Paul F. Currier

Augmenting Communication and Decision Making in the Intensive Care Unit with a Cardiopulmonary Resuscitation Video Decision Support Tool: A Temporal Intervention Study

OBJECTIVE Effective communication between intensive care unit (ICU) providers and families is crucial given the complexity of decisions made regarding goals of therapy. Using video images to supplement medical discussions is an innovative process to standardize and improve communication. In this six-month, quasi-experimental, pre-post intervention study we investigated the impact of a cardiopulmonary resuscitation (CPR) video decision support tool upon knowledge about CPR among surrogate decision makers for critically ill adults. METHODS We interviewed surrogate decision makers for patients aged 50 and over, using a structured questionnaire that included a four-question CPR knowledge assessment similar to those used in previous studies. Surrogates in the post-intervention arm viewed a three-minute video decision support tool about CPR before completing the knowledge assessment and completed questions about perceived value of the video. RESULTS We recruited 23 surrogates during the first three months (pre-intervention arm) and 27 surrogates during the latter three months of the study (post-intervention arm). Surrogates viewing the video had more knowledge about CPR (p=0.008); average scores were 2.0 (SD 1.1) and 2.9 (SD 1.2) (out of a total of 4) in pre-intervention and post-intervention arms. Surrogates who viewed the video were comfortable with its content (81% very) and 81% would recommend the video. CPR preferences for patients at the time of ICU discharge/death were distributed as follows: pre-intervention: full code 78%, DNR 22%; post-intervention: full code 59%, DNR 41% (p=0.23).

Online learning and clinical procedures: rapid development and effective deployment of game-like interactive simulations

Traditionally, medical education has used live patients to teach medical procedures. This carries a significant risk to patients. As learning technology advances, the early integration of computer-aided medical simulations into medical training before patient contact is becoming an ethical imperative, yet development costs are constraining. In this paper, we describe the use of a gaming engine to create rapidly a game-like interactive simulation for medical training at a low cost. Our process model, driven by the simulation storyboard provided by the instructors, allows for easy simulation refinements and permits an early evaluation of the educational outcome. We also describe its initial integration into the existing matrix of low-tech simulation (procedures practiced on mannequins) and an educational platform (e-learning system) used to support and track novice physicians within a large academic training center.

Faculty staff-guided versus self-guided ultrasound training for internal medicine residents

Ultrasonography is of growing importance within internal medicine (IM), but the optimal method of training doctors to use it is uncertain. In this study, the authors provide the first objective comparison of two approaches to training IM residents in ultrasonography.

Surfactant protein-B polymorphisms and mortality in the acute respiratory distress syndrome

Objective:To determine whether polymorphisms of the surfactant protein B gene may be associated with increased mortality in patients with the acute respiratory distress syndrome. Design:A prospective cohort study. Setting:Four adult intensive care units at a tertiary academic medical center. Patients:Two hundred fourteen white patients who had met criteria for acute respiratory distress syndrome. Interventions:None. Measurements and Main Results:Patients were genotyped for a variable nuclear tandem repeat polymorphism in intron 4 of the surfactant protein B gene and the surfactant protein B gene +1580 polymorphism. For the variable nuclear tandem repeat surfactant protein B gene polymorphism, patients were found to have either a homozygous wild-type genotype or a variant genotype consisting of either a heterozygous insertion or deletion polymorphism. Logistic regression was performed to analyze the relationship of the polymorphisms to mortality in patients with acute respiratory distress syndrome. In multivariate analysis, the presence of variable nuclear tandem repeat surfactant protein B gene polymorphism was associated with a 3.51 greater odds of death at 60 days in patients with acute respiratory distress syndrome as compared to those patients with the wild-type genotype (95% confidence interval 1.39–8.88, p = 0.008). There was no association found between the +1580 variant and outcome (p = 0.15). Conclusions:In this study, the variable nuclear tandem repeat surfactant protein B gene polymorphism in intron 4 is associated with an increased 60 day mortality in acute respiratory distress syndrome after adjusting for age, severity of illness, and other potential confounders. Additional studies in other populations are needed to confirm this finding.

Assessment of satisfaction with care among family members of survivors in a neuroscience intensive care unit.

ABSTRACT Many prior nursing studies regarding family members specifically of neuroscience intensive care unit (neuro-ICU) patients have focused on identifying their primary needs. A concept related to identifying these needs and assessing whether they have been met is determining whether families explicitly report satisfaction with the care that both they and their loved ones have received. The objective of this study was to explore family satisfaction with care in an academic neuro-ICU and compare results with concurrent data from the same hospital’s medical ICU (MICU). Over 38 days, we administered the Family Satisfaction-ICU instrument to neuro-ICU and MICU patients’ families at the time of ICU discharge. Those whose loved ones passed away during ICU admission were excluded. When asked about the respect and compassion that they received from staff, 76.3% (95% CI [66.5, 86.1]) of neuro-ICU families were completely satisfied, as opposed to 92.7% in the MICU (95% CI [84.4, 101.0], p = .04). Respondents were less likely to be completely satisfied with the courtesy of staff if they reported participation in zero formal family meeting. Less than 60% of neuro-ICU families were completely satisfied by (1) frequency of physician communication, (2) inclusion and (3) support during decision making, and (4) control over the care of their loved ones. Parents of patients were more likely than other relatives to feel very included and supported in the decision-making process. Future studies may focus on evaluating strategies for neuro-ICU nurses and physicians to provide better decision-making support and to implement more frequent family meetings even for those patients who may not seem medically or socially complicated to the team. Determining satisfaction with care for those families whose loved ones passed away during their neuro-ICU admission is another potential avenue for future investigation.

Anxiety and depression symptoms among families of adult intensive care unit survivors immediately following brief length of stay

PURPOSE Prior studies of anxiety and depression among families of intensive care unit patients excluded those admitted for less than 2 days. We hypothesized that families of surviving patients with length of stay less than 2 days would have similar prevalence of anxiety and depression compared with those admitted for longer. MATERIALS AND METHODS One hundred six family members in the neurosciences and medical intensive care units at a university hospital completed the Hospital Anxiety and Depression Scale at discharge. RESULTS The 106 participants represented a response rate of 63.9% among those who received surveys. Fifty-eight surveys (54.7%) were from relatives of patients who were discharged within 2 days of admission, whereas 48 (45.3%) were from those admitted for longer. No difference in anxiety was detected; prevalence was 20.7% (95% confidence interval, 10.4) among shorter stay families and 8.3% (7.8) among longer stay families (P = .10). No difference was also seen with depression; prevalence was 8.6% (7.2) among shorter stay families and 4.2% (5.7) among longer stay families (P = .45). CONCLUSIONS Families of surviving patients with brief length of stay may have similar prevalence of anxiety and depression at discharge to those with longer length of stay.

Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement: A Randomized Controlled Trial.

Background Simulation training may improve proficiency at and reduce complications from central venous catheter (CVC) placement, but the scope of simulation’s effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes. Methods Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns’ performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees. Results We observed 52 interns placing 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (P = 0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores, or complication rates. Conclusions Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.

The association between physician turnover (the “July Effect”) and survival after in-hospital cardiac arrest

IMPORTANCE The July Effect refers to adverse outcomes that occur as a result of turnover of the physician workforce in teaching hospitals during the month of June. OBJECTIVE As a surrogate for physician turnover, we used a multivariable difference-in-difference approach to determine if there was a difference in outcomes between May and July in teaching versus non-teaching hospitals. DESIGN We used prospectively collected observational data from United States hospitals participating in the Get With The Guidelines®-Resuscitation registry. Participants were adults with index in-hospital cardiac arrest between 2005-2014. They were a priori divided by location of arrest (general medical/surgical ward, intensive care unit, emergency department). The primary outcome was survival to hospital discharge. Secondary outcomes included neurological outcome at discharge, return of spontaneous circulation, and several process measures. RESULTS We analyzed 16,328 patients in intensive care units, 11,275 in general medical/surgical wards and 3790 in emergency departments. Patient characteristics were similar between May and July in both teaching and non-teaching hospitals. The models for intensive care unit patients indicated the presence of a July Effect with the difference-in-difference ranging between 1.9-3.1%, which reached statistical significance (p<0.05) in all but one model (p=0.07). Visual inspection of monthly survival curves did not show a discernible trend, and no July Effect was observed for return of spontaneous circulation, neurological outcome or process measures except for airway confirmation in the intensive care unit. We found no July Effect for survival in emergency departments or general medical/surgical wards (p>0.20 for all models). CONCLUSIONS There may be a July Effect in the intensive care unit but the results were mixed. Most survival models showed a statistically significant difference but this was not supported by the secondary analyses of return of spontaneous circulation and neurological outcome. We found no July Effect in the emergency department or the medical/surgical ward for patients with in-hospital cardiac arrest.

How we implemented a resident-led medical simulation curriculum in a large internal medicine residency program

Abstract Mannequin-based simulation in graduate medical education has gained widespread acceptance. Its use in non-procedural training within internal medicine (IM) remains scant, possibly due to the logistical barriers to implementation of simulation curricula in large residency programs. We report the Massachusetts General Hospital Department of Medicine’s scale-up of a voluntary pilot program to a mandatory longitudinal simulation curriculum in a large IM residency program (n = 54). We utilized an eight-case curriculum implemented over the first four months of the academic year. An intensive care unit curriculum was piloted in the spring. In order to administer a comprehensive curriculum in a large residency program where faculty resources are limited, thirty second-year and third-year residents served as session facilitators and two senior residents served as chairpersons of the program. Post-session anonymous survey revealed high learner satisfaction scores for the mandatory program, similar to those of the voluntary pilot program. Most interns believed the sessions should continue to be mandatory. Utilizing residents as volunteer facilitators and program leaders allowed the implementation of a well-received mandatory simulation program in a large IM residency program and facilitated program sustainability.

How can we best use electronic data to find and treat the critically ill

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