Simulation-Based Assessment of Critical Care "Front-Line" Providers.

OBJECTIVES: Develop a standardized simulation method to assess clinical skills of ICU providers. DESIGN: Simulation assessment. SETTING: Simulation laboratory. SUBJECTS: Residents, Critical Care Medicine fellows, acute care nurse practitioner students. INTERVENTIONS: Performance scoring in scenarios from multiple Critical Care Medicine competency domains. MEASUREMENTS AND MAIN RESULTS: Three-hundred eighty-four performances by 48 participants were scored using checklists (% correct) and holistic "global" ratings (1 [unprepared] to 9 [expert]). One-hundred eighty were scored by two raters. Mean checklist and global scores (± SD) ranged from 65.0% (± 16.3%) to 84.5% (± 17.3%) and 4.7 (± 1.4) to 7.2 (± 1.2). Checklist and global scores for Critical Care Medicine fellows and senior acute care nurse practitioner students (Experienced group, n = 26) were significantly higher than those for the Novice acute care nurse practitioner students (Novice group, n = 14) (75.6% ± 15.6% vs 68.8% ± 21.0% and 6.1 ± 1.6 vs 5.4 ± 1.5, respectively; p < 0.05). Residents (Intermediate group, n = 8) scored between the two (75.4% ± 18.3% and 5.7 ± 1.7). 38.5% of the Experienced group scored in the top quartile for mean global score, compared with 12.5% of the Intermediate and 7.1% of the Novice groups. Conversely, 50% of the Novice group scored in the lower quartile (< 5.3), compared with 37.5% of the Intermediate and 11.5% of the Experienced groups. Psychometric analyses yielded discrimination values greater than 0.3 for most scenarios and reliability for the eight-scenario assessments of 0.51 and 0.60, with interrater reliability of 0.71 and 0.75, for checklist and global scoring, respectively. CONCLUSIONS: The simulation assessments yielded reasonably reliable measures of Critical Care Medicine decision-making skills. Despite a wide range of performance, those with more ICU training and experience performed better, providing evidence to support the validity of the scores. Simulation-based assessments may ultimately prove useful to determine readiness to assume decision-making roles in the ICU.

Resumption of Short-term Burn Reconstruction Missions to Ukraine in Light of COVID-19: A Paradigm Shift.

The COVID-19 pandemic has disrupted the lives of billions of people globally. Some medical systems continue to be overburdened due to the viral illness leading to incredible public health challenges domestically as well as abroad. However, with vaccination distribution increasing globally, many are pushing for a return to some form of normalcy. In the medical community, some are weighing the risks of returning to global health missions and considering protective strategies to minimize risk of viral spread. Here, we describe our experience in returning to an annual burn reconstruction mission in a low- and middle-income country. We have successfully carried out a return surgical mission trip. Our team of 10 individuals was able to perform over 75 procedures on 25 pediatric patients in 4 operative days. We applied a variety of protective strategies and altered mission protocol to limit exposure and transmission risk while focusing heavily on education and training. Additionally, we increased the use of telemedicine and eliminated typical in-person clinic visits. We increased operative complexity to increase impact while limiting patient exposure. Rigorous perioperative safety and follow-up protocols were implemented. The increased use of telemedicine, reduction of in-person visits, emphasis on education, and implementation of safety and follow-up protocols have led to an improvement in efficiency, safety, and accountability. Our adaptations have provided guidance on responsibly resuming surgical outreach missions, with changes that are likely to endure beyond the COVID-19 pandemic.

Collagen density promotes mammary tumor initiation and progression.

BACKGROUND: Mammographically dense breast tissue is one of the greatest risk factors for developing breast carcinoma. Despite the strong clinical correlation, breast density has not been causally linked to tumorigenesis, largely because no animal model has existed for studying breast tissue density. Importantly, regions of high breast density are associated with increased stromal collagen. Thus, the influence of the extracellular matrix on breast carcinoma development and the underlying molecular mechanisms are not understood. METHODS: To study the effects of collagen density on mammary tumor formation and progression, we utilized a bi-transgenic tumor model with increased stromal collagen in mouse mammary tissue. Imaging of the tumors and tumor-stromal interface in live tumor tissue was performed with multiphoton laser-scanning microscopy to generate multiphoton excitation and spectrally resolved fluorescent lifetimes of endogenous fluorophores. Second harmonic generation was utilized to image stromal collagen. RESULTS: Herein we demonstrate that increased stromal collagen in mouse mammary tissue significantly increases tumor formation approximately three-fold (p < 0.00001) and results in a significantly more invasive phenotype with approximately three times more lung metastasis (p < 0.05). Furthermore, the increased invasive phenotype of tumor cells that arose within collagen-dense mammary tissues remains after tumor explants are cultured within reconstituted three-dimensional collagen gels. To better understand this behavior we imaged live tumors using nonlinear optical imaging approaches to demonstrate that local invasion is facilitated by stromal collagen re-organization and that this behavior is significantly increased in collagen-dense tissues. In addition, using multiphoton fluorescence and spectral lifetime imaging we identify a metabolic signature for flavin adenine dinucleotide, with increased fluorescent intensity and lifetime, in invading metastatic cells. CONCLUSION: This study provides the first data causally linking increased stromal collagen to mammary tumor formation and metastasis, and demonstrates that fundamental differences arise and persist in epithelial tumor cells that progressed within collagen-dense microenvironments. Furthermore, the imaging techniques and signature identified in this work may provide useful diagnostic tools to rapidly assess fresh tissue biopsies.

Decision-making skills improve with critical care training: Using simulation to measure progress.

PURPOSE: Health care professionals are expected to acquire decision-making skills during their training, but few methods are available to assess progress in acquiring these essential skills. The purpose of this study was to determine whether a simulation methodology could be used to assess whether decision-making skills improve during critical care training. MATERIALS AND METHODS: Sixteen simulated scenarios were designed to assess a critical care provider's ability to make decisions in the care of a critical ill patient. Seventeen (17) critical care providers managed 8 of the scenarios early during their training and then managed a second set of 8 scenarios (T2) at the conclusion of their training. RESULTS: Provider's mean global scenario scores (0-9) increased significantly fromT1 and T2 (5.64 ±â€¯0.74) and (6.54 ±â€¯0.64) with a large effect size (1.3). Acute care nurse practitioners and fellows achieved similar overall scores at the conclusion of their training (ACNP 6.43 ±â€¯0.57; Fellows 6.64 ±â€¯0.72). CONCLUSIONS: These findings provide evidence to support the validity of a simulation-based method to assess progress in decision-making skills. A simulation methodology could be used to establish a performance standard that determined a provider's ability to make independent decisions.

Preoperative Assessment of Geriatric Patients.

Geriatric patients are over-represented in hospitalizations, surgeries, and perioperative complications. Special consideration is required for this patient group in the perioperative period because of the prevalence of comorbid diseases, functional impairments, and other deficits. A comprehensive preoperative evaluation strategy is recommended to identify and address these issues. Systematic, multidomain assessments should be performed and paired with risk reduction efforts. A shared understanding of patient function and long-term health goals is also important for providing patient-centered care of the geriatric surgical patient.