Lillian L. Emlet

Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer : A pilot feasibility study

Objective:To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. Design:Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview. Setting:Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. Subjects:Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists. Measurements and Main Results:Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient’s code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043). Conclusions:Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units.

Background:Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a “shift” model, both with increased handoffs. Objective:To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments. Design:Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1–2 month periods. Setting:A mixed medical–surgical intensive care unit at a tertiary care academic center. Subjects:Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients. Interventions:Implementation of shift-work schedule, combined with structured sign-out curriculum. Measurements:Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance. Main Results:There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15). Conclusions:A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

ED intensivists and ED intensive care units

a Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY, USA b Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA c Departments of Critical Care Medicine & Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA d Department of Surgery/ Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, NM, USA e Department of Emergency Medicine & Department of Surgery, Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, VA, USA f Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Reintubation in critically ill patients: procedural complications and implications for care

IntroductionIn critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population.MethodsWe performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient’s first and last intubation.ResultsOur registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations.ConclusionIn this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.

Procalcitonin-guided antibiotics in severe sepsis

Subjects 79 adult patients with suspected severe sepsis or septic shock. Intervention All patients had circulating PCT levels drawn daily. In patients randomly assigned to the intervention group, antibiotics were stopped when PCT levels had decreased 90% or more from the initial value (if clinicians agreed) but not before Day 3 (if baseline PCT levels were 1 mg/L). In control patients, clinicians decided on the duration of antibiotic therapy based on empirical rules.

Physician burnout: can we make a difference together?

Expanded abstractCitationWest CP, Dyrbye LN, Rabatin JT, Call TG, Davidson JH, Multari A, Romanski SA, Hellyer JMH, Sloan JA, Shanafelt TF. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174:527–33.BackgroundDespite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem.MethodsObjective: To test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being. Design: A randomized clinical trial of practicing physicians. Additional data were collected on nontrial participants responding to annual surveys timed to coincide with the trial surveys. Setting: Department of Medicine at the Mayo Clinic in Rochester, Minnesota between September 2010 and June 2012. Participants: The study involved 74 practicing physicians in the Department of Medicine and 350 nontrial participants responding to annual surveys. Interventions: The intervention involved 19 biweekly facilitated physician discussion groups incorporating elements of mindfulness, reflection, shared experience, and small-group learning for 9 months. Protected time (1 hour of paid time every other week) for participants was provided by the institution. Outcomes: Meaning in work, empowerment and engagement in work, burnout, symptoms of depression, quality of life, and job satisfaction were assessed using validated metrics.ResultsEmpowerment and engagement at work increased by 5.3 points in the intervention arm vs. a 0.5-point decline in the control arm by 3 months after the study (P = .04), an improvement sustained at 12 months (+5.5 vs. +1.3 points; P = .03). Rates of high depersonalization at 3 months had decreased by 15.5 % in the intervention arm vs. a 0.8 % increase in the control arm (P = .004). This difference was also sustained at 12 months (9.6 % vs. 1.5 % decrease; P = .02). No statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction were seen. In additional comparisons including the nontrial physician cohort, the proportion of participants strongly agreeing that their work was meaningful increased 6.3 % in the study intervention arm but decreased 6.3 % in the study control arm and 13.4 % in the nonstudy cohort (P = .04). Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the trial intervention arm, decreased slightly in the trial control arm, and increased in the nontrial cohort (P = .03, P = .007, and P = .002 for each outcome, respectively).ConclusionsAn intervention for physicians based on a facilitated small-group curriculum improved meaning and engagement in work and reduced depersonalization, with sustained results 12 months after the study.

EM Talk: communication skills training for emergency medicine patients with serious illness

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patients values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.

Early recombinant activated factor VII for intracerebral hemorrhage reduced hematoma growth and mortality, while improving functional outcomes

Subjects: 399 adults age 18 years or older with spontaneous intracerebral hemorrhage documented by CT scanning within 3 hours of onset of symptoms. Exclusion criteria included a score of 3 to 5 on the Glasgow Coma Scale (indicating deep coma); planned surgical evacuation of hematoma within 24 hours after admission; secondary intracerebral hemorrhage related to aneurysm, arteriovenous malformation, trauma, or other causes; known use of oral anticoagulant agents; known thrombocytopenia; history of coagulopathy, acute sepsis, crush injury, or disseminated intravascular coagulation; pregnancy; preexisting disability; and symptomatic thrombotic or vasoocclusive disease within 30 days before the onset of symptoms of intracerebral hemorrhage. Midway through the trial, the last criterion was amended to exclude patients with any history of thrombotic or vaso-occlusive disease.

PAC in FACTT: Time to PAC it in?

The groups had similar baseline characteristics. The rates of death during the first 60 days before discharge home were similar in the PAC and CVC groups (27.4 percent and 26.3 percent, respectively; P=0.69; absolute difference, 1.1 percent; 95 percent confidence interval, -4.4 to 6.6 percent), as were the mean (+/-SE) numbers of both ventilator-free days (13.2+/-0.5 and 13.5+/-0.5; P=0.58) and days not spent in the intensive care unit (12.0+/-0.4 and 12.5+/-0.5; P=0.40) to day 28. PAC-guided therapy did not improve these measures for subgroup of patients in shock at the time of enrollment. There were no significant differences between groups in lung or kidney function, rates of hypotension, ventilator settings, or use of dialysis or vasopressors. Approximately 90 percent of protocol instructions were followed in both groups, with a 1 percent rate of crossover from CVCto PAC-guided therapy. Fluid balance was similar in the two groups, as was the proportion of instructions given for fluid and diuretics. Dobutamine use was uncommon. The PAC group had approximately twice as many catheter-related complications (predominantly arrhythmias), though rates per catheter insertion were similar between groups.

Surgical Critical Care Training for Emergency Physicians: Curriculum Recommendations

Received March 16, 2013; Revised May 28, 2013; Accepted May 2 From the Departments of Critical Care Medicine (Tisherman, Surgery (Tisherman), and Emergency Medicine (Emlet), University burgh, Pittsburgh, PA, Department of Surgery, University of M Ann Arbor, MI (Alam), Department of Surgery, University of M Baltimore, MD (Chiu), Department of Acute Care Surgery, So Hospital/Northshore LIJ Trauma Network, Bay Shore, NY (Gro Department of Surgery, Loyola University, Maywood, IL (Lu Departments of Emergency Medicine and Neurology, Yale U New Haven, CT (Marcolini), and Departments of Surgery and Em Medicine, Virginia Commonwealth University, Richmon (Mayglothling). Correspondence address: Samuel A Tisherman, MD, FACS, Department of Critical Care Medicine, University of Pittsburg 1215, Lillian S Kaufmann Bldg, 3471 Fifth Ave, Pittsburgh, PA email: tishermansa@upmc.edu