William F. Dunn

Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: A randomized controlled trial

Objective:To evaluate a mastery learning, simulation-based curriculum for laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair. Background:Clinically relevant benefits from improvements in operative performance, time, and errors after simulation-based training are not clearly established. Methods:After performing a baseline TEP in the OR, general surgery residents randomized to mastery learning (ML) or standard practice (SP) were reassessed during subsequent TEPs. The ML curriculum involved Web-based modules followed by training on a TEP simulator until expert performance was achieved. Operative time, performance, and patient outcomes adjusted for staff, resident participation, difficulty of repair, PGY-level, and patient comorbidities were compared between groups with mixed effects-ANOVA and generalized linear models. Results:Fifty residents (PGY1-5) performed 219 TEP repairs on 146 patients. Baseline operative time, performance, and demographics were similar between groups. To achieve mastery, ML-residents (n = 26) required a median of 16 (range 7–27) simulated repairs. After training, TEPs performed by ML-residents were faster than those by SP-residents, with time corrected for participation (mean ± SD, 34 ± 8 minutes vs. 48 ± 14 minutes; difference –13; 95%CI, –18 to –8; P < 0.001). Operative performance scores (GOALS, scale 6–30) were better for ML residents (21.9 ± 2.8 vs. 18.3 ± 3.8; P = 0.001). Intraoperative complications (peritoneal tear, procedure conversion), postoperative complications (urinary retention, seroma), and need for overnight stay were less likely in the ML group (adjusted odds ratios 0.14, 0.04, and 0, respectively; all P < 0.05). Conclusions:A simulation-based ML curriculum decreased operative time, improved trainee performance, and decreased intra- and postoperative complications and overnight stays after laparoscopic TEP inguinal hernia repair. ClinicalTrials.gov Identifier: NCT01085500

Evaluating the Impact of Simulation on Translational Patient Outcomes

Introduction: A long and rich research legacy shows that under the right conditions, simulation-based medical education (SBME) is a powerful intervention to increase medical learner competence. SBME translational science demonstrates that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3). Method: This is a qualitative synthesis of SBME translational science research (TSR) that employs a critical review approach to literature aggregation. Results: Evidence from SBME and health services research programs that are thematic, sustained, and cumulative shows that measured outcomes can be achieved at T1, T2, and T3 levels. There is also evidence that SBME TSR can yield a favorable return on financial investment and contributes to long-term retention of acquired clinical skills. The review identifies best practices in SBME TSR, presents challenges and critical gaps in the field, and sets forth a TSR agenda for SBME. Conclusions: Rigorous SBME TSR can contribute to better patient care and improved patient safety. Consensus conference outcomes and recommendations should be presented and used judiciously.

The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.

Purpose: To develop and evaluate a participant rating scale for assessing high performance teamwork skills in simulation medicine settings. Methods: In all, 107 participants in crisis resource management (CRM) training in a multidisciplinary medical simulation center generated 273 ratings of key CRM skills after participating in two or three simulation exercises. These data were analyzed using Rasch and traditional psychometric approaches to develop the 16-item Mayo High Performance Teamwork Scale (MHPTS). Sensitivity to change as a result CRM training was also evaluated. Results: The MHPTS showed satisfactory internal consistency and construct validity by Rasch (person reliability = 0.77; person separation = 1.85; item reliability = 0.96; item separation = 5.04) and traditional psychometric (Cronbach’s alpha = 0.85) indicators. The scale demonstrated sensitivity to change as a result of CRM training (pretraining mean = 21.44 versus first posttraining rating mean = 24.37; paired t = −4.15, P < 0.0001; first posttraining mean = 24.63 versus second posttraining mean = 26.83; paired t = −4.31 P < 0.0001). Conclusions: The MHPTS provides a brief, reliable, practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team. Further evaluation of validity and appropriateness in other simulation and medical settings is desirable.

Human Immunodeficiency Virus Infection and Pulmonary Hypertension: Two New Cases and a Review of 86 Reported Cases

In this article, we describe pulmonary hypertension in two men (31 and 43 years of age) with human immunodeficiency virus (HIV) infection who were examined at Mayo Clinic Rochester. Among 88 reported cases (including the two current ones) of HIV- or acquired immunodeficiency syndrome (AIDS)-associated pulmonary hypertension, 61% were male; the age range was 2 to 56 years (mean, 32). Dyspnea was the usual initial symptom. Of the 74 patients in whom pulmonary artery pressure was recorded or calculated by echocardiography, systolic pressures ranged from 49 to 118 mm Hg (mean, 68). Of the 33 cases in which lung tissue was evaluated microscopically, 28 (85%) were of the plexogenic variant of pulmonary arterial hypertension. Of the other five cases examined histologically, three consisted of thrombotic pulmonary arteriopathy (one was due to recurrent thromboembolism, and the other two were due to in situ thrombosis), and two were of pulmonary venoocclusive disease. No correlation existed between either CD4 counts or a history of pulmonary infections and the development of pulmonary hypertension. In 15 of the 88 patients (17%), confounding factors for hypertensive pulmonary vascular disease were present, including coexisting liver disease in 13 and coagulation abnormalities in 2. In 83% of the patients, the development of pulmonary hypertension seems to have been related primarily to the chronic HIV infection. Pulmonary hypertension was more rapidly progressive in patients with HIV or AIDS than in those with primary pulmonary hypertension; the reported time intervals between onset of symptoms and diagnosis were 6 months and 30 months, respectively. The 1-year survival rate for patients with HIV and pulmonary hypertension was 51%, based on the follow-up data compiled from the 63 patients in whom it was described; this compares with a 1-year survival rate of 68% for patients with primary pulmonary hypertension. Death was considered a direct consequence of pulmonary hypertension in 29 (76%) of the 38 fatal cases.

Simulation-Based Objective Assessment Discerns Clinical Proficiency in Central Line Placement : A Construct Validation

BACKGROUND Central venous catheterization (CVC) is associated with patient risks known to be inversely related to clinician experience. We developed and evaluated a performance assessment tool for use in a simulation-based central line workshop. We hypothesized that instrument scores would discriminate between less experienced and more experienced clinicians. METHODS Participants included trainees enrolled in an institutionally mandated CVC workshop and a convenience sample of faculty attending physicians. The workshop integrated several experiential learning techniques, including practice on cadavers and part-task trainers. A group of clinical and education experts developed a 15-point CVC Proficiency Scale using national and institutional guidelines. After the workshop, participants completed a certification exercise in which they independently performed a CVC in a part-task trainer. Two authors reviewed videotapes of the certification exercise to rate performance using the CVC Proficiency Scale. Participants were grouped by self-reported CVC experience. RESULTS One hundred and five participants (92 trainees and 13 attending physicians) participated. Interrater reliability on a subset of 40 videos was 0.71, and Cronbach a was 0.81. The CVC Proficiency Scale Composite score varied significantly by experience: mean of 85%, median of 87% (range 47%-100%) for low experience (0-1 CVCs in the last 2 years, n = 27); mean of 88%, median of 87% (range 60%-100%) for moderate experience (2-49 CVCs, n = 62); and mean of 94%, median of 93% (range 73%-100%) for high experience (> 49 CVCs, n = 16) (P = .02, comparing low and high experience). CONCLUSIONS Evidence from multiple sources, including appropriate content, high interrater and internal consistency reliability, and confirmation of hypothesized relations to other variables, supports the validity of using scores from this 15-item scale for assessing trainee proficiency following a central line workshop.

Staging Systems of Lung Cancer

The staging of lung cancer involves assessment of the anatomic extent of disease based on the best available data. Such a definition of neoplastic burden facilitates the systematic analysis and meaningful communication of diagnostic, therapeutic, and prognostic information. Clinical staging involves the best estimate of extent of disease before performance of surgical resection or biopsy procedures (or both). Surgical-pathologic staging is based on the histopathologic analysis of resected specimens, including determining the extent of local and regional disease. During the past 50 years, two major classification schemes for staging of lung cancer have evolved--one for non-small-cell lung cancers (the TNM system, indicating the status of primary tumor [T], regional lymph node [N], and metastatic [M] involvement) and the other for small-cell carcinoma of the lung (based on limited versus extensive disease). In this report, we review the evolution of the current staging systems used for primary lung cancer and their prognostic implications.

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.

Medical errors and poor communication.

S William Osler is correctly regarded as the foremost medical educator of the late 19th and early 20th centuries, but like all of us, he too was subject to human foibles and the “thinking of the era in which he lived.” In this well-known quotation on medical communication, he is almost certainly wrong, as viewed from our current perspective on the importance of carefully choreographed clinical teamwork in the management of critically ill patients. In this issue of CHEST (see page 1475) Hess et al 1

Diagnosing Ventilator-Associated Pneumonia: The Role of Bronchoscopy

OBJECTIVE To discuss the two diagnostic procedures used most frequently to obtain uncontaminated lower airway secretions during bronchoscopy. DESIGN This article reviews the contributing risk factors of ventilator-associated pneumonia (VAP) and the recent studies that have assessed the usefulness of the protected specimen brush (PSB) and bronchoalveolar lavage (BAL) in the nonimmunocompromised host. RESULTS A prompt, accurate diagnosis of VAP, including specific identification of the bacterial pathogen, remains a common challenge in the intensive-care unit. Standard clinical criteria are of suboptimal specificity for making decisions, including selecting antibiotic therapy. Bronchoscopic techniques of lung secretion sampling can be used in the intensive-care unit in an effort to overcome the effects of oropharyngeal contamination. The PSB and BAL, used appropriately, can help intensive-care clinicians formulate specific antimicrobial therapy. Evaluation of intracellular bacteria obtained by BAL has been reported to be useful in guiding empiric antibiotic therapy while the final results of cultures obtained with the PSB are pending. Prior antibiotic therapy, however, may confound the interpretation and clinical utility of results. CONCLUSION Currently, for a patient taking antibiotic therapy, no reliable technique nor quantitative culture threshold exists to help in diagnosing suspected VAP or in guiding antibiotic therapy. If the clinical situation allows, antibiotic therapy should be discontinued for 48 hours; then, the PSB, BAL, protected BAL, or endobronchial aspiration should be used. These contemporary modalities, however, necessitate further clinical trials before widespread use is warranted.

Changing Culture: A New View of Human Error and Patient Safety

Editorials Financial/nonfi nancial disclosures: The author has reported to the CHEST the following confl ict of interest: Dr Curtis receives research funding from the National Institutes of Health (National Institute of Nursing Research and National Heart Lung and Blood Institute). Dr Curtis is also the President of the American Thoracic Society. Correspondence to: J. Randall Curtis, MD, MPH, FCCP, Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Box 359762, 325 Ninth Ave, Seattle, WA 98104-2499; e-mail: jrc@u.washington.edu