Creation of an asynchronous faculty development curriculum on well-written narrative assessments that avoid bias.

BACKGROUND: The COVID-19 pandemic in parallel with concerns about bias in grading resulted in many medical schools adopting pass/fail clinical grading and relying solely on narrative assessments. However, narratives often contain bias and lack specificity. The purpose of this project was to develop asynchronous faculty development to rapidly educate/re-educate > 2000 clinical faculty spread across geographic sites and clinical disciplines on components of a well-written narrative and methods to minimize bias in the assessment of students. METHODS: We describe creation, implementation, and pilot data outcomes for an asynchronous faculty development curriculum created by a committee of volunteer learners and faculty. After reviewing the literature on the presence and impact of bias in clinical rotations and ways to mitigate bias in written narrative assessments, the committee developed a web-based curriculum using multimedia learning theory and principles of adult learning. Just-in-time supplemental materials accompanied the curriculum. The Dean added completion of the module by 90% of clinical faculty to the department chairperson's annual education metric. Module completion was tracked in a learning management system, including time spent in the module and the answer to a single text entry question about intended changes in behavior. Thematic analysis of the text entry question with grounded theory and inductive processing was used to define themes of how faculty anticipate future teaching and assessment as a result of this curricula. OUTCOMES: Between January 1, 2021, and December 1, 2021, 2166 individuals completed the online module; 1820 spent between 5 and 90 min on the module, with a median time of 17 min and an average time of 20.2 min. 15/16 clinical departments achieved completion by 90% or more faculty. Major themes included: changing the wording of future narratives, changing content in future narratives, and focusing on efforts to change how faculty teach and lead teams, including efforts to minimize bias. CONCLUSIONS: We developed a faculty development curriculum on mitigating bias in written narratives with high rates of faculty participation. Inclusion of this module as part of the chair's education performance metric likely impacted participation. Nevertheless, time spent in the module suggests that faculty engaged with the material. Other institutions could easily adapt this curriculum with provided materials.

Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department.

BACKGROUND: Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration. METHODS: An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked. RESULTS: Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students. CONCLUSIONS: Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness.

BACKGROUND: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. OBJECTIVES: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. PARTICIPANTS: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. DESIGN: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. MEETING OUTCOMES: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). CONCLUSIONS: Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative.

OBJECTIVES: Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN: We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING: Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS: Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS: A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study.

BACKGROUND: Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. OBJECTIVE: To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. DESIGN: 1-year prospective cohort study. SETTING: 5 intensive care units at Duke University Medical Center, Durham, North Carolina. PARTICIPANTS: 126 patients receiving prolonged mechanical ventilation (defined as ventilation for >or=4 days with tracheostomy placement or ventilation for >or=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. MEASUREMENTS: Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. RESULTS: 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306,135 (SD, $285,467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year. LIMITATION: The results of this single-center study may not be applicable to other centers. CONCLUSION: Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. PRIMARY FUNDING SOURCE: None.

Longitudinal Milestone Assessment Extending Through Subspecialty Training: The Relationship Between ACGME Internal Medicine Residency Milestones and Subsequent Pulmonary and Critical Care Fellowship Milestones.

PURPOSE: Accreditation Council for Graduate Medical Education (ACGME) milestones were implemented across medical subspecialties in 2015. Although milestones were proposed as a longitudinal assessment tool potentially providing opportunities for early implementation of individualized fellowship learning plans, the association of subspecialty fellowship ratings with prior residency ratings remains unclear. This study aimed to assess the relationship between internal medicine (IM) residency milestones and pulmonary and critical care medicine (PCCM) fellowship milestones. METHOD: A multicenter retrospective cohort analysis was conducted for all PCCM trainees in ACGME-accredited PCCM fellowship programs, 2017-2018, who had complete prior IM milestone ratings from 2014 to 2017. Only professionalism and interpersonal and communication skills (ICS) were included based on shared anchors between IM and PCCM milestones. Using a generalized estimating equations model, the association of PCCM milestones ≤ 2.5 during the first fellowship year with corresponding IM subcompetencies was assessed at each time point, nested by program. Statistical significance was determined using logistic regression. RESULTS: The study included 354 unique PCCM fellows. For ICS and professionalism subcompetencies, fellows with higher IM ratings were less likely to obtain PCCM ratings ≤ 2.5 during the first fellowship year. Each ICS subcompetency was significantly associated with future lapses in fellowship (ICS01: ß = -0.67, P = .003; ICS02: ß = -0.70, P = .001; ICS03: ß = -0.60, P = .004) at various residency time points. Similar associations were noted for PROF03 (ß = -0.57, P = .007). CONCLUSIONS: Findings demonstrated an association between IM milestone ratings and low milestone ratings during PCCM fellowship. IM trainees with low ratings in several professionalism and ICS subcompetencies were more likely to be rated ≤ 2.5 during the first PCCM fellowship year. This highlights a potential use of longitudinal milestones to target educational gaps at the beginning of PCCM fellowship.

Implementation of Changes to Medical Student Documentation at Duke University Health System: Balancing Education With Service.

PURPOSE: When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships. METHOD: In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2018 to August 2019, locations and types of student-involved services (student-faculty or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed before August 2018, it was not possible to compare with prior student experiences. RESULTS: In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents, and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (> 90%) viewed their documentation as having a moderate or high impact on patient care. CONCLUSIONS: Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.

Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine.

RATIONALE: Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioner's career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning. OBJECTIVES: To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care. METHODS: A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote. MEASUREMENTS AND MAIN RESULTS: The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. CONCLUSIONS: Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

The Duke Hotspotting Initiative: Providing Meaningful Clinical Experiences and Improving Clinical Readiness for First-Year Medical Students.

PROBLEM: Many medical schools now incorporate meaningful clinical experiences for first-year medical students (MS1s). However, these clinical placements often fail to teach components of the physician experience, including health care logistics, cost-conscious care, longitudinal patient care, and interaction with an interprofessional team. The Duke Hotspotting Initiative (DHSI) is a student-led elective longitudinal experience for MS1s to serve as a patient's health care liaison to encourage proactive health management and efficient use of resources. APPROACH: DHSI is a combined didactic-clinical experience at Duke University School of Medicine. Students complete a didactic curriculum to develop relevant skills and maintain weekly contact with a patient in Durham, North Carolina, for the duration of the academic year. In their meetings with patients, students help them set and monitor health goals, identify and address barriers to health resources, and efficiently access primary care. Across 2 academic years (2017-2018 and 2018-2019), 54 MS1s were surveyed electronically before and after their participation in DHSI. They were asked about their comfort navigating various patient management scenarios, using communication tools, and assuming clinical responsibilities. OUTCOMES: DHSI offers MS1s a unique immersive opportunity to gain experience applying the clinical skills they will need in their future careers. Based on comparisons of responses from the 48 students (89%) who completed the pre-DHSI survey and 40 students (74%) who completed the post-DHSI survey, there was a significant increase in comfort with communication and patient advising, managing common chronic diseases, using interview skills, and assuming clinical responsibilities. NEXT STEPS: DHSI continues to expand in both size and scope, with the goal of incorporating team members from other health professions training programs at multiple institutions. Future analysis will investigate the longer-term impact of the program on students' professional development, objective changes in clinical skills, and outcomes for patients involved with DHSI.

Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?

OBJECTIVE: To determine the impact of the Accreditation Council for Graduate Medical Education mandates for duty hours and competencies on instruction, evaluation, and patient care in intensive care units in the United States. DESIGN: A Web-based survey was designed to determine the current methods of teaching and evaluation in the intensive care unit, barriers to changing methods of teaching and evaluation, and the impact of Accreditation Council for Graduate Medical Education regulations on teaching and patient care. SETTING: An anonymous Web-based survey was used; cumulative data were analyzed. SUBJECTS: A total of 125 of 380 program directors (33%) for pediatric critical care, pulmonary critical care, anesthesiology critical care, and surgery critical care fellowship programs completed questionnaires. MEASUREMENTS AND MAIN RESULTS: Bedside case-based teaching and standardized lectures are the most common methods of education in the intensive care unit. Patient safety and resident demands are two factors most likely to result in changes in instruction in the intensive care unit. Barriers to changes in education include clinical workload and lack of protected time and funding. Younger respondents viewed influences to change differently than older respondents. Respondents felt that neither education nor patient care had improved as a result of the Accreditation Council for Graduate Medical Education mandates. CONCLUSIONS: Medical education teaching methods and assessment in the intensive care unit have changed little since the initiation of the Accreditation Council for Graduate Medical Education regulations despite respondents' self-report of a willingness to change. Instead, the Accreditation Council for Graduate Medical Education regulations are thought to have negatively impacted resident attitudes, continuity of care, and even availability for teaching. These concerns, coupled with lack of protected time and funding, serve as barriers toward changes in critical care graduate medical education.

Expectations and outcomes of prolonged mechanical ventilation.

OBJECTIVE: To compare prolonged mechanical ventilation decision-makers' expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. DESIGN: Prospective observational cohort study. SETTING: Academic medical center. PATIENTS: A total of 126 patients receiving prolonged mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all kappa = <0.08), as was their accuracy in outcome prediction (range = 23%-44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. CONCLUSIONS: One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Surviving critical illness: acute respiratory distress syndrome as experienced by patients and their caregivers.

OBJECTIVE: To characterize the effects of critical illness in the daily lives and functioning of acute respiratory distress syndrome survivors. Survivors of acute respiratory distress syndrome, a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of acute respiratory distress syndrome survivors have not been reported. DESIGN: We conducted semistructured interviews with 23 acute respiratory distress syndrome survivors and 24 caregivers 3 to 9 mos after intensive care unit admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed, using Colaizzi's qualitative methodology, to identify significant ways in which survivors' critical illness experience impacted their lives. SETTING: Medical and surgical intensive care units of an academic medical center and a community hospital. PATIENTS: We recruited consecutively 31 acute respiratory distress syndrome survivors and their informal caregivers. Eight patients died before completing interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Participants related five key elements of experience as survivors of acute respiratory distress syndrome: 1) pervasive memories of critical care; 2) day-to-day impact of new disability; 3) critical illness defining the sense of self; 4) relationship strain and change; and 5) ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers' interviews revealed substantial strain from caregiving responsibilities as well as frequent symptom minimization by patients. CONCLUSIONS: The diverse and unique experiences of acute respiratory distress syndrome survivors reflect the global impact of severe critical illness. We have identified symptom domains important to acute respiratory distress syndrome patients who are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after acute respiratory distress syndrome.

Design and Implementation of a Peer-Reviewed Medical Education Video Competition: The Best of American Thoracic Society Video Lecture Series.

BACKGROUND: Video is an increasingly popular medium for consuming online content, and video-based education is effective for knowledge acquisition and development of technical skills. Despite the increased interest in and use of video in medical education, there remains a need to develop accurate and trusted collections of peer-reviewed videos for medical learners. OBJECTIVE: We developed the first professional society-based, open-access library of crowd-sourced and peer-reviewed educational videos for medical learners and health care providers. METHODS: A comprehensive peer-review process of medical education videos was designed, implemented, reviewed, and modified using a plan-do-study-act approach to ensure optimal accuracy and effective pedagogy, while emphasizing modern teaching methods and brevity. The number of submissions and views were tracked as metrics of interest and engagement of medical learners and educators. RESULTS: The Best of American Thoracic Society Video Lecture Series (BAVLS) was launched in 2016. Total video submissions for 2016, 2017, and 2018 were 26, 55, and 52, respectively. Revisions to the video peer-review process were made after each submission cycle. By 2017, the total views of BAVLS videos on www.thoracic.org and YouTube were 9100 and 17 499, respectively. By 2018, total views were 77 720 and 152 941, respectively. BAVLS has achieved global reach, with views from 89 countries. CONCLUSIONS: The growth in submissions, content diversity, and viewership of BAVLS is a result of an intentional and evolving review process that emphasizes creativity and innovation in video-based pedagogy. BAVLS can serve as an example for developing institutional or society-based video platforms.

Effects of respiratory-therapist driven protocols on house-staff knowledge and education of mechanical ventilation.

High practice variability in critical care medicine contributes to medical errors and the high cost of ICU care. Clinical guidelines and protocol-based strategies can reduce the variation and cost of ICU medicine, increase adherence to evidence-based interventions, and reduce error, thereby improving the morbidity and mortality of critically ill patients. There are various barriers to guideline adherence, and protocols often are more successful when implemented by nonphysicians. However, this has potential consequences for house-staff knowledge and education. This article discusses the implications of mechanical ventilation protocols on patient care and medical education, and this article offers suggestions for synchronizing the processes for improving patient care to improve medical education.

Hyperammonemia in the ICU.

Patients experiencing acute elevations of ammonia present to the ICU with encephalopathy, which may progress quickly to cerebral herniation. Patient survival requires immediate treatment of intracerebral hypertension and the reduction of ammonia levels. When hyperammonemia is not thought to be the result of liver failure, treatment for an occult disorder of metabolism must begin prior to the confirmation of an etiology. This article reviews ammonia metabolism, the effects of ammonia on the brain, the causes of hyperammonemia, and the diagnosis of inborn errors of metabolism in adult patients.

How Prepared Are Medical and Nursing Students to Identify Common Hazards in the Intensive Care Unit?

RATIONALE: Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. Although the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students' formal education may not prepare them adequately for this role. OBJECTIVES: To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified. METHODS: Mixed-methods observational study of graduating nursing (n = 51) and medical (n = 93) students who completed two "Room of Horrors" simulations to identify patient safety hazards. Qualitative analysis was used to extract themes from students' written hazard descriptions. Fisher's exact test was used to determine differences in frequency of hazards identified between groups. RESULTS: Identification of hazards by students was low: 66% did not identify missing personal protective equipment for a patient on contact isolation, and 58% did not identify a medication administration error (medication hanging for a patient with similar name). Interprofessional differences existed in how hazards were identified: medical students noted that restraints were not indicated (73 vs. 2%, P < 0.001), whereas nursing students noted that there was no order for the restraints (58.5 vs. 0%, P < 0.0001). Nursing students discovered more issues with malfunctioning or incorrectly used equipment than medical students. Teams performed better than individuals, especially for hazards in the second simulation that were similar to those in the first: need to replace a central line with erythema (73% teams identified) versus need to replace a peripheral intravenous line (10% individuals, P < 0.0001). Nevertheless, teams of students missed many intensive care unit-specific hazards: 54% failed to identify the presence of pressure ulcers; 85% did not notice high tidal volumes on the ventilator; and 90% did not identify the absence of missing spontaneous awakening/breathing trials and absent stress ulcer prophylaxis. CONCLUSIONS: Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each other's roles and responsibilities.

CaPOW! Using Problem Sets in a Capstone Course to Improve Fourth-Year Medical Students' Confidence in Self-Directed Learning.

PROBLEM: Despite the importance of self-directed learning (SDL) in the field of medicine, individuals are rarely taught how to perform SDL or receive feedback on it. Trainee skill in SDL is limited by difficulties with self-assessment and goal setting. APPROACH: Ninety-two graduating fourth-year medical students from Duke University School of Medicine completed an individualized learning plan (ILP) for a transition-to-residency Capstone course in spring 2015 to help foster their skills in SDL. Students completed the ILP after receiving a personalized report from a designated faculty coach detailing strengths and weaknesses on specific topics (e.g., pulmonary medicine) and clinical skills (e.g., generating a differential diagnosis). These were determined by their performance on 12 Capstone Problem Sets of the Week (CaPOWs) compared with their peers. Students used transitional-year milestones to self-assess their confidence in SDL. OUTCOMES: SDL was successfully implemented in a Capstone course through the development of required clinically oriented problem sets. Coaches provided guided feedback on students' performance to help them identify knowledge deficits. Students' self-assessment of their confidence in SDL increased following course completion. However, students often chose Capstone didactic sessions according to factors other than their CaPOW performance, including perceived relevance to planned specialty and session timing. NEXT STEPS: Future Capstone curriculum changes may further enhance SDL skills of graduating students. Students will receive increased formative feedback on their CaPOW performance and be incentivized to attend sessions in areas of personal weakness.

Engaging Survivors of Critical Illness in Health Care Assessment and Policy Development. Ethical and Practical Complexities.

Health systems, granting agencies, and professional societies are increasingly involving patients and their family members in the delivery of health care and the improvement of health sciences. This is a laudable advance toward fully patient-centered medicine. However, patient engagement is not a simple matter, either practically or ethically. The complexities include (1) the physical limitations that patients and their family members may have, from traveling to meetings to special dietary needs; (2) the emotional sensitivities patients and their families might experience-from distress at discussions of disease prognosis, outcomes, and therapies to being inexperienced at public speaking; and (3) the fact that advocacy efforts by patients and family members, which may be encouraged at the national level, may threaten individual professionals providing care to individual patients and may result in risk to patients. In this article, a patient-physician and patient-bioethicist set out the obstacles, including ones that they have encountered in their own advocacy efforts. The aim is to survey the practical and ethical landscape so that solutions to various problems may be identified and solved as we move forward in our efforts to involve patients and their families in research, policy, and quality improvement in critical care medicine.

How We Engage Graduating Professional Students in Interprofessional Patient Safety.

PROBLEM: Interprofessional curricula on patient safety do not acknowledge the culture and vulnerabilities of the student experience and often do not engage students. METHODS: We describe a patient safety collaboration between graduating nursing and medical students during their Capstone courses that fostered conversations about the similarities and differences in professional school experiences around patient safety. Students wrote reflections about an unanticipated patient outcome. Qualitative content analysis was used to characterize themes within student reflections, and to create audience response system questions to highlight differences in each profession's reflections and to facilitate discussion about those differences during the collaboration. FINDINGS: Medical students identified events in which perceived patient outcomes were worse than events identified by nursing students. Nursing students identified more near-miss events. Nursing students positively impacted the event and attributed action to the presence of a clinical instructor and personal responsibility for patient care. Medical students described themselves as "only a witness" and attributed inaction to hierarchy and concern about grades. CONCLUSIONS: Students felt the session would change their future attitudes and behaviors. Stevenson Chudgar Molloy Phillips Engle Clay.