The Impact of Chronic Disease on the Corrected QT (QTc) Value in Women in a British Columbia First Nations Population.

BACKGROUND: Indigenous women have higher rates of chronic disease than Indigenous men and non-Indigenous women. Long QT syndrome (LQTS) can be inherited or acquired; the latter may occur with chronic disease. A prolonged corrected QT value (QTc) is an independent risk factor for ventricular arrhythmias and sudden death, but few studies have quantified the impact of chronic disease on the QTc. We assessed the association between chronic disease and QTc prolongation in a population of First Nations women previously ascertained to study a high rate of inherited LQTS due to a unique genetic (founder) variant in their community. METHODS: This substudy focusing on women expands on the original research where patients with clinical features of LQTS and their relatives were assessed for genetic variants discovered to affect the QTc. Medical records were retrospectively reviewed and chronic diseases documented. Using multivariate linear regression, adjusting for the effect of genetic variants, age, and QTc-prolonging medications, we evaluated the association between chronic disease and the QTc. RESULTS: In total, 275 women were included. After adjustments, a prolonged QTc was associated with coronary artery disease (26.5 ms, 95% confidence interval [CI] 9.0-44.1 ms; P = 0.003), conduction system disease (26.8 ms, 95% CI 2.2-51.4 ms; P = 0.033), rheumatoid arthritis (28.9 ms, 95% CI 12.7-45.1 ms; P = 0.001), and type 2 diabetes mellitus (17.9 ms, 95% CI 3.6-32.3 ms; P = 0.015). CONCLUSIONS: This quantification of the association between chronic disease and QTc prolongation in an Indigenous cohort provides insight into the nongenetic determinants of QTc prolongation. Corroboration in other populations will provide evidence for generalisability of these results.

Comparing the stress response using heart rate variability during real and simulated crises: a pilot study.

Medical personnel often experience stress when responding to a medical emergency. A known stress-response is a measurable reduction in heart rate variability. It is currently unknown if crisis simulation can elicit the same stress response as real clinical emergencies. We aim to compare heart rate variability changes amongst medical trainees during simulated and real medical emergencies. We performed a single center prospective observational study, enrolling 19 resident physicians. Heart rate variability was measured in real time, using a 2-lead heart rate monitor (Bodyguard 2, Firstbeat Technologies Ltd) worn during 24 h critical care call shifts. Data was collected at baseline, during crisis simulation and when responding to medical emergencies. 57 observations were made to compare participant's heart rate variability. Each heart rate variability metric changed as expected in response to stress. Statistically significant differences were observed between baseline and simulated medical emergencies in Standard Deviation of the N-N interval (SDNN), Root mean square standard deviation of the N-N interval (RMSSD), Percentage of successive R-R intervals that differ by more than 50 ms (PNN50), Low Frequency (LF) and Low Frequency: High Frequency ratios (LF:HF). No statistically significant differences between simulated and real medical emergencies were identified in any heart rate variability metrics. We have shown using objective results, that simulation can elicit the same psychophysiological response as actual medical emergencies. Therefore, simulation may represent a reasonable way to practice not only essential skills in a safe environment but has the additional benefit of creating a realistic, physiological response in medical trainees.

A Systematic Review of Heart Rate Variability as a Measure of Stress in Medical Professionals.

Understanding the physiological effects of responding to crises is a critical component in understanding how to manage and prepare medical professionals to be crisis responders. Heart rate variability (HRV) is the variation in rate between a succession of R-R intervals. This variation is not only affected by physiological processes such as respiration or metabolic rate but is also directly controlled by the autonomic nervous system. As such, heart rate variability has been proposed as a noninvasive tool to measure the physiological stress response. The aim of this systematic review is to consolidate heart rate variability literature in the context of medical emergencies to determine if heart rate variability changes predictably from baseline when responding to medical crises. This may demonstrate utility as an objective, noninvasive measure of stress response. A systematic literature review of six databases yielded 413 articles, 17 of which met our inclusion criteria of being written in English, measuring HRV in healthcare providers, and measuring HRV in real or simulated medical resuscitations or procedures. Articles were then analyzed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) scoring system. Out of the 17 articles reviewed, 11 demonstrated statistically significant results showing heart rate variability responding in a predictable manner to stress. Three articles utilized a medical simulation as the stressor, six used medical procedures, and eight used medical emergencies encountered during clinical work. Overall, a predictable trend in heart rate variability metrics of standard deviation from the mean value of normal-to-normal (N-N) intervals (SDNN), root mean square of the successive differences (RMSSD), mean number of times per time interval in which the change in successive normal sinus (N-N) intervals exceeds 50 ms (PNN50), low frequency % (LF%), and low-frequency-to-high-frequency ratio (LF/HF) was observed when responding to stress. This systematic literature review showed that heart rate variability among healthcare providers responding to stressful scenarios follows a predictable pattern of change and expands our understanding of the physiology of stress in healthcare providers. This review supports the use of HRV to monitor stress during high-fidelity simulation to ensure that appropriate physiological arousal is achieved during the training of medical personnel.

Psychological safety in simulation: Perspectives of nursing students and faculty.

BACKGROUND: As simulation education continues to grow, more consideration has been given to creating and maintaining a psychologically safe simulation learning environment. It is known that failing to provide psychological safety can lead to feelings of incompetence and a lack of confidence with students. However, it is essential to understand what makes and maintains psychological safety in simulation from both student and facilitator's perspectives. In further understanding psychological safety, nursing educators can challenge students to think beyond that of task attainment and into the deeper realm of critical thinking and critical reflection. OBJECTIVES: The aim of this study was to understand students' and facilitators perspectives of psychological safety in simulation. METHODS: Participants in this qualitative interpretive description study were seven students and four faculty that were chosen using convenience sampling. The data was collected over a 2-week period where semi-structured interviews were used to collect the participants perspectives. Data analysis was continuous and iterative and used inductive analysis. RESULTS: There were two student themes which focused on the student-facilitator interaction: 1) dynamic interaction, 2) student self-efficacy. The facilitators results showed two themes which focused on 1) simulation design and 2) trust. CONCLUSION: Diverging thoughts are present between faculty and students in what constitutes psychological safety. In describing both the similarities and differences, we have a better understanding on how to create and maintain psychological safety thereby, providing students with the best learning experience possible.

A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

A cross-sectional study evaluating the relationship between followership type and burnout amongst critical care followers.

INTRODUCTION: Healthcare teams include both leaders and followers, with followers making up the majority of the healthcare team. There are five followership styles which have been described by Kelly (1992) based on critical thinking and active engagement. We aim to explore if a relationship exists between followership style and burnout, and also with job satisfaction of followers within the critical care setting. Additionally, we aim to quantify the distribution of followership types amongst followers within the critical care setting. METHODS: Participants were recruited in person at random to participate in a single centered, cross sectional, four-part survey to determine their followership type (Kelly followership type), burnout (Maslach Burnout Inventory) and job satisfaction (Brayfiled-Rothe Survey and Work and Meaning Inventory). Correlations between followership type and burnout as well as followership type and job satisfaction were then determined. RESULTS: A total of 64 participants (27 residents and 37 critical care nurses) took part in the study. There was a weak-moderate correlation between independent critical thinking and personal accomplishment (R = 0.297), and moderate correlation to meaningful work (R = 0.390), and job satisfaction (R = -0.300). Active engagement was moderately correlated with personal accomplishment (R = 0.302), meaningful work (R = 0.448) and job satisfaction (R = -0.418). Neither independent critical thinking nor active engagement showed significant correlation with depersonalization and emotional exhaustion subscales. Most participants were characterized into effective/exemplary followership type with no statistically significant differences between nurses and residents. CONCLUSION: This research shows that by creating an environment which promotes critical thinking and active engagement, nurses and residents may display less burnout, and enhanced job satisfaction.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Accuracy of Optic Nerve Sheath Diameter Measurements in Pocket-Sized Ultrasound Devices in a Simulation Model.

Introduction: Transorbital sonographic measurement of optic nerve sheath diameter (ONSD) is an emerging non-invasive technique for the identification and monitoring of intracranial hypertension. In recent years, new pocket ultrasound devices have become available, and it is uncertain if they have the resolution to measure such small structures appropriately as compared to their predecessors. In this study, we measure the performance of three ultrasound units on a simulation model to establish their precision and accuracy. Methods: ONSD was measured by three expert point-of-care sonographers using ultrasound machines three times on each of seven discrete ONS model sizes ranging from 3.5 to 7.9 mm. Two pocket ultrasounds (IVIZ, Sonosite, and Lumify, Philips) and one standard-sized portable ultrasound (M-Turbo, Sonosite) were used. Measurements were analyzed for mean error and variance and tested for significance using blocked covariance matrix regression analyses. Results: The devices differed in their variances (Lumify: 0.19 mm2, M-Turbo: 0.26 mm2, IVIZ: 0.34 mm2) and their mean error (Lumify: -0.05 mm, M-Turbo: 0.10 mm, IVIZ: -0.10 mm). The difference in mean error between users is not significant (p = 0.45), but there is a significant difference in mean error between devices (p = 0.02). Conclusions: Accurate ONSD measurement is possible utilizing pocket-sized ultrasound, and in some cases, may be more accurate than larger portable ultrasound units. While the differences in these devices were statistically significant, all three were highly accurate, with one pocket device (Lumify) outperforming the rest. Further study in human subjects should be conducted prior to using pocket ultrasound devices for in vivo diagnosis of intracranial hypertension.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

INTRODUCTION: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. METHODS: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. RESULTS: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. CONCLUSIONS: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Multidisciplinary, multisite trauma team training during COVID-19: lessons from the first virtual E-S.T.A.R.T.T. course.

Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

Design and Validity Evidence for a Unique Endoscopy Simulator Using a Commercial Video Game.

Background Procedural simulation enhances early endoscopy training. Multiple commercial simulators are available; however, their application is limited by cost and poor user compliance. First-person "shooter" (FPS) video games are popular. In this study, we aimed to show that a novel in-house designed colonoscope controller used to play an FPS video game shares similar constructs with real-life endoscopy. Methodology Participants completed the first three levels on an FPS video game, Portal (Valve Corporation, Bellevue, WA), first using a conventional controller and then the modified endoscope controller. A total of 12 expert endoscopists and 12 surgical residents with minimal endoscopy experience were evaluated based on completion time, button presses, and hand motion analyses. Results Experts outperformed novices for completion time (expert: 944 seconds; novice: 1,515 seconds; p = 0.006) and hand movements (expert: 1,263.1; novice: 2,052.6; p = 0.004) in using the novel colonoscope controller. There was no difference in button presses or total path length traveled. Furthermore, performance did not differ using conventional game controls. Conclusions Experts outperformed novices using the endoscope but not the conventional controller with respect to the economy of movement and completion time. This result confirms that our endoscope-controlled video game shares similar paradigms with real-life endoscopy and serves as a first step toward creating a more enjoyable and cheaper alternative to commercially available endoscopy simulators.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers.

BACKGROUND: Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS: This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS: Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION: Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE: Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

Strategies to improve communication in telementoring in acute care coordination: a scoping review.

Background: Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring. Methods: Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme. Results: We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment. Conclusion: The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

Contexte: Le mentorat en ligne facilite la coordination des soins médicaux de pointe dans les environnements ruraux, éloignés ou rudimentaires. Toutefois, le facteur relationnel de ce type d'interaction est resté plutôt sous-exploré. C'est pourquoi nous avons réalisé une revue exploratoire pour dégager des stratégies d'amélioration de la communication en contexte de mentorat en ligne. Méthodes: Deux réviseurs indépendants ont cherché à recenser les articles portant sur les interactions de mentorat en ligne entre professionnels de la santé parmi tous les articles de langue anglaise publiés entre 1964 et 2017 indexés dans les bases de données MEDLINE et Scopus, ainsi que dans les listes bibliographiques des articles pertinents. Les résultats de recherche ont été recueillis en juin 2017 et actualisés en janvier 2018, et les articles recensés ont été regroupés par thèmes. Résultats: Nous avons retenu 144 articles, dont 56 répondant à nos critères d'inclusion. De ce total, 41 portaient sur l'amélioration de la réanimation cardiorespiratoire (RCR) dirigée par un répartiteur. Parmi les thèmes principaux, on retrouve l'importance du langage dans l'identification des arrêts cardiaques hors de l'hôpital, ainsi que la manière de fournir des instructions permettant de pratiquer une RCR efficace. Une approche normalisée avec des questions scénarisées a été associée à une meilleure détection des arrêts cardiaques hors de l'hôpital, alors qu'un scénario concis a été associé à une amélioration de la qualité de la RCR comparativement à une approche sans mentorat, avec mentorat non scénarisé ou avec des instructions plus complexes. Six des articles retenus portaient sur la consultation de type médecin­médecin. Ils ont conclu que l'utilisation d'un outil de transfert mettant en évidence l'information importante était plus efficace qu'une approche non structurée pour la transmission de renseignements vitaux. Finalement, 9 articles portaient sur le mentorat en ligne en réanimation traumatologique. Un des thèmes communs de ces articles était le besoin d'établir une compréhension mutuelle entre mentors et professionnels en ce qui concerne les restrictions de ces derniers et de leur environnement. Conclusion: Les données disponibles semblent indiquer que la normalisation associée à des scénarios courts, concis et éprouvés pourrait améliorer l'efficacité, la sécurité et l'engagement. Cependant, toute amélioration nécessitera un encadrement multidisciplinaire, de la pratique et des efforts délibérés pour surmonter les obstacles.

Teaching Crisis Resource Management Skills to Nurses Using Simulation.

BACKGROUND: Education programs teaching crisis resource management (CRM) skills (problem solving, situational awareness, resource utilization, communication, and leadership) have been shown to positively affect learner competence in handling crisis events. As part of an education program, a high-fidelity simulation program was used as a learning intervention to teach these skills to practicing nurses. METHOD: In this repeated-measures observational study, 11 RNs were evaluated at four time points, measuring the effect of an education program on observed performance of CRM skills. Performance was measured using the Ottawa Global Rating Scale and a checklist tool. RESULTS: Statistically significant changes in mean scores occurred between times one and two, and nonstatistically significant improvement occurred in means overall. CONCLUSION: This study adds evidence of the effectiveness of high-fidelity simulation education and highlights the need for further research. [J Contin Educ Nurs. 2020;51(6):257-266.].

Fidelity in surgical simulation: further lessons from the S.T.A.R.T.T. course

Summary: Simulation has become a popular and ubiquitous medical education tool. In response to learner demands, and because of technological advancement, there is a trend toward increasing the realism of simulation. However, there is a paucity of evidence regarding what degree of fidelity is needed to deliver optimal simulation-based medical education. Feedback from the Simulated Trauma And Resuscitation Team Training (S.T.A.R.T.T.) course suggests that higherfidelity simulation is viewed as highly valuable to learners. Research is needed in order to guide the growing demand for higher-fidelity simulation in our medical training curricula and in order to justify or mitigate the associated costs and logistical challenges.

A New Inexpensive Simulation Model for Ultrasound Assessment of Optic Nerve Sheath Diameter.

BACKGROUND: Sonographic measurement of optic nerve sheath diameter (ONSD) is becoming increasingly accepted as a diagnostic modality to detect elevations in intracranial pressure. As this technique becomes more widespread, methods to address the inherent operator-dependent nature of this modality will need to be developed. We propose a novel low-cost model to accurately simulate sonographic ONSD measurement for purposes of training and assessment. METHODS: We designed models composed of medical tubing of various diameters readily available from typical hospital supplies and suspended them in gelatin. The models were evaluated by ultrasound by three expert point-of-care sonographers using a standard linear array probe and technique proposed in the literature. RESULTS: This model generates faithful simulation of the ONS that closely approximates in vivo images and can be used to produce accurate, reproducible measurements. Materials are low cost and easy to acquire and assemble. CONCLUSIONS: Our model provides realistic simulated images of the ONS. Through comparison of sonographic measurements to the known tube diameters, this model serves as a promising inexpensive tool to teach the method of ultrasound assessment of ONSD or as a way to determine accuracy of this novel ultrasound technology.

The impact of rater training on the psychometric properties of standardized surgical skill assessment tools.

INTRODUCTION: Competency-based frameworks are common in surgical training. However, the optimal use of standardized technical assessments is not well defined. We investigated the effect of rater training (RT) on the reliability and validity of four assessment tools. MATERIALS AND METHODS: Forty-Seven surgeons were randomized to RT (N = 24) and no training (N = 23) groups. A task-specific checklist, pass-fail, visual analog, and OSATS global rating scale (GRS) were used to assess trainee knot-tying and suturing tasks. Delayed assessment was performed two weeks later. Internal consistency, intra/inter-rater reliability, and construct validity were measured. RESULTS: The GRS had superior reliability and validity compared to the other tools regardless of training. No significant differences between training groups was found. However, the RT group trended to improved reliability for all tools at both assessments. CONCLUSIONS: RT did not lead to significant improvements in skills assessments. Standardized assessments (OSATS GRS) are preferred due to their superior reliability and validity over other methods. Despite findings, we believe more effective training methods or repeated sessions may be required for sustained and significant effects.

Ultrasound in the surgical ICU: uses, abuses, and pitfalls.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has become an integral component of daily care in the surgical ICU. There have been many novel advancements in the past two decades, too numerous to count. Many are of critical importance to the intensive care physician, whereas others are still accumulating evidence. Without appropriate training, diligence, and incorporation of the ultrasound findings into the whole clinical picture, this technique can be gravely misused. This review examines POCUS use in the surgical ICU, as well as highlights potential hazards and common pitfalls. RECENT FINDINGS: POCUS is essential for guidance of vascular access procedures, as well as in the characterization and treatment of respiratory failure, shock, and unstable blunt abdominal trauma. Ultrasound has growing evidence for rapidly evaluating many other diseases throughout the entire body, as well as guidance for procedures. Using advanced ultrasound techniques should only be done with corresponding levels of training and experience. SUMMARY: Ultrasound in the critical care setting has become an essential component of the assessment of most ICU patients. As more evidence accumulates, along with ever-increasing availability of ultrasound technology, its use will continue to expand. It, thus, behoves clinicians to not only ensure they are adept at obtaining and interpreting POCUS images but also efficiently incorporate these skills into holistic bedside care without delaying lifesaving therapies.

Evaluating Extravascular Lung Water in Sepsis: Three Lung-Ultrasound Techniques Compared against Transpulmonary Thermodilution.

BACKGROUND: Excessive extravascular lung water (EVLW) is associated with increased morbidity and mortality. We compared three lung-ultrasound (L-US) techniques against the reference-standard transpulmonary thermodilution (TPTD) technique to access EVLW. MATERIALS AND METHODS: This was a prospective, single-blind, cross-sectional study. Forty-four septic patients were enrolled. EVLW index was measured by the TPTD method, and an index of ≥10 mL/kg was considered diagnostic of pulmonary edema. EVLW index was then compared to three established bedside L-US protocols that evaluate sonographic B-lines: (1) a 28-zone protocol (total B-line score [TBS]) (2) a scanning 8-region examination, and (3) a 4-point examination. RESULTS: Eighty-nine comparisons were obtained. A statistically significant positive correlation was found between L-US TBS and an EVLW index ≥10 mL/kg (r = 0.668,P < 0.001). The 28-zone protocol score ≥39 has a sensitivity of 81.6% and a specificity of 76.5% to define EVLW index ≥10 mL/kg. In contrast, the positive 4-point examination and scanning 8-regions showed low sensitivity (23.7% and 50.0%, respectively) but high specificity (96.1% and 88.2%, respectively). Ten patients with a total of 21 comparisons met criteria for acute respiratory distress syndrome (ARDS). In this subgroup, only the TBS had statistically significant positive correlation to EVLW (r = 0.488,P = 0.025). CONCLUSION: L-US is feasible in patients with severe sepsis. In addition, L-US 28-zone protocol demonstrated high specificity and better sensitivity than abbreviated 4- and 8-zone protocols. In ARDS, the L-US 28-zone protocol was more accurate than the 4- and 8-zone protocols in predicting EVLW. Consideration of limitations of the latter protocols may prevent clinicians from reaching premature conclusions regarding the prediction of EVLW. TRIAL REGISTRATION: ISRCTN11419081. Registered 4 February 2015 retrospectively.

Effect of rater training on the reliability of technical skill assessments: a randomized controlled trial.

BACKGROUND: Rater training improves the reliability of observational assessment tools but has not been well studied for technical skills. This study assessed whether rater training could improve the reliability of technical skill assessment. METHODS: Academic and community surgeons in Royal College of Physicians and Surgeons of Canada surgical subspecialties were randomly allocated to either rater training (7-minute video incorporating frame-of-reference training elements) or no training. Participants then assessed trainees performing a suturing and knot-tying task using 3 assessment tools: a visual analogue scale, a task-specific checklist and a modified version of the Objective Structured Assessment of Technical Skill global rating scale (GRS). We measured interrater reliability (IRR) using intraclass correlation type 2. RESULTS: There were 24 surgeons in the training group and 23 in the no-training group. Mean assessment tool scores were not significantly different between the 2 groups. The training group had higher IRR than the no-training group on the visual analogue scale (0.71 v. 0.46), task-specific checklist (0.46 v. 0.33) and GRS (0.71 v. 0.61). However, confidence intervals were wide and overlapping for all 3 tools. CONCLUSION: For education purposes, the reliability of the visual analogue scale and GRS would be considered "good" for the training group but "moderate" for the no-training group. However, a significant difference in IRR was not shown, and reliability remained below the desired level of 0.8 for high-stakes testing. Training did not significantly improve assessment tool reliability. Although rater training may represent a way to improve reliability, further study is needed to determine effective training methods.

CONTEXTE: La formation des évaluateurs améliore la fiabilité des outils d'évaluation observationnels, mais n'a pas été rigoureusement étudiée au plan des habiletés techniques. Cette étude a tenté de vérifier si la formation des évaluateurs permettait d'améliorer la fiabilité de l'évaluation des habiletés techniques. MÉTHODES: On a assigné des chirurgiens universitaires et communautaires appartenant aux surspécialités chirurgicales du Collège royal des médecins et chirurgiens du Canada, soit à une formation des évaluateurs (vidéo de 7 minutes comprenant des éléments de formation afférents au cadre de référence), soit à l'absence de formation. les participants ont ensuite évalué des stagiaires qui effectuaient tâches, telles sutures et nœuds, à l'aide de trois outils d'évaluation : échelle analogique visuelle, liste de vérification spécifique à la tâche et version modifiée de l'échelle d'appréciation globale (ÉAG) de l'Objective Structured Assessment of Technical Skill. Nous avons mesuré la fiabilité interévaluateurs (FIÉ) à l'aide de la corrélation intraclasse de type 2. RÉSULTATS: Il y avait 24 chirurgiens dans le groupe soumis à la formation et 23 dans le groupe non soumis à la formation. Les scores moyens des outils d'évaluation n'ont pas été significativement différents entre les deux groupes. Le groupe soumis à la formation a présenté une FIÉ plus élevée que l'autre groupe à l'échelle analogique visuelle (0,71 c. 0,46), à la liste de vérification spécifique à la tâche (0,46 c. 0,33) et à l'ÉAG (0,71 c. 0,61). Par contre, les intervalles de confiance étaient larges et se recoupaient pour les trois outils. CONCLUSION: Aux fins de la formation, la fiabilité de l'échelle analogique visuelle et de l'ÉAG serait considérée «.bonne.¼ pour le groupe soumis à la formation, mais «.modérée.¼ pour le groupe non soumis à la formation. On n'a toutefois pas démontré de différence significative quant à la FIÉ et la fiabilité est demeurée inférieure au niveau souhaité de 0,8 pour les tests importants. La formation n'a pas significativement amélioré la fiabilité de l'outil d'évaluation. Même si la formation des évaluateurs représente potentiellement une façon d'améliorer la fiabilité, il faudra approfondir la recherche pour déterminer quelles méthodes de formation sont efficaces.