Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

Effect of Pause Procedures on Participant Reflection and Commitment-to-Change in Continuing Medical Education.

Problem: Conferences are the most common form of continuing medical education (CME), but their effect on clinician practice is inconsistent. Reflection is a critical step in the process of practice change among clinicians and may lead to improved outcomes following conference-based CME. However, reflection requires time to process newly-learned material. Adequate time for reflection may be noticeably absent during many conference presentations. Intervention: The pause procedure is a 90-second 'pause' during a 30-minute presentation so learners can review and discuss content. The goal of the pause procedure is to stimulate learners' active engagement with newly learned material which will, in turn, promote learner reflection. Context: Fifty-six presentations at two hospital medicine CME conferences were assigned to the pause procedure or control. Study outcomes provided by conference participants were validated reflection scores and commitment-to-change (CTC) statements for each presentation. A post-hoc survey of the intervention group was conducted to assess presenters' experiences with the pause procedure. Impact: A total of 527 conference participants completed presentation evaluations (response rate 72.7%). Presentations incorporating the pause procedure failed to lead higher participant reflection scores (percentage 'top box' score; intervention: 39.2% vs. control: 41.7%, p = 0.40) or participant CTC rates (median [IQR]; intervention: 4.64 [3.04, 10.57] vs. control: 8.16 [5.28, 17.12], p = 0.13) than control presentations. However, the majority of presenters (16 out of 17 survey respondents) had never before used the intervention and little active engagement among learners was noted during the pause procedure. Lessons Learned: Adding the pause procedure to CME presentations did not lead to greater reflection or CTC among clinician learners. However, presenters had limited experience with the intervention, which may have reduced their fidelity to the educational principles of the pause procedure. Faculty development may be necessary when planning a new educational intervention that is to be implemented by conference presenters.

Patient Length of Stay Under the Two-Midnight Rule: Assessing the Accuracy of Providers' Predictions.

EXECUTIVE SUMMARY: We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Medical moulages of farm accidents.

Although popular for displaying dermatologic conditions before the advent of photography, the medical moulage has also illustrated injuries and accidents. Explored here are three farm accidents and the moulages based on them that occurred in rural Minnesota in the early 20th century. Besides being an object of historical interest, the medical moulage also provides a valuable learning and training opportunity, and can even be thought of as the predecessor of three dimensional printing.

Patient Outcomes Compared Between Admissions Coordinated by the Transfer Center and Emergency Department at a U.S. Tertiary Care Hospital.

BACKGROUND: Patient admissions at a U.S. tertiary care hospital occur via the emergency department (ED), or transfer center. We aim to compare the clinical outcomes of patients admitted from the ED to admissions coordinated by the transfer center. METHODS: Admissions to Mayo Clinic Hospital, Rochester, MN, between July 2019 to June 2021 were identified in this retrospective study and categorized into two cohorts-transfer center and ED. The two cohorts were then matched for age, sex, admitting service, and Charlson Comorbidity Index. Univariate and multivariate analyses were performed to compare hospital length of stay (LOS), mortality, 30-day mortality, and 30-day readmissions between the two cohorts. RESULTS: 73,685 admissions were identified, of which 24,262 (33%) were transfer center admissions. In the matched cohorts (n = 19,093, each), in-hospital mortality (2.4% versus 1.9%), 30-day mortality (5.4% versus 3.9%), 30-day readmission (12.7% versus 7.2%), and LOS (6.4 days versus 5.1 days) were significantly higher ( P < 0.001) among the admissions coordinated by transfer center. A higher palliative care consultation rate (9.4% versus 6.2%, P < 0.001), and a lower proportion of home discharges home (76.2% versus 82.5%, P < 0.001) among transfer center admissions was observed. Similar findings were noted in multivariate analysis, even when adjusting for LOS. CONCLUSIONS: Transfer center admissions had higher in-hospital mortality, LOS, 30-day mortality, and 30-day readmission compared to ED admissions. This study also highlights new considerations for palliative care consultation before transfer acceptance, especially to avoid futile transfers. Additional studies analyzing factors behind the outcomes of transfer center admissions are required.

Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial.

BACKGROUND: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.

Retrievability and device-related complications of the G2 filter: a retrospective study of 139 filter retrievals.

PURPOSE: To evaluate the retrievability and safety of the G2 filter. MATERIALS AND METHODS: A retrospective study of all G2 filter retrievals at a single institution was conducted. Hospital records and imaging studies were reviewed for complications, and factors affecting retrieval were analyzed. RESULTS: From 2005 to 2009, a total of 139 patients presented for retrieval of their G2 filter, and 131 pairs of pre- and post-placement cavagrams and 39 computed tomography scans were available for analysis. The following findings were recorded: limb penetration (n = 33), tilt greater than 15° (n = 22), local migration greater than 2 cm (n = 17), retained thrombus within the filter (n = 16), deformity (n = 10), inferior vena cava (IVC) occlusion (n = 3), fracture (n = 2), and pulmonary embolism breakthrough (n = 2). A total of 118 filters were removed, with a mean indwelling time of 131.8 days (range, 3-602 d). Indwell time (< 90, 90-180, or > 180 d) did not affect retrieval (P = .4). There were 21 filters (15.1%) left in situ as a result of severe tilt (n = 9), significant thrombus in the filter (n = 5), IVC occlusion (n = 3), filter incorporation into the caval wall (n = 3), or lack of central venous access (n = 1). There was a strong relationship between penetration and caudal migration (P < .0001). Severe tilt was associated with prolonged fluoroscopic times for retrieval (P = .003). CONCLUSIONS: The majority of G2 filters can be removed without difficulty. The most common factor affecting retrieval was severe tilting. The indwelling time had no impact on retrieval. G2 filter-related complications were frequent but most, including fractures, were clinically insignificant.

A historical perspective on the problem of the retained surgical sponge: Have we really come that far?

Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.

The Elevated High-Sensitivity Cardiac Troponin T Pilot: Diagnoses and Outcomes.

OBJECTIVE: To identify the diagnoses and outcomes associated with elevated high sensitivity cardiac troponin T (hs-cTnT) compared with the 4th-generation troponin T and to validate the Mayo Clinic hs-cTnT myocardial infarction algorithm cutoff values. PATIENTS AND METHODS: Consecutive blood samples of patients presenting to the emergency department between July 2017 and August 2017, who had 4th-generation troponin T, were also analyzed using the hs-cTnT assay. Troponin T values, discharge diagnoses, comorbidities, and outcomes were assessed. In addition, analyses of sex-specific and hs-cTnT cutoff values were assessed. RESULTS: Of 830 patients, 32% had an elevated 4th-generation troponin T, whereas 64% had elevated hs-cTnT. With serial sampling, 4th-generation troponin missed a chronic myocardial injury pattern and acute myocardial injury pattern in 64% and 16% of patients identified with hs-cTnT, respectively. Many of these "missed" patients had discharge diagnoses associated with cardiovascular disease, infection, or were postoperative. Five of the 6 patients with unstable angina ruled in for myocardial infarction. CONCLUSION: There were many increases in hs-cTnT that were missed by the 4th-generation cTnT assay. Most new increases are not related to acute cardiac causes. They were more consistent with chronic myocardial injury. High-sensitivity cTnT did reclassify most patients with unstable angina as having non-ST-elevation myocardial infarction. Older age, more comorbidities, and lower hemoglobin were associated with elevated hs-cTnT. Our data also support the use of our sex-specific cutoff values.

The Ideal Hospital Discharge Summary: A Survey of U.S. Physicians.

BACKGROUND: Hospital discharge summaries enable communication between inpatient and outpatient physicians. Despite existing guidelines for discharge summaries, they are frequently suboptimal. OBJECTIVE: The aim of this study was to assess physicians' perspectives about discharge summaries and the differences between summaries' authors (hospitalists) and readers (primary care physicians [PCPs]). METHODS: A national survey of 1600 U.S. physicians was undertaken. Primary measures included physicians' preferences in discharge summary standardization, content, format, and audience. RESULTS: A total of 815 physicians responded (response rate = 51%). Eighty-nine percent agreed that discharge summaries "should have a standardized format." Most agreed that summaries should "document everything that was done, found, and recommended in the hospital" (64%) yet "only include details that are highly pertinent to the hospitalization" (66%). Although 74% perceived patients as an important audience of discharge summaries, only 43% agreed that summaries "should be written in language that patients…can easily understand," and 68% agreed that it "should be written solely for provider-to-provider communication." Compared with hospitalists, PCPs preferred comprehensive summaries (68% versus 59%, P = 0.002). More PCPs agreed that separate summaries should be created for patients and for provider-to-provider communication than hospitalists (60% versus 47%, P < 0.001). Compared with PCPs, more hospitalists believe that "hospitalists are too busy to prepare a high-quality discharge summary" (44% versus 23%, P < 0.001) and "PCPs have insufficient time to read an entire discharge summary" (60% versus 38%, P < 0.001). CONCLUSIONS: Physicians believe that discharge summaries should have a standardized format but do not agree on how comprehensive or in what format they should be. Efforts are necessary to build consensus toward the ideal discharge summary.

Demystifying airline syncope.

Syncope forms a major part of medical in-flight emergencies contributing one-in-four in-flight medical events accounting to 70% of flight diversions. In such patients, it is important to elucidate the pathophysiology of syncope prior to diversion. Postural hypotension is the most common etiology of in-flight syncopal events. However, individuals without any underlying autonomic dysfunction can still experience syncope from hypoxia also known as airline syncope. Initial steps in managing such patients include positioning followed by the airway, breathing and circulation of resuscitation. These interventions need to be in close coordination with ground control to determine decision for flight diversion. Interventions which have been tried for prevention include mental challenge and increased salt and fluid intake. The current paper enhances the understanding of airline syncope by summarizing the associated pathophysiologic mechanisms and the management medical personnel can initiate with limited resources.

Venous Thromboembolism Prophylaxis: Need for Continuous Assessment Due to Changes in Risk During the Same Hospitalization.

OBJECTIVE: To explore the role of venous thromboembolism (VTE) risk reassessment in hospitalized medically ill patients without a change in level of care. PATIENTS AND METHODS: In this exploratory retrospective study, the medical records of 171 consecutive adult patients (≥18 years) hospitalized under the medicine service for more than 3 days without a change in the level of care from January 1, 2015, to March 1, 2015, were reviewed. The primary outcome was a change in the risk score between day 1 and day 3 of hospital stay (using the Padua Prediction Score). The secondary outcomes were changes in risk stratification class (low vs high) and cost-benefit analysis. RESULTS: The risk score was significantly different between day 1 and day 3 (4.7±1.7 vs 4.2±1.8; P=.008). All the patients with low risk on day 1 remained at low risk on day 3. However, 25 of 136 patients (18.4%) with high risk on day 1 were reclassified as low risk on day 3 (P<.001). No patients changed from low risk to high risk at day 3. The reclassification could have saved $35 per patient-day of inappropriate pharmacological prophylaxis in addition to patient discomfort, bleeding risk, and heparin-induced thrombocytopenia. CONCLUSION: This is the first study to suggest the need for regular assessment for VTE risk on medicine wards because of changing patient risk. Regular reassessment could reduce health care waste and patient discomfort.

Characteristics of Effective Continuing Medical Education for Physician Assistants and Nurse Practitioners in Hospital Medicine.

PURPOSE: The purpose of this study was to describe participant characteristics and effective teaching methods at a national continuing medical education (CME) conference on hospital medicine for physician assistants (PAs) and nurse practitioners (NPs). METHODS: In this cross-sectional study, participants provided demographic information and teaching effectiveness scores for each presentation. Associations between teaching effectiveness score and presentation characteristics were determined. RESULTS: In total, 163 of 253 participants (64.4%) completed evaluations of 28 presentations. Many of the participants were younger than 50 years (69.0%), had practiced for fewer than 5 years (41.5%), and worked in nonacademic settings (76.7%). Teaching effectiveness scores were significantly associated with the use of clinical cases (perfect scores for 68.8% of presentations with clinical cases vs. 59.8% without; P = .04). CONCLUSION: Many PAs and NPs at an HM CME conference were early-career clinicians working in nonacademic settings. Presenters at CME conferences in hospital medicine should consider using clinical cases to improve their teaching effectiveness among PA and NP learners.

Effectiveness of coil embolization in angiographically detectable versus non-detectable sources of upper gastrointestinal hemorrhage.

PURPOSE: To determine whether the effectiveness of arterial embolization in patients with acute upper gastrointestinal hemorrhage is related to the visualization of contrast medium extravasation at angiography. MATERIALS AND METHODS: Transcatheter embolization was performed in 108 patients who experienced acute upper gastrointestinal hemorrhage during a 5-year period. Patient charts were retrospectively reviewed. Thirty-six patients who underwent embolization after angiography demonstrated active contrast medium extravasation from an involved artery. Seventy-two patients underwent embolization in the absence of contrast medium extravasation into a bowel lumen. Embolization technique, requirement for further blood products, need for further surgery, and 30-day mortality were recorded. RESULTS: The gastroduodenal artery (GDA) was embolized in 26 of the 36 patients (72%) with extravasation, and the left gastric artery was embolized in 10 (28%). The GDA was embolized in 64 of the 72 patients (89%) without extravasation, and the left gastric artery was embolized in 13 (18%). After embolization, 23 of the 36 patients (64%) with extravasation and 44 of the 72 (61%) without extravasation required additional blood product transfusions. Seven of the 36 patients (19%) with extravasation and 16 of the 72 (22%) without extravasation required subsequent surgery secondary to bleeding. Thirty-day hemorrhage-related mortality was 17% (six of 36 patients) in the positive extravasation group and 22% (16 of 72 patients) in the negative extravasation group. The treatment success rate was 44% (16 of 36 patients) in the positive extravasation group and 44% (32 of 72 patients) in the negative extravasation group. CONCLUSIONS: In patients with acute upper gastrointestinal hemorrhage, arterial embolization is equally effective in patients who demonstrate active contrast medium extravasation at angiography as in those who do not show contrast extravasation.

Sister Mary Joseph and her nodule: historical and clinical perspective.

Sister Mary Joseph's nodule is referred to a metastatic lesion of the umbilicus originating from intra-abdominal or pelvic malignant disease. Metastases from other locations have been also reported. In 1949 the English surgeon Sir Hamilton Bailey coined this term after Sister Mary Joseph (1856-1939), a superintendent nurse at St. Mary's Hospital in Rochester, Minnesota, USA, who was the first to observe the association between the umbilical nodule and intra-abdominal malignancy. In this article, we discuss both the historical and clinical perspectives of Sister Mary Joseph's nodule.

Ethylene glycol and methanol ingestion cared for by tele-emergency pharmacy and tele-emergency medicine.

We believe this is the first documented case of a critically ill patient managed by telepharmacy in a remote, rural critical access hospital. We outline the case and the benefits of telepharmacy in under-resourced, rural critical access emergency departments.

Incidence and risk factors for surgical intervention after uterine artery embolization.

OBJECTIVE: To determine the incidence and risk factors for surgical intervention after uterine artery embolization for symptomatic uterine fibroids. STUDY DESIGN: Electronic medical records of all patients who underwent uterine artery embolization for symptomatic uterine leiomyomata were reviewed. Logistic regression was used to identify independent risk factors for any surgical intervention and for hysterectomy alone after uterine artery embolization. RESULTS: Uterine artery embolization was performed in 454 patients during the study period, with a median follow-up time (range) of 14 (0-128) months. Overall, 99 patients (22%) underwent any surgical intervention after uterine artery embolization in the operating room. Risk factors for any surgical intervention included younger age (P < .003), bleeding as an indication for uterine artery embolization (P < .01), presence of significant collateral ovarian vessel contribution to the uterus (P < .01), or use of 355-500 mum particles (P < .008). CONCLUSION: Patients undergoing uterine artery embolization have a 22% risk for requiring additional surgical intervention, but overall uterine artery embolization is an effective minimally invasive option.