Torrey A. Laack

A 1-week simulated internship course helps prepare medical students for transition to residency

Introduction: The transition from medical student to intern is inherently stressful, with potentially negative consequences for both interns and patients. Methods: We describe Internship Boot Camp, an innovative course specifically designed to prepare fourth-year medical students for the transition from medical school to internship. An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns. Results: In March 2007, 12 students participated in the course as an elective in their final year of medical school, and the other 28 students in their class did not. After beginning internship and 5 to 7 months after the completion of Internship Boot Camp, all 40 former students were asked to complete a blinded survey about their preparation for internship. The overall response rate for the survey was 80%. Of responders to an open-ended question about the aspects of medical school training that best prepared them for internship, 89% (8 of 9) of course participants listed “Internship Boot Camp.” The next highest response (“subinternship”) was given by 45% (9 of 20) of nonparticipants and 33% (3 of 9) of course participants. Discussion: Internship Boot Camp is a unique learning environment that is recalled by participants as the most helpful, of all components of their medical school education, in preparation for internship.

Comparison of trauma mortality and estimated cancer mortality from computed tomography during initial evaluation of intermediate-risk trauma patients.

BACKGROUND Computed tomography (CT) is the primary source of nontherapeutic medical radiation exposure. Radiation exposure is associated with an increased risk of cancer mortality. Although the risk of cancer mortality is negligible in comparison with that of trauma mortality in high-risk patients, the balance of risk versus benefit in patients with less severe mechanisms of injury is unknown. METHODS This observational cohort study using a trauma center registry included blunt trauma patients prospectively triaged to an intermediate risk group (level II). Radiation dose was calculated using average dosage for each CT scan. Age-adjusted attributable radiation risk for cancer mortality was calculated using Biological Effects of Ionizing Radiation VII data. RESULTS Six hundred forty-two level II trauma patients were analyzed, with a mean age of 43.8 years and a median Injury Severity Score of 8. Patients received a median radiation effective dose of 24.7 mSv in the first 24 hours of medical evaluation. Higher Injury Severity Score was associated with greater total radiation dose. Of the four deaths, all were 80 years or older with intracranial injuries. The estimated risk of cancer death attributable to CT exposure was 0.1%. CONCLUSIONS The risk of mortality from trauma is six times higher than the estimated risk of radiation-induced cancer mortality in intermediate level trauma patients. The mortality due to trauma is greatest in older patients, suggesting lower clinical suspicion is needed to warrant CT studies in this population. Efforts to reduce radiation exposure to trauma patients should focus on young patients with minor injuries.

Short-term and Long-term Impact of the Central Line Workshop on Resident Clinical Performance During Simulated Central Line Placement

Introduction The Central Line Workshop (CLW) was introduced at our institution to better train residents in safe placement of the central venous catheter (CVC). This study sought to determine if immediate performance improvements from the CLW are sustained 3 months after the training for residents with various levels of experience. Methods Twenty-six emergency medicine residents completed the CLW, which includes online modules and experiential sessions in anatomy, ultrasound, sterile technique, and procedural task training. Demonstration of the synthesis of these skills including placement of both internal jugular and subclavian CVCs was assessed using a task trainer. Each resident was also tested approximately 3 months before and 3 months after the CLW. Residents were assessed using a validated CVC proficiency scale. Results Residents’ CVC proficiency scores (percentage of items performed correctly during the assessment station) improved after CLW (0.6 vs. 0.93, P < 0.05). At 3 months after CLW testing, there was apparent skill decay from the CLW but overall improvement compared with baseline testing (0.6 vs. 0.8, P < 0.05). There was no significant difference in procedure time after CLW training. The postgraduate year 1 group showed the greatest improvement of CVC skill after CLW training. Conclusions Resident CVC placement performance improved immediately after the CLW. Although performance 3 months after the CLW revealed evidence of skill decay, it was improved when compared with initial baseline assessment. Novice learners had the greatest benefit from the CLW.

Ultrasound evaluation of appendicitis: Importance of the 3 × 2 table for outcome reporting

INTRODUCTION Despite a relatively high frequency of appendix nonvisualization when using ultrasound to diagnose appendicitis, many studies either fail to report these results or inconsistently analyze outcomes. OBJECTIVES The objective of this study is to determine the most transparent and accurate way of reporting and analyzing ultrasound results for the diagnosis of appendicitis. METHODS This was an observational cohort study of emergency department patients age 18 years or older who underwent right lower quadrant ultrasonography from September 2010 to October 2011. Patient characteristics, imaging, pathology, and follow-up data were analyzed. Test characteristics were calculated using conventional 2 × 2 contingency table analysis excluding inconclusive ultrasound results and an intention-to-diagnose approach with a 3 × 2 table. RESULTS Sixty-five patients were included. Forty-four (68%) patients had a nonvisualized appendix resulting in an overall diagnostic yield of 32%. Twenty-one patients had a visualized appendix (14 [22%] negative and 7 [11%] positive for appendicitis). Using 2 × 2 contingency table analysis, sensitivity and specificity were 100%. Using the 3 × 2 table with and the intention-to-diagnose principle, sensitivity was 70% and specificity was 25%. Three (7%) of 44 patients with a nonvisualized appendix had appendicitis (likelihood ratio = 0.40). DISCUSSION We suggest reporting ultrasound results using a 3 × 2 table (including nonvisualized findings) but using the traditional 2 × 2 type of analysis for test characteristic calculations. This approach allows for the determination of diagnostic yield and calculation of likelihood ratios when the appendix is not visualized. This approach to reporting should be considered for all types of diagnostic ultrasound studies.

Predictors of medical school clerkship performance: a multispecialty longitudinal analysis of standardized examination scores and clinical assessments

BackgroundEvidence suggests that poor performance on standardized tests before and early in medical school is associated with poor performance on standardized tests later in medical school and beyond. This study aimed to explore relationships between standardized examination scores (before and during medical school) with test and clinical performance across all core clinical clerkships.MethodsWe evaluated characteristics of 435 students at Mayo Medical School (MMS) who matriculated 2000–2009 and for whom undergraduate grade point average, medical college aptitude test (MCAT), medical school standardized tests (United States Medical Licensing Examination [USMLE] 1 and 2; National Board of Medical Examiners [NBME] subject examination), and faculty assessments were available. We assessed the correlation between scores and assessments and determined USMLE 1 cutoffs predictive of poor performance (≤10th percentile) on the NBME examinations. We also compared the mean faculty assessment scores of MMS students vs visiting students, and for the NBME, we determined the percentage of MMS students who scored at or below the tenth percentile of first-time national examinees.ResultsMCAT scores correlated robustly with USMLE 1 and 2, and USMLE 1 and 2 independently predicted NBME scores in all clerkships. USMLE 1 cutoffs corresponding to poor NBME performance ranged from 220 to 223. USMLE 1 scores were similar among MMS and visiting students. For most academic years and clerkships, NBME scores were similar for MMS students vs all first-time examinees.ConclusionsMCAT, USMLE 1 and 2, and subsequent clinical performance parameters were correlated with NBME scores across all core clerkships. Even more interestingly, faculty assessments correlated with NBME scores, affirming patient care as examination preparation. USMLE 1 scores identified students at risk of poor performance on NBME subject examinations, facilitating and supporting implementation of remediation before the clinical years. MMS students were representative of medical students across the nation.

Effect of spinal needle characteristics on measurement of spinal canal opening pressure

Objective: A wide variety of spinal needles are used in clinical practice. Little is currently known regarding the impact of needle length, gauge, and tip type on the needles ability to measure spinal canal opening pressure. This study aimed to investigate the relationship between these factors and the opening‐pressure measurement or time to obtain an opening pressure. Methods: Thirteen distinct spinal needles, chosen to isolate the effects of length, gauge, and needle‐point type, were prospectively tested on a lumbar puncture simulator. The key outcomes were the opening‐pressure measurement and the time required to obtain that measure. Pressures were recorded at 10‐s intervals until 3 consecutive, identical readings were observed. Results: Time to measure opening pressure increased with increasing spinal needle length, increasing gauge, and the Quincke‐type (cutting) point (P < 0.001 for all). The time to measurement ranged from 30 s to 530 s, yet all needle types were able to obtain a consistent opening pressure measure. Conclusion: Although opening pressure estimates are unlikely to vary markedly by needle type, the time required to obtain the measurement increased with increasing needle length and gauge and with Quincke‐type needles.

Multidisciplinary medical simulation: a novel educational approach to preparing radiation oncology residents for oncologic emergent on-call treatments.

Multidisciplinary Medical Simulation: A Novel Educational Approach to Preparing Radiation Oncology Residents for Oncologic Emergent On-Call Treatments Lindsay C. Brown, MD,* Torrey A. Laack, MD,y Daniel J. Ma, MD,* Kenneth R. Olivier, MD,* and Nadia N. Laack, MD* *Department of Radiation Oncology, and yMayo Clinic Multidisciplinary Simulation Center and Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota

Clinical care review systems in healthcare: a systematic review

BackgroundClinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review.MethodsA librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction.ResultsWe found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review.ConclusionWhile guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.

Simulation and lessons learned from the Ebola epidemic

The West African Ebola epidemic that began in 2014 has exposed the vulnerability of medical facilities when a patient presents with a life‐threatening and highly contagious infectious disease. The transmissibility and extremely high morbidity and mortality of Ebola Virus Disease (EVD) make it unique among infectious diseases. This epidemic has specifically been more challenging than prior threats due to the high infection risk of all those in contact, requiring multidisciplinary coordination to minimize risk to other patients, staff and the community. This is not the first time that an epidemic has created a time‐sensitive and complex task for hospitals across North America and the world. Previous epidemics, including novel influenza A/H1N1 in 2009 and Severe Acute Respiratory Syndrome (SARS) in 2003, have demonstrated that there are significant barriers to developing these strategies. Disaster planning and training remains a complex process, and implementation of hospital‐wide plans can be daunting, especially when information and responses need to change daily.

Board #236 - Program Innovation Use of Smulation in the Development of Optimal Workflow for a Newly Remodeled Resuscitation Bay in a Tertiary Care Emergency Department (Submission #8229)

Objectives The use of simulation-based teaching has been shown to be highly successful in implementing skills learned into practice.1-2 Previous literature has demonstrated the ability of simulation to improve teamwork and identify factors inherent to the environment that may inhibit patient care.3-4 Our tertiary care facility is a regional referral center and a level 1 adult and pediatric trauma center with approximately 55,000 adult and 15,000 pediatric emergency department (ED) visits. In April 2013, we began renovation and expansion of our existing pediatric ED and introduced the concept of a separate pediatric only resuscitation room. This was an innovation within our practice and was instituted due to single pediatric provider coverage and a desire for efficiency in staffing of critically ill/injured children without losing sight of overall patient flow. Our ED Renovation Simulation Committee was tasked to utilize simulated patient scenarios in order to identify barriers to treatment and provide recommendations for improvement to the pediatric resuscitation room design and proposed model of care. Description In situ simulation was used to enact medical and traumatic pediatric resuscitations using a multi-disciplinary approach. Both scenarios utilized a high-fidelity pediatric mannequin for patient representation. The two scenarios included the medical resuscitation of a 10-month old with status epilepticus and trauma resuscitation of a 5-year old ejected from a vehicle with left femur fracture and splenic hematoma. The medical resuscitation team included emergency medical services (EMS), a pediatric emergency medicine (EM) attending physician, EM resident, patient nurse, recording nurse, pharmacist, respiratory therapy, radiography technicians and laboratory services. The pediatric level red trauma team included all members listed above and a trauma surgery attending physician, trauma surgery resident, anesthesia, operating room charge nurse and IV transfusion service. For each case, the patient was brought into the room by EMS and a complete history and physical evaluation was performed. Interventions included intraosseous and central venous access, rapid sequence intubation, and acquisition of laboratory and radiologic studies. Following each resuscitation, the teams were debriefed for input. Recommendations were submitted to the ED Renovation Oversight Committee for review. Conclusion The simulations identified the following key aspects to improving spatial dynamics and accessibility of equipment: 1) Ideal bed placement to enhance entry/exit pathways for EMS; 2) Flow of providers into and out of the resuscitation room was identified to be problematic with multiple ancillary services positioned outside a single entrance. Laboratory and IV/transfusion services were moved to the west entrance. Radiology was relocated to the east entrance; 3) During intubation, the video laryngoscope monitor was not easily viewed from its position on the overhead equipment boom. The location of the monitor was adjusted to allow for better visualization; and 4) Following intubation, medication pumps for sedation were not readily available. These were added to the equipment boom to facilitate timely medication administration. The use of simulation during ED renovation identified barriers to efficient and safe patient care allowing improvements to be made prior to actual patient encounters. The ED Renovation Simulation Committee remains active as our expansion continues through 2015. Future directions include development of recommended response for emergency codes within the waiting area, processes for decontamination and ED lockdown. References 1. LaVelle, BA, & McLaughlin, JJ. (2008). Simulation-Based Education Improves Patient Safety in Ambulatory Care. Advances in Patient Patient Safety: New Directions and Alternative Approaches. 2. Pascual, JL, Holena DN, Vella MA. (2011). Short simulation training improves objective skills in established advanced practitioners managing emergencies on the ward and surgical intensive care unit. J Trauma. 71(2):330-7. 3. Frengley, RW, Weller, JM, Torrie J. (2011). The effect of a simulation-based training intervention on the performance of established critical care unit teams. Crit Care Med. 39(12): 2605-11 4. Merien AE, van de Ven J, Mol BW. (2012). Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol. 115(5):1021-31 Disclosures None