Impact of Simulation-based Mastery Learning on Management of Massive Hemoptysis.

Background: The management of massive hemoptysis is a high-risk, low-volume procedure that is associated with high mortality rates, and pulmonary and critical care medicine (PCCM) fellows often lack training. Simulation-based mastery learning (SBML) is an educational strategy that improves skill but has not been applied to massive hemoptysis management. Objective: This pilot study aimed to develop a high-fidelity simulator, implement an SBML curriculum, and evaluate the impact on PCCM fellows managing massive hemoptysis. Methods: We modified a simulator to bleed from segmental airways. Next, we developed an SBML curriculum and a validated 26-item checklist and set a minimum passing standard (MPS) to assess massive hemoptysis management. A cohort of traditionally trained providers was assessed using the checklist. First-year PCCM fellows reviewed a lecture before a pretest on the simulator using the skills checklist and underwent rapid-cycle deliberate practice with feedback. Subsequently, fellows were posttested on the simulator, with additional training as necessary until the MPS was met. We compared pretest and posttest performance and also compared SBML-trained fellows versus traditionally trained providers. Results: The MPS on the checklist was set at 88%. All first-year PCCM fellows (N = 5) completed SBML training. Mean checklist scores for SBML participants improved from 67.7 ± 8.4% (standard deviation) at pretest to 84.6 ± 6.7% at the initial posttest and 92.3 ± 5.4% at the final (mastery) posttest. Traditionally trained participants had a mean test score of 60.6 ± 13.1%. Conclusion: The creation and implementation of a massive hemoptysis simulator and SBML curriculum was feasible and may address gaps in massive hemoptysis management training.

Impact of healthcare system strain on the implementation of ICU sedation practices and encephalopathy burden during the early COVID-19 pandemic.

The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (ß = - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (ß = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (ß = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.

Simulation-based Mastery Learning Improves Critical Care Skills of Advanced Practice Providers.

Background: Advanced practice providers (APPs) are essential members of intensive care unit (ICU) interprofessional teams and are expected to be competent in performing procedures. There are no published criteria for establishing when APPs can independently perform procedures. Simulation-based mastery learning (SBML) is an effective strategy for improving critical care skills but has not been applied to practicing ICU APPs. Objective: The purpose of this study was to evaluate if an SBML curriculum could improve the critical care skills and procedural self-confidence of ICU APPs. Methods: We performed a pretest-posttest study of central venous catheter (CVC) insertion, thoracentesis, and mechanical ventilation (MV) management skills among ICU APPs who participated in an SBML course at an academic hospital. For each skill, APPs underwent baseline skills assessments (pretests) on a simulator using previously published checklists, followed by didactic sessions and deliberate practice with individualized feedback. Within 2 weeks, participants were required to meet or exceed previously established minimum passing standards (MPS) on simulated skills assessments (posttests) using the same checklists. Further deliberate practice was provided for those unable to meet the MPS until they retested and met this standard. We compared pretest to posttest skills checklist scores and procedural confidence. Results: All 12 eligible ICU APPs participated in internal jugular CVC, subclavian CVC, and MV training. Five APPs participated in thoracentesis training. At baseline, no APPs met the MPS on all skills. At training completion, all APPs achieved the mastery standard. Internal jugular CVC pretest performance improved from a mean of 67.2% (standard deviation [SD], 28.8%) items correct to 97.1% (SD, 3.8%) at posttest (P = 0.005). Subclavian CVC pretest performance improved from 29.2% (SD, 32.7%) items correct to 93.1% (SD 3.9%) at posttest (P < 0.001). Thoracentesis pretest skill improved from 63.9% (SD, 30.6%) items correct to 99.2% (SD, 1.7%) at posttest (P = 0.054). Pretest MV skills improved from 54.8% (SD, 19.7%) items correct to 92.3% (SD, 5.0%) at posttest (P < 0.001). APP procedural confidence improved for each skill from pre to posttest. Conclusion: SBML is effective for training APPs to perform ICU skills. Relying on traditional educational methods does not reliably ensure that APPs are adequately prepared to perform skills such as CVC insertion, thoracentesis, and MV management.

Incidence, treatment options, and outcomes of lung cancer in patients with chronic obstructive pulmonary disease.

PURPOSE OF REVIEW: An associative and mechanistic link between chronic obstructive pulmonary disease (COPD) and lung cancer has long been suspected. This review describes the current understanding of the incidence, mechanism of association, treatment options, and outcome for lung cancer with COPD. RECENT FINDINGS: COPD patients have an increased risk of lung cancer that is independent of smoking. New evidence suggests that there is an inverse relationship between the severity of airflow obstruction and the risk of lung cancer. Chronic inflammation associated with COPD may play a role in the development of lung cancer, and targeting airway inflammation with inhaled corticosteroids has been suggested as a possible preventive strategy. Although surgical lobectomy remains the standard of care for early stage lung cancer, less invasive approaches such as sublobar resection, stereotactic body radiation therapy, and radiofrequency ablation are promising techniques for patients with limited pulmonary reserve. SUMMARY: Progress is being made in identifying mechanistic links between COPD and lung cancer, which may lead to novel therapeutic strategies for both disorders. Patients with COPD are likely to benefit from less-invasive surgical and nonsurgical treatment strategies for lung cancer, but further study is needed to determine the safety and efficacy of these procedures.

Got 15? Try Faculty Development on the Fly: A Snippets Workshop for Microlearning.

Introduction: Faculty development (FD) is an element critical to the professional growth of medical educators and a necessary component in developing effective educators. FD offerings are prevalent across academic institutions; however, faculty report they are unable to participate in these initiatives due to time limitations and competing priorities. The snippet FD approach can address these concerns but requires training for FD providers to be effectively used. Methods: This snippet train-the-trainer workshop was presented to approximately 310 physician and nonphysician medical educators at a national medical education conference. The session incorporated multiple teaching modalities (e.g., lecture, demonstrations, structured small-group snippet development groups, and large-group debriefs). A 14-item Likert-scale survey was used to obtain participant evaluations. Narrative feedback was collected using constructed response items. Results: Ninety-five percent of respondents (125 of 132) planned to use snippets as an FD strategy at least once per year, with 38% (50 of 132) noting they planned to use snippets at least four times per year. Respondents indicated that FD snippets could positively impact educational practices (94%) and that the session was a valuable use of their time (94%), as well as expressing interest in a snippet repository (90%). Discussion: A brief FD train-the-trainer workshop for snippets can successfully prepare FD providers to create and use this approach.

Advancing Academic Continuing Medical Education/Continuing Professional Development: Adapting a Classical Framework to Address Contemporary Challenges.

Lifelong learning is essential for the practicing physician, yet continuing medical education (CME) and continuing professional development (CPD) units at academic medical centers (AMCs) have been historically underappreciated and under-resourced. Their integration into AMC leadership structures continues to vary widely among institutions. Without necessary resources and leadership alignment, many units are less able to focus on advancing CME/CPD to offer and study innovative educational opportunities that may enhance learner and patient outcomes. Using benchmarking data and recommendations from national leaders in the field, a CPD Hierarchy of Needs was created to frame the strategic development of CME/CPD units. This five-level hierarchy includes priorities such as (1) securing investment, (2) building infrastructure, (3) integrating into AMC leadership structures, (4) promoting data-driven interventions, and (5) advancing educational innovation. Recommendations to use the CME/CPD Hierarchy of Needs are described to convey the significance of CME/CPD units to AMCs and to the lifelong learning of practicing physicians.

Impact of Simulation-based Mastery Learning on Resident Skill Managing Mechanical Ventilators.

Background: Caring for patients requiring mechanical ventilation is complex, and residents may lack adequate skill for managing these patients. Simulation-based mastery learning (SBML) is an educational model that trains clinicians to a high standard and can reduce complications. The mastery learning model has not been applied to ventilator management. Objective: The purpose of this study was to determine whether SBML, as compared with traditional training, is an effective strategy for teaching residents the skills necessary to manage patients requiring mechanical ventilation. Methods: We developed an SBML curriculum and a 47-item skills checklist to test ventilator management for patients with normal, restricted, and obstructed lung physiology. A minimum passing standard (MPS) on the checklist was set using the Mastery Angoff method. Residents rotating through the medical intensive care unit in Academic Year 2017-2018 were assigned to SBML or traditional training based on their medical intensive care unit team. The SBML group was pretested on a ventilator simulator using the skills checklist. They then received a 1.5-hour session (45 min didactic and 45 min deliberate practice on the simulator with feedback). At rotation completion, they were posttested on the simulator using the checklist until the MPS was met. Both SBML-trained and traditionally trained groups received teaching during daily bedside rounds and twice weekly didactic lectures. At rotation completion, traditionally trained residents were tested using the same skills checklist on the simulator. We compared pretest and posttest performance among SBML-trained residents and end of the rotation test performances between the SBML-trained and traditionally trained residents. Results: The MPS was set at 87% on the checklist. Fifty-seven residents were assigned to the SBML-trained group and 49 were assigned to the traditionally trained group. Mean checklist scores for SBML-trained residents improved from 51.4% (standard deviation [SD] = 17.5%) at pretest to 86.1% (SD = 7.6%) at initial posttest and 92.5% (SD = 3.7%) at final (mastery) posttest (both P < 0.001). Forty-two percent of residents required more than one attempt at the posttest to meet or exceed the MPS. At rotation completion, the traditionally trained residents had a mean test score of 60.9% (SD = 13.3%). Conclusion: SBML is an effective strategy to train residents on mechanical ventilator management. An SBML curriculum may augment traditional training methods to further equip residents to safely manage ventilated patients.

Are USMLE Scores Valid Measures for Chief Resident Selection?

BACKGROUND: The US Medical Licensing Examination (USMLE) Step 1 and Step 2 scores are often used to inform a variety of secondary medical career decisions, such as residency selection, despite the lack of validity evidence supporting their use in these contexts. OBJECTIVE: We compared USMLE scores between non-chief residents (non-CRs) and chief residents (CRs), selected based on performance during training, at a US academic medical center that sponsors a variety of graduate medical education programs. METHODS: This was a retrospective cohort study of residents' USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores from 2015 to 2020. The authors used archived data to compare USMLE Step 1 and Step 2 CK scores between non-CR residents in each of the eligible programs and their CRs during the 6-year study period. RESULTS: Thirteen programs enrolled a total of 1334 non-CRs and 211 CRs over the study period. There were no significant differences overall between non-CRs and CRs average USMLE Step 1 (239.81 ± 14.35 versus 240.86 ± 14.31; P = .32) or Step 2 scores (251.06 ± 13.80 versus 252.51 ± 14.21; P = .16). CONCLUSIONS: There was no link between USMLE Step 1 and Step 2 CK scores and CR selection across multiple clinical specialties over a 6-year period. Reliance on USMLE Step 1 and 2 scores to predict success in residency as measured by CR selection is not recommended.

Outpatient palliative care for chronic obstructive pulmonary disease: a case series.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have well-documented symptoms that affect quality of life. Professional societies recommend palliative care for such patients, but the optimal way of delivering this care is unknown. OBJECTIVE: To describe an outpatient palliative medicine program for patients with COPD. DESIGN: Retrospective case series. SETTING/SUBJECTS: Thirty-six patients with COPD followed in a United States academic outpatient palliative medicine clinic. MEASUREMENTS: Descriptive analysis of sociodemographic data, disease severity and comorbidities, treatments, hospitalizations, mortality, topic discussion, and symptom assessment. RESULTS: Thirty-six patients (representing 5% of the total number of patients with COPD seen in a specialty pulmonary clinic) were seen over 11 months and followed for 2 years. Seventy-seven percent of patients were Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 3-4 and 72% were on oxygen at home. No patients had documented advanced directives at the initial visit but documentation increased to 61% for those who had follow-up appointments. The most commonly documented topics included symptoms (100%), social issues (94%), psychological issues (78%), and advance care planning (75%). Of symptoms assessed, pain was the least prevalent (51.6%), and breathlessness and fatigue were the most prevalent (100%). Symptoms were often undertreated prior to the palliative care appointment. During the 3-year study period, there were 120 hospital admissions (median, 2) and 12 deaths (33%). CONCLUSIONS: The patients with COPD seen in the outpatient palliative medicine clinic had many comorbid conditions, severe illness, and significant symptom burden. Many physical and psychological symptoms were untreated prior to the palliative medicine appointment. Whether addressing these symptoms through a palliative medicine intervention affects outcomes in COPD is unknown but represents an important topic for future research.

A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care?

RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) have high symptom burdens and poor health-related quality of life. The American Thoracic Society issued a consensus statement outlining the need for palliative care for patients with chronic respiratory diseases. A better understanding of the unmet healthcare needs among patients with COPD may help determine which aspects of palliative care are most beneficial. OBJECTIVES: To identify the unmet healthcare needs of patients with COPD hospitalized for exacerbation using qualitative methods. METHODS: We conducted 20 semistructured interviews of patients admitted for acute exacerbations of COPD focused on patient understanding of diagnosis and prognosis, effect of COPD on daily life and social relationships, symptoms, healthcare needs, and preparation for the end of life. Transcribed interviews were evaluated using thematic analysis. MEASUREMENTS AND MAIN RESULTS: Six themes were identified. (1) Understanding of disease: Most participants correctly identified their diagnosis and recognized their symptoms worsening over time. Only half understood their disease severity and prognosis. (2) SYMPTOMS: Breathlessness was universal and severe. (3) Physical limitations: COPD prevented participation in activities. (4) Emotional distress: Depressive symptoms and/or anxiety were present in most participants. (5) Social isolation: Most participants identified social limitations and felt confined to their homes. (6) Concerns about the future: Half of participants expressed fear about their future. CONCLUSIONS: There are many unmet healthcare needs among patients hospitalized for COPD exacerbation. Relief of symptoms, physical limitations, emotional distress, social isolation, and concerns about the future may be better managed by integrating specialist palliative care into our current care model.

First-year residents outperform third-year residents after simulation-based education in critical care medicine.

INTRODUCTION: Previous research shows that gaps exist in internal medicine residents' critical care knowledge and skills. The purpose of this study was to compare the bedside critical care competency of first-year residents who received a simulation-based educational intervention plus clinical training with third-year residents who received clinical training alone. METHODS: During their first 3 months of residency, a group of first-year residents completed a simulation-based educational intervention. A group of traditionally trained third-year residents who did not receive simulation-based training served as a comparison group. Both groups were evaluated using a 20-item clinical skills assessment at the bedside of a patient receiving mechanical ventilation at the end of their medical intensive care unit rotation. Scores on the skills assessment were compared between groups. RESULTS: Simulator-trained first-year residents (n = 40) scored significantly higher compared with traditionally trained third-year residents (n = 27) on the bedside assessment (91.3% [95% confidence interval, 88.2%-94.3%] vs. 80.9% [95% confidence interval, 76.8%-85.0%]; P < 0.001). CONCLUSIONS: First-year residents who completed a simulation-based educational intervention demonstrated higher clinical competency compared with third-year residents who did not undergo simulation training. Critical care competency cannot be assumed after clinical intensive care unit rotations; simulation-based curricula can help ensure residents are proficient to care for critically ill patients.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial.

PURPOSE: The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU). METHODS AND MATERIALS: From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test. RESULTS: Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%, P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum. CONCLUSIONS: Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

Bleomycin induces alveolar epithelial cell death through JNK-dependent activation of the mitochondrial death pathway.

Exposure to bleomycin in rodents induces lung injury and fibrosis. Alveolar epithelial cell death has been hypothesized as an initiating mechanism underlying bleomycin-induced lung injury and fibrosis. In the present study we evaluated the contribution of mitochondrial and receptor-meditated death pathways in bleomycin-induced death of mouse alveolar epithelial cells (MLE-12 cells) and primary rat alveolar type II cells. Control MLE-12 cells and primary rat alveolar type II cells died after 48 h of exposure to bleomycin. Both MLE-12 cells and rat alveolar type II cells overexpressing Bcl-X(L) did not undergo cell death in response to bleomycin. Dominant negative Fas-associating protein with a death domain failed to prevent bleomycin-induced cell death in MLE-12 cells. Caspase-8 inhibitor CrmA did not prevent bleomycin-induced cell death in primary rat alveolar type II cells. Furthermore, fibroblast cells deficient in Bax and Bak, but not Bid, were resistant to bleomycin-induced cell death. To determine whether the stress kinase JNK was an upstream regulator of Bax activation, MLE-12 cells were exposed to bleomycin in the presence of an adenovirus encoding a dominant negative JNK. Bleomycin-induced Bax activation was prevented by the expression of a dominant negative JNK in MLE-12 cells. Dominant negative JNK prevented cell death in MLE-12 cells and in primary rat alveolar type II cells exposed to bleomycin. These data indicate that bleomycin induces cell death through a JNK-dependent mitochondrial death pathway in alveolar epithelial cells.

Hypoxic but not anoxic stabilization of HIF-1alpha requires mitochondrial reactive oxygen species.

The molecular mechanisms by which cells detect hypoxia (1.5% O2), resulting in the stabilization of hypoxia-inducible factor 1alpha (HIF-1alpha) protein remain unclear. One model proposes that mitochondrial generation of reactive oxygen species is required to stabilize HIF-1alpha protein. Primary evidence for this model comes from the observation that cells treated with complex I inhibitors, such as rotenone, or cells that lack mitochondrial DNA (rho(0)-cells) fail to generate reactive oxygen species or stabilize HIF-1alpha protein in response to hypoxia. In the present study, we investigated the role of mitochondria in regulating HIF-1alpha protein stabilization under anoxia (0% O2). Wild-type A549 and HT1080 cells stabilized HIF-1alpha protein in response to hypoxia and anoxia. The rho(0)-A549 cells and rho(0)-HT1080 cells failed to accumulate HIF-1alpha protein in response to hypoxia. However, both rho(0)-A549 and rho(0)-HT1080 were able to stabilize HIF-1alpha protein levels in response to anoxia. Rotenone inhibited hypoxic, but not anoxic, stabilization of HIF-1alpha protein. These results indicate that a functional electron transport chain is required for hypoxic but not anoxic stabilization of HIF-1alpha protein.