet common criteria, namely, these assessments should: 1) measure competency of an individual resident, 2) occur in the context of an interprofessional team, 3) be ascertained via direct observation of the resident, 4) be performed in a real-world clinical practice setting (such as a hospital ward, outpatient clinic, or operating room). We present the evidence-based rationale for these criteria and cite examples of published assessment instruments that fulfill one or more of the criteria, however further research is needed to ensure fidelity of assessments.SummaryThe proposed criteria may assist residency educators as they endeavor to provide robust and consistent assessments of interprofessional collaboration milestones.

Mindfulness Meditation and Interprofessional Cardiopulmonary Resuscitation: A Mixed-Methods Pilot Study

ABSTRACT Problem: Mindfulness training includes mindfulness meditation, which has been shown to improve both attention and self-awareness. Medical providers in the intensive care unit often deal with difficult situations with strong emotions, life-and-death decisions, and both interpersonal and interprofessional conflicts. The effect of mindfulness meditation training on healthcare providers during acute care tasks such as cardiopulmonary resuscitation remains unknown. Mindfulness meditation has the potential to improve provider well-being and reduce stress in individuals involved in resuscitation teams, which could then translate into better team communication and delivery of care under stress. A better understanding of this process could lead to more effective training approaches, improved team performance, and better patient outcomes. Intervention: All participants were instructed to use a mindfulness meditation device (Muse™ headband) at home for 7 min twice a day or 14 min daily over the 4-week training period. This device uses brainwave sensors to monitor active versus relaxing brain activity and provides real-time feedback. Context: We conducted a single-group pretest–posttest convergent mixed-methods study. We enrolled 24 healthcare providers, comprising 4 interprofessional code teams, including physicians, nurses, respiratory therapists, and pharmacists. Each team participated in a simulation session immediately before and after the mindfulness training period. Each session consisted of two simulated cardiopulmonary arrest scenarios. Both quantitative and qualitative outcomes were assessed. Outcome: The median proportion of participants who used the device as prescribed was 85%. Emotional balance, as measured by the critical positivity ratio, improved significantly from pretraining to posttraining (p = .02). Qualitative findings showed that mindfulness meditation changed how participants responded to work-related stress, including stress in real-code situations. Participants described the value of time for self-guided practice with feedback from the device, which then helped them develop individual approaches to meditation not reliant on the technology. Time measures during the simulated scenarios improved, specifically, time to epinephrine in Scenario 1 (p = .03) and time to defibrillation in Scenario 2 (p = .02), improved. In addition, team performance, such as teamwork (p = .04), task management (p = .01), and overall performance (p = .04), improved significantly after mindfulness meditation training. Physiologic stress (skin conductance) improved but did not reach statistical significance (p = .11). Lessons Learned: Mindfulness meditation practice may improve individual well-being and team function in high-stress clinical environments. Our results may represent a foundation to design larger confirmatory studies.

Methylene Blue for Bronchopleural Fistula Localization

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. BPFs are challenging to diagnose and are associated with a high morbidity and mortality. Sequential balloon occlusion is commonly used for localization of a BPF. We describe our experience with 4 cases of successful localization of the BPF by instillation of methylene blue into the pleural space through a pigtail catheter, with simultaneous bronchoscopic visualization of dye in the tracheobronchial tree. Two patients were treated with endobronchial valves and 3 had a surgical thoracic muscle flap placed.

Paclitaxel-coated balloon dilation for central airway obstruction

Introduction Central airway obstruction (CAO) often requires repeated interventional procedures which offer variable efficacy, a time-limited effect, and have inherent limitations. Paclitaxel has been used to prevent restenosis in blood vessels. The literature describing the use of paclitaxel to prevent recurrent airway stenosis is limited. We sought to describe our experience using a paclitaxel-coated balloon (PCB) for CAO. Material and methods We performed a retrospective review of all patients who underwent PCB airway dilation. We collected: basic demographics, details of the CAO, details of the bronchoscopes used, PCB size, PCB dilation pressure, duration of PCB inflation, concurrent non-PCB interventions, estimated pre- and post-PCB CAO luminal diameter, follow up bronchoscopy date and luminal diameter, and spirometry results. Results PCB dilation was performed in 10 cases on 5 patients. Eight PCB dilations were performed for CAO related to distal airway stent stenosis. Concurrent non-PCB interventions were performed with 6 PCB dilations. Nine cases documented improvements and 1 was unchanged immediately post-PCB dilation. Median luminal diameter pre-PCB dilation was 2 mm. Immediately post-PCB dilation, the median change in luminal diameter was 2 mm. Follow up bronchoscopy information was available for 9 cases. For these 9 cases, luminal diameter was unchanged in 5 and worse in 4 when compared to immediate post-PCB dilation. Conclusion PCB dilation in benign CAO produced a modest effect in this cohort of challenging airways. Larger prospective studies are needed to assess how a PCB would perform when compared to a non-drug coated balloon.

Epithelioid angiosarcoma: A rare cause of pericarditis and pleural effusion

Angiosarcomas are rare cancers accounting for less than 2% of all soft tissue sarcomas. We report the case of an unusual presentation of pleural epithelioid angiosarcoma in a patient with constrictive pericarditis and recurrent pleural effusion. A 62 year old smoker presented with acute chest pain. ECG showed diffuse elevation of ST segments in the precordial leads. After extensive evaluation, he was diagnosed with viral pericarditis and treated with colchicine. Two weeks later the patient presented to the emergency department with a large right pleural effusion. Evaluation of the pleural fluid obtained from a thoracentesis revealed an exudative effusion with negative microbial studies and no evidence of malignant cells. His pleural effusion re-accumulated rapidly, requiring repeated thoracenteses over several weeks. Medical thoracoscopy was performed and pleural biopsy revealed primary pleural epithelioid angiosarcoma. Staging PET scan revealed malignant enhancement of right pleura, pericardium, right iliac bone and right shoulder. He died suddenly within 6 weeks of diagnosis, prior to initiating palliative chemotherapy. Pleural angiosarcoma should be considered in the differential diagnosis of recurrent pleural effusions of unknown etiology. Negative cytology does not rule out the diagnosis; excisional biopsy is required. Reported risk factors include asbestos exposure, prior chest radiation, active smoking and history of complicated pleural tuberculosis. Pleural epithelioid angiosarcomas carry a very poor prognosis, with the majority of patients dying within months of diagnosis.

Comparison of Programmed Death Ligand-1 Immunohistochemical Staining Between Endobronchial Ultrasound Transbronchial Needle Aspiration and Resected Lung Cancer Specimens

Background In advanced non‐small cell lung cancer (NSCLC), small biopsy specimens from endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) are often the only available material from cancer tissue for the analysis of programmed death ligand‐1 (PD‐L1) expression. We aim to assess the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PD‐L1 expression at ≥ 1% and ≥ 50% on EBUS‐TBNA samples compared with their corresponding surgically resected tumor. Methods We retrospectively reviewed all patients who underwent EBUS‐TBNA followed by surgical resection of NSCLC between July 2006 and September 2016. Demographic information and periprocedural/surgical data were collected. The archived specimens were retrieved and assessed for PD‐L1. A positive PD‐L1 stain was defined using two separate cutoff points: ≥ 1% and ≥ 50% of tumor cell positivity. EBUS‐TBNA aspirates were compared with the surgically resected specimen to calculate the sensitivity, specificity, PPV, and NPV. Results Sixty‐one patients were included. For PD‐L1 ≥ 1%, the sensitivity, specificity, PPV, and NPV were 72%, 100%, 100%, and 80%, respectively. For PD‐L1 ≥ 50%, the sensitivity, specificity, PPV, and NPV were 47%, 93%, 70%, and 84%, respectively. The concordance rates for PD‐L1 ≥ 1% and ≥ 50% were 87% and 82%, respectively. Conclusions A PD‐L1 cutoff of ≥ 1% on EBUS‐TBNA has a strong correlation with resected tumor specimen. For PD‐L1 ≥ 50%, there is a significant decrease in the sensitivity and PPV of EBUS‐TBNA specimen when compared with resected tumor. When analyzing for PD‐L1 expression using a cutoff of ≥ 50%, EBUS‐TBNA specimens may misclassify the status of PD‐L1.

Pulmonary Hemorrhage Treated With Oxidized Regenerated Cellulose

amine drip at 5mcg/kg was initiated. The patient was awake, though confused. He was transferred to the intensive care unit for further monitoring. The complete heart block resolved 2 hours after the procedure. No significant elevation in troponin levels were noted. A repeat echocardiogram did not demonstrate any new changes. Pathologic review of the biopsies revealed squamous cell carcinoma of the lung and the patient was initiated on chemotherapy after discharge.

Pleural fluid infection caused by Dietzia cinnamea

Dietzia cinnamea was recovered from pleural fluid in an immunocompromised patient by inoculating blood culture bottles and was identified with matrix-assisted laser desorption ionization-time-of-flight mass spectrometry. The case shows the expanding ability of microbiology laboratories to identify rare organisms through newer techniques and technology.