Sharon Muret-Wagstaff

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Objective:To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. Background:Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. Methods:A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. Results:A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. Conclusions:A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

Can Falls on Stairs Result in Small Intestine Perforations

Objective. Abusive parents often report that a fall on stairs resulted in their childrens injuries. This review explores whether there is any evidence in the medical literature that a fall on stairs could be a plausible explanation for a small intestine perforation. Methodology. The English-language medical literature was searched by Medline, for a 29-year period (1970–1998), for reports of the types of injuries sustained in falls on stairs and for reports of the types of blunt abdominal trauma that result in small intestine perforations. Articles that exclusively focused on infant walker injuries or the elderly were excluded. Duodenal, jejunal, and ileal perforations were included, whereas intestinal hematomas and undescribed intestinal injuries were excluded. All types of injuries to the stomach, colon, and rectum were excluded. Results. Falls on stairs were not reported to be a cause for any of the 312 cases of small intestine perforations reviewed. There were no reports of any intraabdominal injuries, including small intestine perforations, in any of the 677 cases of falls on stairs reviewed. Falls on stairs rarely resulted in any type of truncal injury. Conclusions. Although falls on stairs have been reported to be the most common cause of injury in childhood, no evidence was found to support the contention that an unobstructed fall on stairs could be consistent with perforation of the small intestine.

Pediatric Hospitalists: Report of a Leadership Conference

OBJECTIVES. To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field. METHODS. The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed. RESULTS. More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees. CONCLUSIONS. Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Simulation-based assessment to identify critical gaps in safe anesthesia resident performance.

Background:Valid methods are needed to identify anesthesia resident performance gaps early in training. However, many assessment tools in medicine have not been properly validated. The authors designed and tested use of a behaviorally anchored scale, as part of a multiscenario simulation-based assessment system, to identify high- and low-performing residents with regard to domains of greatest concern to expert anesthesiology faculty. Methods:An expert faculty panel derived five key behavioral domains of interest by using a Delphi process (1) Synthesizes information to formulate a clear anesthetic plan; (2) Implements a plan based on changing conditions; (3) Demonstrates effective interpersonal and communication skills with patients and staff; (4) Identifies ways to improve performance; and (5) Recognizes own limits. Seven simulation scenarios spanning pre-to-postoperative encounters were used to assess performances of 22 first-year residents and 8 fellows from two institutions. Two of 10 trained faculty raters blinded to trainee program and training level scored each performance independently by using a behaviorally anchored rating scale. Residents, fellows, facilitators, and raters completed surveys. Results:Evidence supporting the reliability and validity of the assessment scores was procured, including a high generalizability coefficient (&rgr;2 = 0.81) and expected performance differences between first-year resident and fellow participants. A majority of trainees, facilitators, and raters judged the assessment to be useful, realistic, and representative of critical skills required for safe practice. Conclusion:The study provides initial evidence to support the validity of a simulation-based performance assessment system for identifying critical gaps in safe anesthesia resident performance early in training.

Impact of a Hospitalist System on Length of Stay and Cost for Children With Common Conditions

OBJECTIVE. This study examined mechanisms of efficiency in a managed care hospitalist system on length of stay and total costs for common pediatric conditions. PATIENTS AND METHODS. We conducted a retrospective cohort study (October 1993 to July 1998) of patients in a not-for-profit staff model (HMO 1) and a non–staff-model (HMO 2) managed care organization at a freestanding childrens hospital. HMO 1 introduced a hospitalist system for patients in October 1996. Patients were included if they had 1 of 3 common diagnoses: asthma, dehydration, or viral illness. Linear regression models examining length-of-stay–specific costs for prehospitalist and posthospitalist systems were built. Distribution of length of stay for each diagnosis before and after the system change in both study groups was calculated. Interrupted time series analysis tested whether changes in the trends of length of stay and total costs occurred after implementation of the hospitalist system by HMO1 (HMO 2 as comparison group) for all 3 diagnoses combined. RESULTS. A total of 1970 patients with 1 of the 3 study conditions were cared for in HMO 1, and 1001 in HMO 2. After the hospitalist system was introduced in HMO 1, length of stay was reduced by 0.23 days (13%) for asthma and 0.19 days (11%) for dehydration; there was no difference for patients with viral illness. The largest relative reduction in length of stay occurred in patients with a shorter length of stay whose hospitalizations were reduced from 2 days to 1 day. This shift resulted in an average cost-per-case reduction of

Notifying emergency department patients of negative test results: pitfalls of passive communication.

105.51 (9.3%) for patients with asthma and

Inspiring careers in STEM and healthcare fields through medical simulation embedded in high school science education

86.22 (7.8%) for patients with dehydration. During the same period, length of stay and total cost rose in HMO 2. CONCLUSIONS. Introduction of a hospitalist system in one health maintenance organization resulted in earlier discharges and reduced costs for children with asthma and dehydration compared with another one, with the largest reductions occurring in reducing some 2-day hospitalizations to 1 day. These findings suggest that hospitalists can increase efficiency and reduce costs for children with common pediatric conditions.

Are we closing the gap in faculty development needs for feedback training

Objective Many emergency departments that perform a high volume of group A Streptococcus throat cultures inform patients or parents that unless they are notified of a positive result they can assume that their throat culture result is negative. Thus, positive throat culture results are communicated actively and negative results are communicated passively. We sought to determine the effectiveness and safety of such a system. Methods Prospective cohort study of 301 consecutive patients who had group A Streptococcus throat cultures obtained between March 28, 2000, and May 10, 2000, in the emergency department of an urban, academic, tertiary-care children’s hospital. Outcomes were determined by telephone surveys of patients or their parents or guardians. The primary outcome was whether respondents had accurate knowledge of the throat culture result. Secondary outcomes included receipt of appropriate treatment instructions, need for another telephone call to the emergency department or primary-care provider to clarify the result or treatment instructions, satisfaction with the communication process, and preference to receive both positive and negative results or just positive results. Results Fifty-three percent of respondents did not have accurate knowledge of the throat culture result, 5% received inappropriate treatment instructions, 13% sought further clarification, 29% were dissatisfied with the communication process, and 85% preferred to receive both positive and negative results. Parents of patients with positive results were more likely to have accurate knowledge of the result (odds ratio 6.9, 95% confidence interval 1.4-65.7) and to be satisfied with the communication process. Conclusions Passive communication of negative throat culture results to patients seen in the emergency department can be unreliable. Active communication of both positive and negative results may improve patient knowledge and satisfaction and ensure appropriate therapy, but in the absence of automated notification systems, would be resource intensive.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes

The most effective ways to promote learning and inspire careers related to science, technology, engineering, and mathematics (STEM) remain elusive. To address this gap, we reviewed the literature and designed and implemented a high-fidelity, medical simulation-based Harvard Medical School MEDscience course, which was integrated into high school science classes through collaboration between medical school and K-12 faculty. The design was based largely on the literature on concepts and mechanisms of self-efficacy. A structured telephone survey was conducted with 30 program alumni from the inaugural school who were no longer in high school. Near-term effects, enduring effects, contextual considerations, and diffusion and dissemination were queried. Students reported high incoming attitudes toward STEM education and careers, and these attitudes showed before versus after gains (P < .05). Students in this modest sample overwhelmingly attributed elevated and enduring levels of impact on their interest and confidence in pursuing a science or healthcare-related career to the program. Additionally, 63% subsequently took additional science or health courses, 73% participated in a job or educational experience that was science related during high school, and 97% went on to college. Four of every five program graduates cited a health-related college major, and 83% offered their strongest recommendation of the program to others. Further study and evaluation of simulation-based experiences that capitalize on informal, naturalistic learning and promote self-efficacy are warranted.

Leading Departmental Change to Advance Perioperative Quality

STUDY OBJECTIVE To determine needs, adequacy, types of resources, and challenges in teaching faculty how to provide feedback to residents. DESIGN Survey instrument. SETTING Academic medical center. PARTICIPANTS Of the 115 anesthesia residency program directors surveyed, 69 responses were received (60% response rate). MEASUREMENTS Percentages of respondents who indicated categories of need, adequacy, and types of resources for teaching faculty to give feedback to residents were recorded, as were narrative descriptions of challenges confronted by respondents. MAIN RESULTS While the percentage of programs with faculty development resources has increased from 20.2% in 1999 to 48% today, an overwhelming majority of program directors (90%) feel that faculty require more training in providing feedback to residents. The majority of program directors also want more resources to train their faculty in providing feedback. CONCLUSIONS While the perceived gap in providing training for faculty in giving feedback to anesthesia residents has narrowed, program director responses suggest a substantial unmet need remains. Innovative new approaches are in order.