The lecturer-tutor in undergraduate medical education; navigating complexity as "a recruiter, a timetabler, an administrator, a counsellor".

BACKGROUND: Tutors play an important role in the delivery of effective undergraduate medical education (UGME). These roles commonly involve competing clinical, educational and research commitments. We sought to obtain a rich description of these posts from doctors working in them. METHODS: We used a pragmatist, sequential explanatory mixed-methods design with a sampling frame of clinical lecturer/tutors in 5 Irish medical schools. Purposive sampling was used for recruitment. Quantitative data collected from a validated online questionnaire were used to inform a semi-structured interview question guide. Thematic analysis was conducted independently by each of the study researchers, using a coding frame derived in part from the findings of the online questionnaire. Quantitative and qualitative mixing occurred during data collection, analysis and reporting. RESULTS: 34 tutors completed the online survey with 7 volunteers for interview. Most respondents took the job to gain experience in either educational practice (79.4%) or in research (61.8%). Major themes to emerge were the diverse interactions with students, balancing multiple professional commitments, a high degree of role-autonomy, mis-perception of role by non-tutor colleagues, challenges around work-life balance and unpredictable work demands. Using a complexity theory lens, the tutor role was defined by its relational interactions with numerous stakeholders, all in the context of an environment that changed regularly and in an unpredictable manner. CONCLUSIONS: The undergraduate tutor works in a demanding role balancing educational and non-educational commitments with suboptimal senior guidance and feedback. The role is notable for its position within a complex adaptive system. An understanding of the system's interactions recognises the non-linearity of the role. Using a complex systems lens, we propose improvements to undergraduate education centred around the tutor.

How Do We Learn About Error? A Cross-Sectional Study of Urology Trainees.

OBJECTIVE: This qualitative descriptive study aims to explore trainees' experiences of error disclosure (ED) during their surgical postgraduate training and the factors influencing the intention-behavior gap for ED. DESIGN: This study employs an interpretivist methodology and a qualitative descriptive research strategy. Data were collected using focus group interviews. Data coding was performed by the principal investigator using Braun and Clarke's reflexive thematic analysis. Themes were developed from the data in a deductive manner. Analysis was carried out using NVivo 12.6.1. SETTING: All participants were at various stages of an 8-year specialist program under the auspices of the Royal College of Surgeons in Ireland. The training program involves clinical work in a teaching hospital under the supervision of senior doctors in their specialist field. Trainees attend mandatory communication skills training days throughout the program. PARTICIPANTS: Study participants were recruited using purposive sampling from a sampling frame of 25 urology trainees on a national training scheme. Eleven trainees participated in the study. RESULTS: Participants' stage of training ranged from first to final year. Seven key themes emerged from the data relating to the trainees' experiences of error disclosure and the intention-behavior gap for ED. These themes include observed positive and negative practice in the workplace, impact of stage of training, importance of interpersonal interactions, perceived blame/responsibility for multifactorial error or recognized complication, lack of formal training in ED, cultural aspects of the training environment and medicolegal issues around ED. CONCLUSIONS: While trainees recognize the importance of ED, personal psychological factors, negative environmental culture, and medicolegal concerns are significant barriers to the practice of ED. A training environment that focuses on role-modelling and experiential learning with adequate time for reflection and debriefing is paramount. Areas for further research include broadening the scope of this study of ED across different medical and surgical subspecialties.

Exploring Safety Culture in the ICU of a Large Acute Teaching Hospital through Triangulating Different Data Sources.

Safety Culture (SC) has become a key priority for safety improvement in healthcare. Studies have identified links between positive SC and improved patient outcomes. Mixed-method measurements of SC are needed to account for diverse social, cultural, and subcultural contexts within different healthcare settings. The aim of the study was to triangulate data on SC from three sources in an Intensive Care Unit (ICU) in a large acute teaching hospital. A mixed-methods approach was used, including analysing the Hospital Survey for Patient Safety Culture results, retrospective chart reviews using the Global Trigger Tool (GTT) for the ICU, and staff reporting of adverse events (AE). There was a 47% (101/216) response rate for the survey. Further, 98% of respondents stated a positive patient safety rating. The GTT identified 16 AEs and 11 AEs that were reported in the same timeframe. The triangulation of the data demonstrates the complexity of understanding components of SC in particular: learning, reporting, and just culture.

A Scoping Review of Assessment Methods Following Undergraduate Clinical Placements in Anesthesia and Intensive Care Medicine.

Introduction: Anesthesia and intensive care medicine are relatively new undergraduate medical placements. Both present unique learning opportunities and educational challenges to trainers and medical students. In the context of ongoing advances in medical education assessment and the importance of robust assessment methods, our scoping review sought to describe current research around medical student assessment after anesthesia and intensive care placements. Methods: Following Levac's 6 step scoping review guide, we searched PubMed, EMBASE, EBSCO, SCOPUS, and Web of Science from 1980 to August 2021, including English-language original articles describing assessment after undergraduate medical placements in anesthesia and intensive care medicine. Results were reported in accordance with PRISMA scoping review guidelines. Results: Nineteen articles published between 1983 and 2021 were selected for detailed review, with a mean of 119 participants and a median placement duration of 4 weeks. The most common assessment tools used were multiple-choice questions (7 studies), written assessment (6 studies) and simulation (6 studies). Seven studies used more than one assessment tool. All pre-/post-test studies showed an improvement in learning outcomes following clinical placements. No studies used workplace-based assessments or entrustable professional activities. One study included an account of theoretical considerations in study design. Discussion: A diverse range of evidence-based assessment tools have been used in undergraduate medical assessment after anesthesia and intensive care placements. There is little evidence that recent developments in workplace assessment, entrustable activities and programmatic assessment have translated to undergraduate anesthesia or intensive care practice. This represents an area for further research as well as for curricular and assessment developments.

Collaboration, supervision and patient safety in the era of COVID-19: an analysis of medical wards and ICU.

AIMS: COVID-19 resulted in significant changes across medical wards and ICU in St James's Hospital Dublin. This included the implementation of ward-based medical teams (WBMT). The purpose of this study was to identify how these structural changes affected inter-professional collaboration, supervision and patient safety. METHODS: Questionnaires were distributed to doctors working on medical wards and ICU at the height of the first wave of COVID-19. The sense of collaboration, patient safety and supervision were assessed. RESULTS: Fifty-three doctors took part in the study. Thirty-three (62%) felt that collaboration was better than normal. Forty-six (87%) of participants described supervision as "good" or "excellent". Thirty-one out of 40 participants (77%) felt that patient safety was better than normal. DISCUSSION: Implementation of WBMT may result in improved sense of collaboration, supervision and patient safety during COVID-19; however, the increased sense of solidarity and comradery felt during the initial surge make drawing these conclusions challenging.

Comparison of risk scoring systems for critical care patients with upper gastrointestinal bleeding: predicting mortality and length of stay.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a common reason for intensive care admission. While there exist a number of UGIB scoring systems which are used to predict mortality, there are limited studies assessing the discriminative value of these scores in intensive care unit (ICU) patients. The purpose of this study was to analyse five different UGIB scoring systems in predicting ICU mortality and length of stay and compare them to two commonly used ICU mortality scoring systems. MATERIAL AND METHODS: We retrospectively identified all patients requiring ICU admission for UGIB to St James's Hospital over an 18-month period. We calculated their AIM65, Glasgow- Blatchford score, pre- and post-Rockall score, ABC, APACHE II and SOFA scores. We used area under the receiver operating characteristic curve (AUROC) to compare the predictive values of these six scoring systems for ICU and hospital mortality as well as ICU length of stay greater than seven days. RESULTS: APACHE II showed excellent discriminative value in predicting mortality in ICU patients (AUROC: 0.87; CI: 0.75-0.99) while the SOFA score showed good discriminative value (AUROC: 0.71; CI: 0.50-0.93). None of the UGIB scoring systems predicted mortality in these patients. All scoring systems showed poor discriminative value in predicting ICU length of stay. CONCLUSIONS: We were not able to validate any of these UGIB scoring systems for mortality or length of stay prediction in ICU patients. This study supports the validity of APACHE II as a clinical tool for predicting mortality in ICU patients with UGIB.

Acute respiratory failure in immunosuppressed patients admitted to ICU.

INTRODUCTION: The number of hospitalized immunosuppressed adults is a growing and often develop severe complications that require admission to an Intensive Care Unit (ICU). The main cause of admission is acute respiratory failure (ARF). The goal of the study was to determine if ARF represents an independent risk factor for hospital mortality and in particular, we sought to ascertain if any risk factors were independently and identifiably associated with a bad outcome. METHODS: We perform a retrospective study of a prospectively collected data from patients admitted to an ICU. Adult patients with known immunosuppressive condition admitted to ICU were included. RESULTS: A total of 248 patients were included. Of 248 patients, 117 (47.2%) had a diagnosis of ARF at the time of ICU admission. Patients with ARF had a significantly higher in-hospital mortality (53.4% vs. 28.2% p = 0.001). Factors independently associated with hospital mortality were diagnosis of ARF at ICU admission, the presence of septic shock, use of continuous renal replacement therapy and failure of high-flow nasal canula(HFNC)/non-invasive (NIV) respiratory therapies. CONCLUSION: We identified ARF on admission and failure of HFNC/NIV to be independently associated with increased hospital mortality in immunosuppressed patients.

Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic.

Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.

Information sharing between intensive care and primary care after an episode of critical illness; A mixed methods analysis.

INTRODUCTION: Poor quality communication between hospital doctors and GPs at the time of hospital discharge is associated with adverse patient outcomes. This may be more marked after an episode of critical illness, the complications of which can persist long after hospital discharge. AIMS: 1. to evaluate information sharing between ICU staff and GPs after a critical illness 2. to identify factors influencing the flow and utilisation of this information. METHODS: Parallel mixed methods observational study in an Irish setting, with equal emphasis on quantitative and qualitative data. Descriptive analysis was performed on quantitative data derived from GP and ICU consultant questionnaires. Qualitative data came from semi-structured interviews with GPs and consultants, and were analysed using directed content analysis. Mixing of data occurred at the stage of interpretation. RESULTS: GPs rarely received information about an episode of critical illness directly from ICU staff, with most coming from patients and relatives. Information received from hospital sources was frequently brief and incomplete. Common communication barriers reported by consultants were insufficient time, low perceived importance and difficulty establishing GP contact. When provided information, GPs seldom actioned specific interventions, citing insufficient guidance in hospital correspondence and poor knowledge about critical illness complications and their management. A majority of all respondents thought that improved information sharing would benefit patients. Cultural influences on practice were identified in qualitative data. A priori qualitative themes were: (1) perceived benefits of information sharing, (2) factors influencing current practice and (3) strategies for optimal information sharing. Emergent themes were: (4) the central role of the GP in patient care, (5) the concept of the "whole patient journey" and (6) a culture of expectation around a GP's knowledge of hospital care. CONCLUSIONS: Practical and cultural factors contribute to suboptimal information sharing between ICU and primary care doctors around an episode of critical illness in ICU. We propose a three-milestone strategy to improve the flow and utilisation of information when patients are admitted, discharged or die within the ICU.

Human methyl parathion poisoning.

BACKGROUND: Methyl parathion is classed as an extremely hazardous pesticide with a rodent LD50 of 6 to 24 mg/kg. It has been banned in numerous countries, but there are few reports of acute methyl parathion poisoning. METHODS: Plasma cholinesterase and acetylcholinesterase were measured in blood. Methyl parathion and the major metabolite 4-nitrophenol where measured in serum and urine. Based on the available concentration-time data, the pharmacokinetic parameters of methyl parathion were estimated for this patient. CASE REPORT AND RESULTS: A 29-year-old male ingested 50 to 100mL (12 to 24 g) of methyl parathion causing delayed and prolonged suppression of acetylcholinesterase but almost no clinical effects. Absorption was predicted to last for 30 hours and the bioavailability appeared to be very low. CONCLUSIONS: Although it is feasible the patient ingested much less, a tenth of his alleged ingestion dose is more than the oral LD50 in rats. Methyl parathion appears to be less toxic in humans than parathion for similar amounts ingested, which is not consistent with the two pesticides having similar rodent LD50.

A qualitative study of undergraduate clerkships in the intensive care unit: It's a brand new world.

INTRODUCTION: While ICU clerkships are commonplace in undergraduate medical education, little is known about how students learn there. This study aimed to explore students' perceptions of the ICU as a learning environment, the factors influencing their learning and any perceived differences between learning in the ICU and non-ICU settings. METHODS: We used interpretivist methodology, a social cognitive theoretical framework and a qualitative descriptive strategy. Ten medical students and four graduate doctors participated in four semi-structured focus group discussions. Data were analyzed by six-step thematic data analysis. Peer debriefing, audit trail and a reflexive diary were used. RESULTS: Social cognitive influences on learning were apparent in the discussions. Numerous differences emerged between ICU and non-ICU clinical clerkships, in particular an unfamiliarity with the environment and the complex illness, and difficulty preparing for the clerkship. A key emergent theme was the concept of three phases of student learning, termed pre-clerkship, early clerkship and learning throughout the clerkship. A social cognitive perspective identified changes in learner agency, self-regulatory activities and reciprocal determinism through these phases. The findings were used to construct a workplace model of undergraduate intensive care learning, providing a chronological perspective on the clerkship experience. CONCLUSIONS: The ICU, a rich, social learning environment, is different in many respects to other hospital settings. Students navigate through three phases of an ICU clerkship, each with its own attendant emotional, educational and social challenges and with different dynamics between learner and environment. This chronological perspective may facilitate undergraduate educational design in the ICU.

Clinical and biochemical characteristics of patients admitted to ICU with SARS-CoV-2 / Características clínicas y bioquímicas de pacientes ingresados en UCI con SARS-CoV-2

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Improving blood sugar control during critical illness: a cohort study.

PURPOSE: The aim of this study is to compare blood sugar control and safety profile of nurse-titrated and medically ordered glucose-insulin regimens. MATERIALS AND METHODS: We conducted a retrospective cohort study in a 9-bedded regional intensive care unit (ICU) in Queensland, Australia. Seventy critically ill patients requiring one-on-one nursing and intravenous insulin were included. In the nursing group, the ICU nurse decided initial and ongoing insulin infusion rates and glucose measurement frequency. The medical group had a traditional insulin sliding scale prescription. RESULTS: Thirty-seven patients in the nursing group had 1949 glucose measurements. Thirty-three patients in the medical group had 2118 measurements. Mean blood sugar levels (+/-SD) were 8.33 +/- 2.34 and 8.78 +/- 2.74 in nursing and medical groups (P < .001). Eighteen percent of glucose readings were greater than 10 mmol/L in the nursing group compared with 27% in the medical group (P = .038). The incidence of hypoglycemia (<2.2 mmol/L) was similar in the 2 groups. CONCLUSIONS: In a regional ICU, nurse-titrated glycemic control is safe, effective, and results in high compliance with a glucose target range.