Orlando C. Kirton

Implementation of an intern boot camp curriculum to address clinical competencies under the new Accreditation Council for Graduate Medical Education supervision requirements and duty hour restrictions.

IMPORTANCE Todays general surgery interns are faced with increased duty hour restrictions and stringent competency-based supervision milestone requirements (ie, from direct to indirect supervision). Working within these constraints, we instituted a unique 2-month intern curriculum (boot camp) incorporating knowledge-based, experiential, and practical components. OBJECTIVES To describe our curriculum and the effect on resident performance and teaching faculty and nursing staff perceptions. DESIGN All interns underwent a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment. SETTING Integrated general surgery residency program at the University of Connecticut School of Medicine, Farmington. PARTICIPANTS Postgraduate year 1 general surgery categorical and preliminary residents. MAIN OUTCOMES AND MEASURES We used several assessment tools, including an intern boot camp survey, clinical skills assessment scores, intern American Board of Surgeons In-Training Examination scores, and nursing staff and teaching faculty surveys of intern performance and aptitudes compared with the previous years interns. Data were analyzed by independent group t test, χ2 tests of proportions, and Fisher exact test for small sample cross tables. RESULTS In total, 84% (91 of 108) of intern respondents agreed or strongly agreed with the usefulness, relevance, and execution of the boot camp. Compared with the previous years interns, the nursing staff agreed or strongly agreed that the cohort interns were better at patient assessment, collaboration, and effective communication and provided compassionate and respectful patient care. More than 40% (7 of 17) of surveyed teaching faculty agreed or strongly agreed that the cohort interns demonstrated better patient care and procedural skills and self-confidence compared with the previous years interns. The clinical skills assessment scores after the 2-month boot camp paralleled the scores typically seen at the end of the previous 2 internship years (P > .25 for all). The proportion of nondesignated and categorical interns pursuing careers in general surgery scoring in the top quartile on the American Board of Surgery In-Training Examination increased from 7% (2 of 28) to 50% (5 of 10) compared with the previous 2 internship years (P = .01). CONCLUSIONS AND RELEVANCE Recent changes in intern duty hours and supervision rules mandate that residency training programs must institute a competency-oriented curriculum to provide interns with the necessary knowledge and practical skills to attain clinical competence.

What is taught, what is tested: Findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine

Introduction:Addressing an unexpected shortfall of intensivists requires early identification and training of appropriate personnel. The purpose of this study was to determine how U.S. medical students are currently educated and tested on acute care health principles. Hypothesis/Methods:A survey of critical care education with telephone follow-up was mailed to the deans of all 126 medical schools. Web site review of medical school curricula for critical care education was performed. Upon invited request, four members of the Undergraduate Medical Education Committee (UGMEC) reviewed 1,200 pool questions of step II of the U.S. Medical Licensing Examination (USMLE) given to graduating medical students for critical care content. Descriptive statistics are employed. Results:Survey response rate was 49% and 88% by the second mailing with Web site review. Forty-five percent of U.S. medical schools responding had formal undergraduate critical care didactic curricula averaging 12 ± 3 hrs: 60% were elective, 60% taught in the 4th year. Eighty percent of clinical ICU rotations offered were elective. Sixty percent of schools taught 11 key critical care procedures in the 3rd or 4th year; 17% required them to graduate. Nineteen percent of Step II USMLE questions had critical care content; 58% dealt with pulmonary or cardiac disease. Conclusions:Graduating medical students are tested (and licensed accordingly) on critical care knowledge, despite an inconsistent exposure to the discipline in medical school. The UGMEC has drafted competency-based recommendations for acute health care delivery that encourage mandatory didactic and procedural critical care training. The UGMEC recommends that critical care rotations with didactic curricula be required for undergraduate education and that acute care procedural skills be an important component of these curricula.

Warfarin Resistance After Total Gastrectomy and Roux‐en‐Y Esophagojejunostomy

Nutritional deficiencies due to malabsorption occur after major gastric resection, and drugs that are primarily absorbed in the stomach or duodenum also are likely to exhibit decreased absorption. However, we performed a MEDLINE search (1960–2007) and found no evidence in the literature regarding the specific effects of warfarin absorption after total gastrectomy with Roux‐en‐Y gastric bypass procedure. We describe a 71‐year‐old woman receiving warfarin therapy for chronic atrial fibrillation who underwent a completion gastrectomy and Roux‐en‐Y esophagojejunostomy for an invasive adenocarcinoma of her gastric remnant. Before surgery, her international normalized ratio (INR) had been stable in her target range of 2–3 with warfarin 5–6 mg/day. At the time of her admission for the surgery, however, her INR was subtherapeutic at 1.73; warfarin was discontinued, and heparin and, subsequently, enoxaparin were used throughout her admission. After the surgery, the patient was discharged to a skilled nursing facility to continue bridge therapy with enoxaparin while warfarin was restarted and adjusted to a therapeutic INR of 2–3. Three months after discharge, the patient was hospitalized again for shortness of breath and was found to have an INR of 1.30 on admission, despite good compliance with her drugs. During this admission, the patient demonstrated resistance to warfarin therapy, requiring doses up to 20 mg/day to reach a therapeutic INR. To our knowledge, this is the first case report to demonstrate that patients undergoing a complete gastric resection followed by a Roux‐en‐Y gastric bypass procedure may display warfarin resistance. Close monitoring and dosage adjustment may be necessary to maintain therapeutic anticoagulation in these patients.

Effect of a Mandatory Research Requirement on Categorical Resident Academic Productivity in a University-Based General Surgery Residency

BACKGROUND Our general surgery residency (46 residents, graduating 6 categoricals per year) offers the opportunity for 2 categorical residents at the end of their second year to choose a 2-year research track. Academic productivity for the remaining categorical residents was dependent on personal interest and time investment. To increase academic productivity within the residency, a mandatory research requirement was implemented in July 2010. We sought to examine the effect of this annual individual requirement. METHODS The research requirement consisted of several components: a curriculum of monthly research meetings and lectures, assigned faculty to act as research mentors, an online repository of research projects and ideas, statistical support, and a faculty member appointed Director of Research. In July 2010, the requirement was applied to all categorical postgraduate year 1-3 residents and expanded to postgraduate year 1-4 in 2011. The research requirement culminated in an annual research day at the end of the academic year. We compared the number of abstract presentations in local, national, and international meetings between the first 2 years of the research program and the 2 years before it. We also compared the total number of publications between the 2 periods, acknowledging that any differences at this point do not necessarily reflect an effect of the research requirement. RESULTS From July 2008 to June 2010 (Period A), there were 18 podium and poster presentations in local, national, and international meetings, and 30 publications in peer-reviewed journals, whereas between July 2010 and June 2012 (Period B), there were 58 presentations and 32 publications. In Period A 9 of 60 (15%) categorical residents had a podium or poster presentation in comparison with Period B when 23 of 58 (40%) categorical residents had a podium or poster presentation (p < 0.01). CONCLUSION The institution of a mandatory research requirement resulted in a 3-fold increase in scientific presentations in our surgical residency. We believe that the mandatory nature of the program is a key component to its success. We expect to see an increase in the number of publications as a result of this research requirement in the next several years.

Intensive Care Monitoring

Intensive care medicine, as a discipline to treat the most critically ill patients, had its beginnings during the last quarter of the twentieth century. From the beginning, hemodynamic monitoring needs evolved as physicians sought to optimize their patients’ hemodynamic status, provide early intervention, and establish a warning system of impending cardiovascular deterioration, A perennial concern of the intensivist is the adequacy of the systemic circulation.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines.

Introduction: Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment “bundle” may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve “bundle” compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance. Methods: Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered. Results: Individual participants’ pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge. Conclusion: Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.

Optimizing advanced practitioner charge capture in high-acuity surgical intensive care units.

OBJECTIVE To determine the impact of standardized critical care documentation tools on charge capture by intensive care unit (ICU) advanced practitioners (APs). DESIGN Prospective charge capture analysis of AP critical care charges (Current Procedural Terminology codes 99291 or 99292). SETTING Neurosurgical, general surgical, and cardiothoracic ICUs in a level I, 800-bed hospital. The AP provider to patient ratio was 1:6, with 24-hour surgical intensivist oversight. PARTICIPANTS Advanced practice registered nurses and physician assistants in the ICU. INTERVENTIONS Standardized templates were developed to simplify documentation and optimize billing of critical care. All APs participated in comprehensive educational sessions on billing compliance and documentation. MAIN OUTCOME MEASURES Charge capture was collected for 3 years, and comparisons were made between the first quarter before (fiscal year [FY] 2008), during (FY 2009) and after (FY 2010) implementation. The number of ICU patient-days, length of stay, and of beds was collected. RESULTS During the implementation/education phase (FY 2009), there were no differences in charge capture compared with FY 2008. Each unit demonstrated an increase in charge capture after implementation, and an overall increase of 48% for all 3 ICUs was seen. The number of admissions and length of stay were not statistically different. The total number of ICU beds increased from 42 to 45 during the evaluation period. The salary offset for APs increased from 62% to 80%. CONCLUSIONS Advanced practitioners represent an important component of the critical care services provided to patients in high-acuity surgical ICUs. Standardized critical care documentation and comprehensive education on evaluation and management guidelines significantly increased charge capture.

Futility and the acute care surgeon.

Managing medical and surgical futility is a challenging aspect of the practice of the acute care surgeon. Analysis of futility and application of multidisciplinary and interprofessional patient care have the potential to optimize clinical management of patients at the end of life. Review of the vast literature on the topic reveals evolving practices for the management of futility. TheCritical CareCommittee of theAmericanAssociation for the Surgery of Trauma (AAST) was charged with addressing this topic in a luncheon session at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery on September 12, 2014, in Philadelphia, Pennsylvania.We surmised that querying surgeons engaged in the management of trauma and emergency general surgery patients nationally would provide a practical context and framework useful for the individual acute care surgeon. To this end, we created a survey defining the attitudes and practices of acute care surgeons related to medical and surgical futility and end-of-life care in the trauma and emergency general surgery patient populations. The survey was distributed to the membership of the AAST on June 10, 2014, and again on June 30, 2014.Responseswere not linked to individuals, and participation was anonymous and confidential. The results of the survey were the focal point of discussion for the aforementioned luncheon session entitled, ‘‘Death, Dying and Futile Care in the ICU, ED and ORVWhat Have We Learned?’’

Increasing Use of Less-Invasive Hemodynamic Monitoring in 3 Specialty Surgical Intensive Care Units A 5-Year Experience at a Tertiary Medical Center

Introduction: Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). Hypothesis: The decrease in use of PACs is not associated with increased mortality. Methods: Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (β-predominant agonists—dobutamine, epinephrine, and dopamine; vasopressors—norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. Results: There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from β-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). Conclusions: In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.

The Accreditation Council for Graduate Medical Education Duty Hour Regulations: How Do We Make the Best of an Unpopular Situation in Training the Surgeons of Tomorrow?

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