Emergency Subglottic Airway Training and Assessment of Skills Retention of Attending Anesthesiologists With Simulation Mastery-Based Learning.

BACKGROUND: Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques. METHODS: Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member. RESULTS: Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results. CONCLUSIONS: We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology.

Perceptions of collaborative relationships between seven different health care professions in Northern Italy.

This article presents quantitative findings from a mixed method study that aimed to explore the status quo of interprofessional collaboration (IPC) in a Health Trust, located in a trilingual region in Northern Italy. The survey targeted seven health professions (physicians, nurses, dieticians, occupational therapists, physiotherapists, speech therapists, and psychologists). The survey was distributed online to more than 5,000 health professionals and completed by 2,238. This paper presents results on the frequency of collaboration as well as data from a multiple-group measurement scale for assessing IPC. Descriptive statistics were calculated for continuous variables while categorical data were analysed as counts and percentages. Pearson's Chi-square test and Fisher's exact test were calculated while Mann Whitney and Kruskal Wallis tests were applied to analyse statistical differences in IPC between groups according to sociodemographic variables. In general, our survey data showed that participants, perceived IPC in a positive way, even if the analysis indicated heterogeneity in the level of collaboration expressed. We also found that not all professions had an opportunity to collaborate with others. In addition, we found evidence to suggest that the way health care is organised impacted on perceptions of collaboration between the health professionals in this study. This study provides an initial insight into the perceived levels of IPC within a North Italian context. As such, it offers an account of the strengths and weaknesses of IPC from seven different professional groups based in this region of Europe.

Critical Analysis of Evidence About the Impacts of Faculty Development in Systematic Reviews: A Systematic Rapid Evidence Assessment.

INTRODUCTION: Faculty Development (FD) encompasses a range of learning activities undertaken to prepare clinical teachers for their various roles as educators, leaders, and scholars. This article presents the findings of a systematic rapid evidence assessment that aimed to investigate the impact of FD on clinical teachers. METHODS: We searched the published and gray literature for systematic reviews of FD to identify evidence to help inform judgments about which kinds of FD activities are effective for which groups of clinical teachers. RESULTS: After screening the literature, we found seven systematic reviews met our inclusion criteria. Following a critical analysis of these reviews, we found that they contained a number of limitations in relation to their use of review methods and reporting of results. DISCUSSION: On the basis of the analysis presented in this systematic rapid evidence assessment, we conclude that the included reviews do not provide high-quality evidence to effectively support decisions about choices of FD activities, even where the review authors made positive claims about impact. Suggestions are provided to improve the quality of systematic reviews in this area.

The Influence of Traffic, Area Location, and Other Factors on Operating Room Microbial Load.

OBJECTIVE To determine how the movement of patients, equipment, materials, staff, and door openings within the operating room (OR) affect microbial loads at various locations within the OR. DESIGN Observation and sampling study. SETTING Academic health center, public hospital. METHODS We first analyzed 27 videotaped procedures to determine the areas in the OR with high and low numbers of people in transit. We then placed air samplers and settle plates in representative locations during 21 procedures in 4 different ORs during 2 different seasons of the year to measure microbial load in colony-forming units (CFU). The temperature and humidity, number of door openings, physical movement, and the number of people in the OR were measured for each procedure. Statistical analysis was conducted using hierarchical regression. RESULTS The microbial load was affected by the time of year that the samples were taken. Both microbial load measured by the air samplers and by settle plates in 1 area of the OR was correlated with the physical movement of people in the same area but not with the number of door openings and the number of people in the OR. CONCLUSIONS Movement in the OR is correlated with the microbial load. Establishing operational guidelines or developing OR layouts that focus on minimizing movement by incorporating desirable internal storage points and workstations can potentially reduce microbial load, thereby potentially reducing surgical site infection risk. Infect Control Hosp Epidemiol 2018;39:391-397.

The Prato Method: A Guide to the Application of Economic Evaluations in Health Professions Education Research.

The estimation of cost and value in health professions education should involve robust methodologies and decision tools. These methods and tools should be applied consistently and transparently, but more importantly, employed in the appropriate context depending on the availability of data, target estimates, and stakeholder focus. Best practice methodology and application of decision tools will allow for a clearer and more comprehensive understanding of the return on investment of health profession education interventions by shedding greater light on the full opportunity cost of providing programs and the value of such programs to learners and recipients of health care services more broadly. This article provides insight into the basic methods, decision tools, and key evaluation concepts that might be considered for the purpose of undertaking cost and value research in continuing education for health professionals. These methods and decision tools are based on consolidated discussions by the organizing delegates of the inaugural Symposium of the Society for Cost and Value of Health Professions Education, held in Prato, Italy, October 2015. In summary, the application of economic methods and tools used for analyzing health professions education is currently inconsistent. This article provides an overview and recommendations on the use of certain economic methods and tools when evaluating health profession education programs. It also provides a clear understanding of key evaluation concepts important for undertaking an economic review of a program.

Framework development for the assessment of interprofessional teamwork in mental health settings.

In mental health settings, interprofessional practice is regarded as a comprehensive approach to prevent relapse and manage chronic conditions with practice of various teamwork interventions. To reinforce the potential of interprofessional teamwork, it is recommended that theories or conceptual frameworks be employed. There continues, however, to be a limited use of such approaches that assess the quality of interprofessional teamwork in mental health settings. This article aimed to present a new conceptual framework for the assessment of interprofessional teamwork based on the findings of a scoping review of the literature. This review was undertaken to identify conceptual frameworks utilised in interprofessional teamwork in mental health settings. After reviewing 952 articles, the methodological characteristics extracted from 12 articles were considered. The included studies were synthesised into the Donabedian structure-process-outcome model. The findings revealed that structural issues comprised three elements: professional characteristics, client-care characteristics, and contextual characteristics in organisations. Process issues comprised two elements: team mechanisms and community-oriented services. Finally, outcome issues comprised the following elements: clients' outcomes and professionals' outcomes. The review findings suggested possibilities for further development of how to assess the quality of interprofessional teamwork and provided information about what specific approach is required to improve interprofessional teamwork. Future research should utilise various areas and cultures to clarify the adaptation potential.

An Approach for Calculating Student-Centered Value in Education - A Link between Quality, Efficiency, and the Learning Experience in the Health Professions.

Health professional education is experiencing a cultural shift towards student-centered education. Although we are now challenging our traditional training methods, our methods for evaluating the impact of the training on the learner remains largely unchanged. What is not typically measured is student-centered value; whether it was 'worth' what the learner paid. The primary aim of this study was to apply a method of calculating student-centered value, applied to the context of a change in teaching methods within a health professional program. This study took place over the first semester of the third year of the Bachelor of Physiotherapy at Monash University, Victoria, Australia, in 2014. The entire third year cohort (n = 78) was invited to participate. Survey based design was used to collect the appropriate data. A blended learning model was implemented; subsequently students were only required to attend campus three days per week, with the remaining two days comprising online learning. This was compared to the previous year's format, a campus-based face-to-face approach where students attended campus five days per week, with the primary outcome-Value to student. Value to student incorporates, user costs associated with transportation and equipment, the amount of time saved, the price paid and perceived gross benefit. Of the 78 students invited to participate, 76 completed the post-unit survey (non-participation rate 2.6%). Based on Value to student the blended learning approach provided a $1,314.93 net benefit to students. Another significant finding was that the perceived gross benefit for the blended learning approach was $4014.84 compared to the campus-based face-to-face approach of $3651.72, indicating that students would pay more for the blended learning approach. This paper successfully applied a novel method of calculating student-centered value. This is the first step in validating the value to student outcome. Measuring economic value to the student may be used as a way of evaluating effective change in a modern health professional curriculum. This could extend to calculate total value, which would incorporate the economic implications for the educational providers. Further research is required for validation of this outcome.

Training for impact: the socio-economic impact of a fit for purpose health workforce on communities.

Across the globe, a "fit for purpose" health professional workforce is needed to meet health needs and challenges while capitalizing on existing resources and strengths of communities. However, the socio-economic impact of educating and deploying a fit for purpose health workforce can be challenging to evaluate. In this paper, we provide a brief overview of six promising strategies and interventions that provide context-relevant health professional education within the health system. The strategies focused on in the paper are:1. Distributed community-engaged learning: Education occurs in or near underserved communities using a variety of educational modalities including distance learning. Communities served provide input into and actively participate in the education process.2. Curriculum aligned with health needs: The health and social needs of targeted communities guide education, research and service programmes.3. Fit for purpose workers: Education and career tracks are designed to meet the needs of the communities served. This includes cadres such as community health workers, accelerated medically trained clinicians and extended generalists.4. Gender and social empowerment: Ensuring a diverse workforce that includes women having equal opportunity in education and are supported in their delivery of health services.5. Interprofessional training: Teaching the knowledge, skills and attitudes for working in effective teams across professions.6. South-south and north-south partnerships: Sharing of best practices and resources within and between countries.In sum, the sharing of resources, the development of a diverse and interprofessional workforce, the advancement of primary care and a strong community focus all contribute to a world where transformational education improves community health and maximizes the social and economic return on investment.

A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39.

BACKGROUND: Interprofessional education (IPE) aims to bring together different professionals to learn with, from, and about one another in order to collaborate more effectively in the delivery of safe, high-quality care for patients/clients. Given its potential for improving collaboration and care delivery, there have been repeated calls for the wider-scale implementation of IPE across education and clinical settings. Increasingly, a range of IPE initiatives are being implemented and evaluated which are adding to the growth of evidence for this form of education. AIM: The overall aim of this review is to update a previous BEME review published in 2007. In doing so, this update sought to synthesize the evolving nature of the IPE evidence. METHODS: Medline, CINAHL, BEI, and ASSIA were searched from May 2005 to June 2014. Also, journal hand searches were undertaken. All potential abstracts and papers were screened by pairs of reviewers to determine inclusion. All included papers were assessed for methodological quality and those deemed as "high quality" were included. The presage-process-product (3P) model and a modified Kirkpatrick model were employed to analyze and synthesize the included studies. RESULTS: Twenty-five new IPE studies were included in this update. These studies were added to the 21 studies from the previous review to form a complete data set of 46 high-quality IPE studies. In relation to the 3P model, overall the updated review found that most of the presage and process factors identified from the previous review were further supported in the newer studies. In regard to the products (outcomes) reported, the results from this review continue to show far more positive than neutral or mixed outcomes reported in the included studies. Based on the modified Kirkpatrick model, the included studies suggest that learners respond well to IPE, their attitudes and perceptions of one another improve, and they report increases in collaborative knowledge and skills. There is more limited, but growing, evidence related to changes in behavior, organizational practice, and benefits to patients/clients. CONCLUSIONS: This updated review found that key context (presage) and process factors reported in the previous review continue to have resonance on the delivery of IPE. In addition, the newer studies have provided further evidence for the effects on IPE related to a number of different outcomes. Based on these conclusions, a series of key implications for the development of IPE are offered.

A Cost-Effectiveness Analysis of Blended Versus Face-to-Face Delivery of Evidence-Based Medicine to Medical Students.

BACKGROUND: Blended learning describes a combination of teaching methods, often utilizing digital technologies. Research suggests that learner outcomes can be improved through some blended learning formats. However, the cost-effectiveness of delivering blended learning is unclear. OBJECTIVE: This study aimed to determine the cost-effectiveness of a face-to-face learning and blended learning approach for evidence-based medicine training within a medical program. METHODS: The economic evaluation was conducted as part of a randomized controlled trial (RCT) comparing the evidence-based medicine (EBM) competency of medical students who participated in two different modes of education delivery. In the traditional face-to-face method, students received ten 2-hour classes. In the blended learning approach, students received the same total face-to-face hours but with different activities and additional online and mobile learning. Online activities utilized YouTube and a library guide indexing electronic databases, guides, and books. Mobile learning involved self-directed interactions with patients in their regular clinical placements. The attribution and differentiation of costs between the interventions within the RCT was measured in conjunction with measured outcomes of effectiveness. An incremental cost-effectiveness ratio was calculated comparing the ongoing operation costs of each method with the level of EBM proficiency achieved. Present value analysis was used to calculate the break-even point considering the transition cost and the difference in ongoing operation cost. RESULTS: The incremental cost-effectiveness ratio indicated that it costs 24% less to educate a student to the same level of EBM competency via the blended learning approach used in the study, when excluding transition costs. The sunk cost of approximately AUD $40,000 to transition to the blended model exceeds any savings from using the approach within the first year of its implementation; however, a break-even point is achieved within its third iteration and relative savings in the subsequent years. The sensitivity analysis indicates that approaches with higher transition costs, or staffing requirements over that of a traditional method, are likely to result in negative value propositions. CONCLUSIONS: Under the study conditions, a blended learning approach was more cost-effective to operate and resulted in improved value for the institution after the third year iteration, when compared to the traditional face-to-face model. The wider applicability of the findings are dependent on the type of blended learning utilized, staffing expertise, and educational context.

The economic value of an investment in physiotherapy education: a net present value analysis.

QUESTIONS: What is the economic value for an individual to invest in physiotherapy undergraduate education in Australia? How is this affected by increased education costs or decreased wages? DESIGN: A cost-benefit analysis using a net present value (NPV) approach was conducted and reported in Australian dollars. In relation to physiotherapy education, the NPV represents future earnings as a physiotherapist minus the direct and indirect costs in obtaining the degree. Sensitivity analyses were conducted to consider varying levels of experience, public versus private sector, and domestic versus international student fees. Comparable calculations were made for educational investments in medicine and nursing/midwifery. RESULTS: Assuming an expected discount rate of 9.675%, investment in education by domestic students with approximately 34 years of average work experience yields a NPV estimated at $784,000 for public sector physiotherapists and $815,000 for private sector therapists. In relation to international students, the NPV results for an investment and career as a physiotherapist is estimated at $705,000 in the public sector and $736,000 in the private sector. CONCLUSION: With an approximate payback period of 4 years, coupled with strong and positive NPV values, physiotherapy education in Australia is a financially attractive prospect and a viable value proposition for those considering a career in this field.

Medical Residents and Interprofessional Interactions in Discharge: An Ethnographic Exploration of Factors That Affect Negotiation.

BACKGROUND: Interprofessional collaboration is an important aspect of patient discharge from a general internal medicine (GIM) unit. However, there has been minimal empirical or theoretical research that has examined interactions that occur between medical residents and other healthcare professionals in the discharge process. This study provides insight into the social processes that shape and characterize such interactions. OBJECTIVE: To explore factors that shape interactions between medical residents and other healthcare professionals in relation to patient discharge, and to examine the opportunities for negotiations about discharge between these professional groups. DESIGN: A qualitative ethnographic approach using observations, interviews and documentary analysis. PARTICIPANTS AND SETTING: Healthcare professionals working in a GIM unit in Canada. APPROACH: Sixty-five hours of observations were undertaken in a range of settings (e.g. interprofessional rounds, medical and nursing rounds, nursing station) in the unit over a 17-month period. A maximum variation sampling approach was used to identify healthcare professionals working in the unit. Twenty-three interviews were completed, recorded and transcribed verbatim. A directed content approach using theories of medical dominance and negotiated order was used to analyze the data. KEY RESULTS: The organization of clinical work in combination with clinical teaching influenced interprofessional interactions and the quality of discharge in this GIM unit. While organizational activities (orientation and rounds) and individual activities (e.g. role modeling, teaching) supported negotiations between medical residents and other healthcare professionals around discharge, participants had varied perspectives about their effectiveness. CONCLUSIONS: This study illuminates social factors and processes that require attention in order to address challenges with interprofessional collaboration and discharge in GIM. These findings have implications for medical education, workplace learning, patient safety and quality improvement.

Improving access to emergent spinal care through knowledge translation: an ethnographic study.

BACKGROUND: For patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery. METHODS: An ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario's call centre. RESULTS: Several themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation. CONCLUSIONS: Our findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts.

Continuing education to go: capacity building in psychotherapies for front-line mental health workers in underserviced communities.

OBJECTIVE: To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers. METHODS: Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed. RESULTS: Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients. CONCLUSION: This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.

Objectif : Aborder l'écart entre les besoins et l'accès, et entre les lignes directrices de traitement et leur mise en œuvre pour la maladie mentale, par la création de capacité des travailleurs de première ligne de la santé. Méthodes : À la suite d'une évaluation des besoins d'apprentissage, des cours de formation continue en milieu de travail sur les psychothérapies fondées sur des données probantes ont été mis au point à l'intention des travailleurs de première ligne dans des milieux communautaires sous-desservis. Les cours de 5 heures sur les fondements de la thérapie cognitivo-comportementale, la psychothérapie interpersonnelle, la technique d'entrevue motivationnelle, et la thérapie comportementale dialectique comportaient tous des simulations enregistrées sur vidéo, des plans de leçon interactifs, et des rappels de comportement en pratique clinique. Deux cours, offerts en ordre séquentiel dans 7 milieux sous-desservis, ont été soumis à une évaluation de méthodes mixtes. Quatre-vingt-treize travailleurs de première ligne non médicaux se sont inscrits au programme. Une analyse de variance des mesures répétées a servi à évaluer les changements des connaissances et de l'auto-efficacité avant et après l'intervention. Les données qualitatives de 5 groupes de discussion semi-structurés de 25 participants ont également été analysées. Résultats : Des changements significatifs des connaissances (P < 0,001) avant et après l'intervention ont été observés chez ceux qui ont terminé le cours. L'auto-efficacité en counseling s'est améliorée chez les participants qui ont suivi le premier cours offert (P = 0,001). Les décrocheurs étaient beaucoup moins fréquents dans les petits groupes d'apprentissage menés par les pairs que dans le format autodirigé. L'analyse qualitative a révélé une confiance améliorée, un meilleur moral, des changements du comportement dans la pratique auto-déclaré, et une plus grande assurance de travailler avec des clients difficiles. Conclusion : Ce programme d'études en milieu de travail, multimodal, interactif, interprofessionnel pour la transmission des connaissances en techniques psychothérapeutiques est faisable et utile. Le format du groupe mené par les pairs est préféré à l'apprentissage autodirigé. Son application peut renforcer la capacité des travailleurs de la santé de première ligne d'aider les patients qui souffrent de troubles mentaux communs.