Patrick G. Hughes

Home treatment of deep venous thrombosis in the era of new oral anticoagulants.

This is a retrospective cohort study of adults with a primary diagnosis of deep venous thrombosis (DVT) unaccompanied by pulmonary embolism (PE), seen in 4 emergency departments in 2013 and part of 2014. The purpose was to assess the prevalence of home treatment of DVT in the present era of new oral anticoagulants. Among 96 patients with DVT and no PE, 85 (88.5%) were hospitalized and 11 (11.5%) were discharged to home. Most of the patients discharged to home received low-molecular-weight heparin, 9 (81.8%) of 11. None were prescribed new oral anticoagulants. Early discharge in ≤2 days occurred 28 (32.9%) of 85 patients. Most (64.3%) received enoxaparin and/or warfarin at early discharge. Rivaroxaban was prescribed in 7 (25.0%) of those discharged in ≤2 days. We conclude that in some emergency departments, patients with DVT are uncommonly discharged to home even though new oral anticoagulants are available.

Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories.

Incorporating simulation-based medical education techniques is paramount to ongoing training of emergency physicians. Effective procedure laboratories give learners hands-on experience in life-saving procedures they may otherwise not have clinical exposure to and also prevent skill decay. Using procedural education, adult learning theory, deliberate practice, and mastery learning strategies, the authors offer 10 tips to educators for designing an effective emergency medicine procedure laboratory.

Emergency Medicine Residency Boot Camp Curriculum: A Pilot Study

Introduction Establishing a boot camp curriculum is pertinent for emergency medicine (EM) residents in order to develop proficiency in a large scope of procedures and leadership skills. In this article, we describe our program’s EM boot camp curriculum as well as measure the confidence levels of resident physicians through a pre- and post-boot camp survey. Methods We designed a one-month boot camp curriculum with the intention of improving the confidence, procedural performance, leadership, communication and resource management of EM interns. Our curriculum consisted of 12 hours of initial training and culminated in a two-day boot camp. The initial day consisted of clinical skill training and the second day included code drill scenarios followed by interprofessional debriefing. Results Twelve EM interns entered residency with an overall confidence score of 3.2 (1–5 scale) across all surveyed skills. Interns reported the highest pre-survey confidence scores in suturing (4.3) and genitourinary exams (3.9). The lowest pre-survey confidence score was in thoracostomy (2.4). Following the capstone experience, overall confidence scores increased to 4.0. Confidence increased the most in defibrillation and thoracostomy. Additionally, all interns reported post-survey confidence scores of at least 3.0 in all skills, representing an internal anchor of “moderately confident/need guidance at times to perform procedure.” Conclusion At the completion of the boot camp curriculum, EM interns had improvement in self-reported confidence across all surveyed skills and procedures. The described EM boot camp curriculum was effective, feasible and provided a foundation to our trainees during their first month of residency.

Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study

Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: 58.9 ± 8.9 versus post: 72.8 ± 6.1, p = 0.01) and CS total scores (pre: 22.2 ± 6.4 versus post: 29.9 ± 3.4, p = 0.007). Significant differences were noted in airway management, p = 0.008; appropriate cycles of drug/shock-CPR, p = 0.008; left uterine displacement, p = 0.008; and identifying causes of cardiac arrest, p = 0.008. Nonsignificant differences were noted for administration of appropriate drugs/doses, p = 0.074; chest compressions, p = 0.074; bag-mask ventilation before intubation, p = 0.074; and return of spontaneous circulation identification, p = 0.074. Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.

The blindfolded code training exercise

Communication errors are the leading cause of preventable patient harm in medicine. There is little description in the literature of advanced techniques to teach crisis resource management (CRM) communication strategies, or how to improve real‐time ineffective behaviour or habits that may persist despite appropriate behaviour and leadership witnessed in the simulation lab.

Development, Validation, and Implementation of a Medical Judgment Metric:

Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss’s Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen’s Kappa 0.851 to 0.880). Discussion: The MJM demonstrated preliminary evidence of reliability and validity.

Neonatal Resuscitation Program Rolling Refresher: Maintaining Chest Compression Proficiency Through the Use of Simulation-Based Education

Background: Structured training courses have shown to improve patient outcomes; however, guidelines are inconsistently applied in up to 50% of all neonatal resuscitations. This is partly due to the fact that psychomotor skills needed for resuscitation decay within 6 months to a year from the completion of a certification course. Currently, there are no recommendations on how often refresher training should occur to prevent skill decay. Purpose: Improve provider proficiency and confidence in the performance of neonatal resuscitation with a focus on chest compression effectiveness. Methods: The study recruited neonatal intensive care unit providers (n = 25). A simulation-based Neonatal Resuscitation Program (NRP) curriculum was developed and executed. Training sessions were delivered utilizing in situ simulations at varying time intervals. Pre- and postconfidence surveys and practicum skill scores were collected and evaluated by a content expert. Categorical data were summarized by frequency and percentage and tested for distributional equality via Pearson chi-square tests or Fisher exact tests depending on cell sample size distribution. All statistical tests were 2-sided with P < .05 considered statistically significant. Results: Provider overall confidence and rate of chest compressions improved; however, there was no statistically significant difference between groups. Rolling refresher training at varied time intervals did not demonstrate statistically significant differences in chest compression quality among NRP providers. Implications for Practice: Rolling refresher training more frequently than every 6 months may not provide added benefit to NRP providers. Implications for Research: Additional research is needed to determine optimal refresher training frequency to prevent skill decay.

A Pilot Curriculum to Integrate Standardized Patient Simulation into Clinical Pastoral Education

Introduction: We describe a novel means of experiential learning for clinical pastoral care residents using standardized patient (SP) simulations. Methods: A prospective cohort study involving 7 clinical pastoral care residents was performed. All residents underwent 2 verbatim SP sessions and 2 simulation sessions. After all sessions, residents completed a self-evaluation. Faculty completed an evaluation and then provided a debriefing session to all residents. Results: Performance ratings were globally higher on simulated scenarios when compared to the verbatim sessions. Conclusions: More research in the field of pastoral care is needed to validate the learned professional skills that enhance a comprehensive training program through the use of medical simulation, verbatim reports, and clinical pastoral education (CPE) competencies. Medical simulation provides a promising teaching methodology for the training of CPE residents.