Satisfaction of Basic Psychological Needs, Self-Determined Exercise Motivation, and Psychological Well-Being in Mothers Exercising in Group-Based Versus Individual-Based Contexts.

We compared mothers who exercised predominantly in group settings, those who exercised predominantly in individual settings, and those who exercised equally in group and individual contexts among the following: (a) satisfaction of basic psychological needs (autonomy, competence, and relatedness); (b) self-determined exercise motivation; and (c) psychological well-being. With clear implications for mothers' exercise interventions we found that exercising either predominantly in group contexts or in mixed group and individual settings was associated with mothers having significantly higher satisfaction of basic psychological needs and self-determined exercise motivation than those exercising predominantly alone.

Prospective analysis of an interprofessional team training program using high-fidelity simulation of contrast reactions.

OBJECTIVE: Successful management of a contrast reaction requires prompt recognition and treatment and effective team dynamics among radiologists, technologists, and nurses. A radiology department implemented a simulation program in which teams of nurses, technologists, and physicians managed simulated contrast reactions. The purpose of this study was to evaluate whether simulation improved the participants' abilities to manage a contrast reaction and work in a team during an emergency. SUBJECTS AND METHODS: Physicians, nurses, and technologists worked in inter-professional teams to manage two high-fidelity simulated adverse contrast reactions. Participants completed surveys before and after the simulation that included knowledge-based questions about the appropriate management of contrast reactions. Surveys also included questions for assessing participants' perceptions of their ability to manage adverse contrast reactions, measured with a 6-point Likert scale. Before and after comparisons were made with the McNemar test with a Bonferroni correction requiring p ≤ 0.003 for significance. For the other analyses, p ≤ 0.05 was considered significant. RESULTS: After completion of the simulation exercises, participants had significant improvement in knowledge (p < 0.001). After the simulation, participants reported significant improvement in their ability to manage an anaphylactoid reaction and their ability to work in a team (p < 0.00001). Participants requested repeat simulation exercises every 6-12 months. CONCLUSION: Simulation exercises improved the self-reported ability of radiology personnel to manage contrast reactions and work in a team during an emergency. Simulation should be incorporated into future educational initiatives to improve patient safety in radiology practices.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

OBJECTIVE: To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. BACKGROUND: Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. METHODS: A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. RESULTS: A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. CONCLUSIONS: A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

How we implemented a resident-led medical simulation curriculum in a large internal medicine residency program.

Mannequin-based simulation in graduate medical education has gained widespread acceptance. Its use in non-procedural training within internal medicine (IM) remains scant, possibly due to the logistical barriers to implementation of simulation curricula in large residency programs. We report the Massachusetts General Hospital Department of Medicine's scale-up of a voluntary pilot program to a mandatory longitudinal simulation curriculum in a large IM residency program (n = 54). We utilized an eight-case curriculum implemented over the first four months of the academic year. An intensive care unit curriculum was piloted in the spring. In order to administer a comprehensive curriculum in a large residency program where faculty resources are limited, thirty second-year and third-year residents served as session facilitators and two senior residents served as chairpersons of the program. Post-session anonymous survey revealed high learner satisfaction scores for the mandatory program, similar to those of the voluntary pilot program. Most interns believed the sessions should continue to be mandatory. Utilizing residents as volunteer facilitators and program leaders allowed the implementation of a well-received mandatory simulation program in a large IM residency program and facilitated program sustainability.

Inspiring careers in STEM and healthcare fields through medical simulation embedded in high school science education.

The most effective ways to promote learning and inspire careers related to science, technology, engineering, and mathematics (STEM) remain elusive. To address this gap, we reviewed the literature and designed and implemented a high-fidelity, medical simulation-based Harvard Medical School MEDscience course, which was integrated into high school science classes through collaboration between medical school and K-12 faculty. The design was based largely on the literature on concepts and mechanisms of self-efficacy. A structured telephone survey was conducted with 30 program alumni from the inaugural school who were no longer in high school. Near-term effects, enduring effects, contextual considerations, and diffusion and dissemination were queried. Students reported high incoming attitudes toward STEM education and careers, and these attitudes showed before versus after gains (P < .05). Students in this modest sample overwhelmingly attributed elevated and enduring levels of impact on their interest and confidence in pursuing a science or healthcare-related career to the program. Additionally, 63% subsequently took additional science or health courses, 73% participated in a job or educational experience that was science related during high school, and 97% went on to college. Four of every five program graduates cited a health-related college major, and 83% offered their strongest recommendation of the program to others. Further study and evaluation of simulation-based experiences that capitalize on informal, naturalistic learning and promote self-efficacy are warranted.

Safety climate and medical errors in 62 US emergency departments.

STUDY OBJECTIVE: We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs. METHODS: We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED. RESULTS: We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines. CONCLUSION: Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.

Quality of care for joint dislocation in 47 US EDs.

BACKGROUND: Little is known about emergency department (ED) quality of care for joint dislocation. We sought to determine concordance of ED management of dislocation with guideline recommendations and to assess whether higher concordance was associated with better patient outcomes. METHODS: We conducted a retrospective chart review study of joint dislocation as part of the National ED Safety Study (www.emnet-usa.org). We identified all charts with a primary ED or hospital discharge diagnosis of joint dislocation in 47 EDs across 19 US states between 2003 and 2005. Concordance with guideline recommendations was evaluated using 5 individual quality measures and composite guideline concordance scores. Concordance scores were calculated as the percentage of eligible patients receiving guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance. RESULTS: The cohort consisted of 1980 ED patients; the patients' median age was 38 years, and 63% were men. Care for dislocation was excellent, with a concordance score of more than 85 across all quality measures. The median ED composite guideline concordance score was 93 (interquartile range, 90-95). In multivariable analyses, receiving treatment in EDs with the highest (fourth quartile) composite guideline concordance scores was independently associated with a significantly higher likelihood of successful joint reduction (adjusted odds ratio, 3.28; 95% confidence interval, 1.38-7.81), as compared with treatment in EDs with the lowest (first quartile) scores. CONCLUSIONS: Concordance of ED management of joint dislocation with guideline recommendations was high. Greater concordance with guideline-recommended care may increase the likelihood of successful joint reduction.

Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs.

OBJECTIVE: The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation. METHODS: We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures. RESULTS: Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups. CONCLUSIONS: Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.

Web-conferenced simulation sessions: a satisfaction survey of clinical simulation encounters via remote supervision.

PURPOSE: A critical barrier to expanding simulation-based instruction in medicine is the availability of clinical instructors. Allowing instructors to remotely observe and debrief simulation sessions may make simulation-based instruction more convenient, thus expanding the pool of instructors available. This study compared the impact of simulation sessions facilitated by in-person (IP) faculty versus those supervised remotely using Web-conferencing software (WebEx(®), Cisco [ www.webex.com/ ]). SUBJECTS AND METHODS: A convenience sample of preclinical medical students volunteered to "care for" patients in a simulation laboratory. Students received either standard IP or Web-conferenced (WC) instruction. WC sessions were facilitated by off-site instructors. A satisfaction survey (5-point Likert scale, where 1=strongly disagree and 5=strongly agree) was completed immediately following the sessions. RESULTS: Forty-four surveys were analyzed (WC n=25, IP n=19). In response to the question "Was the communication between faculty and students a barrier to understanding the case?," the average student responses were 2.8 (95% confidence interval [CI] 2.4-3.2) for WC and 4.5 (95% CI 4.0-5.0) for IP (p<0.0001). In response to the question "Would you participate again in such a session?," the average student responses were 4.2 (95% CI 4.0-4.5) for WC and 4.9 (95% CI 4.6-5.2) for IP (p=0.0003). Both groups agreed that they acquired new skills (4.2 for WC, 4.5 for IP; p=0.39) and new knowledge (4.6 for WC, 4.7 for IP; p=0.41). CONCLUSIONS: Telecommunication can successfully enhance access to simulation-based instruction. In this study, a Web interface downgraded the quality of student-faculty communication. Future investigation is needed to better understand the impact of such an effect on the learning process and to reduce barriers that impede implementation of technology-facilitated supervision.

Association of Simulation Participation With Diagnostic Reasoning Scores in Preclinical Students.

PURPOSE: The aim of the study was to evaluate for an association between the number of voluntary mannequin simulation sessions completed during the school year with scores on a year-end diagnostic reasoning assessment among second-year medical students. METHOD: This is retrospective analysis of participation in 0 to 8 extracurricular mannequin simulation sessions on diagnostic reasoning assessed among 129 second-year medical students in an end-of-year evaluation. For the final skills assessment, 2 physicians measured students' ability to reason through a standardized case encounter using the Diagnostic Justification (DXJ) instrument (4 categories each scored 0-3 by raters reviewing students' postencounter written summaries). Rater scores were averaged for a total DXJ score (0-12). To provide additional baseline comparison, zero participation students were divided into 2 groups based on intent to participate: those who signed up for extracurricular sessions but never attended versus those who never expressed interest. Scores across the attendance groups were compared with an analysis of variance and trend analysis. RESULTS: The class DXJ mean equaled 7.56, with a standard deviation of 2.78 and range of 0 to 12. Post hoc analysis after a significant analysis of variance (F = 4.91, df = 8, 128, P < 0.001) showed those participating in 1 or more extracurricular sessions had significantly higher DXJ scores than those not participating. Students doing 7 extracurricular sessions had significantly higher DXJ scores than those doing 0 and 2 (P < 0.05). Zero attendance groups were not different. A significant linear trend (R = 0.48, F = 38.0, df = 1, 127, P < 0.001) was found with 9 groups. A significant quadratic effect, like a dose-response pattern, was found (F = 18.1, df = 2, 125, P < 0.001) in an analysis including both zero attendance groups, a low (1-4 extracurricular sessions) group and a high (5-8) group. CONCLUSIONS: Higher year-end diagnostic reasoning scores were associated with increased voluntary participation in extracurricular mannequin-based simulation exercises in an approximate dose-response pattern.

Discovery of a Novel Class of d-Amino Acid Oxidase Inhibitors Using the Schrödinger Computational Platform.

d-Serine is a coagonist of the N-methyl d-aspartate (NMDA) receptor, a key excitatory neurotransmitter receptor. In the brain, d-serine is synthesized from its l-isomer by serine racemase and is metabolized by the D-amino acid oxidase (DAO, DAAO). Many studies have linked decreased d-serine concentration and/or increased DAO expression and enzyme activity to NMDA dysfunction and schizophrenia. Thus, it is feasible to employ DAO inhibitors for the treatment of schizophrenia and other indications. Powered by the Schrödinger computational modeling platform, we initiated a research program to identify novel DAO inhibitors with the best-in-class properties. The program execution leveraged an hDAO FEP+ model to prospectively predict compound potency. A new class of DAO inhibitors with desirable properties has been discovered from this endeavor. Our modeling technology on this program has not only enhanced the efficiency of structure-activity relationship development but also helped to identify a previously unexplored subpocket for further optimization.

Long-exposure filtering of turbulence-degraded wavefronts.

The quasi-static aberrations of optical telescopes are often determined using light from a star as the reference wavefront. We calculate the exposure time necessary to determine the amplitude of the phase aberrations for a given telescope to a given accuracy in the presence of atmospheric seeing. We implement a computational simulation of the atmosphere and present the root mean square of the generated wavefront Zernike amplitudes for a given exposure time. We find the exposure time τ required to reach a desired precision is strongly dependent on telescope diameter (τ∝D(8/3)) and can be many tens of minutes in extreme cases. We present the results so τ can be calculated for a range of telescopes and atmospheric parameters.

Using immersive healthcare simulation for physiology education: initial experience in high school, college, and graduate school curricula.

In the natural world, learning emerges from the joy of play, experimentation, and inquiry as part of everyday life. However, this kind of informal learning is often difficult to integrate within structured educational curricula. This report describes an educational program that embeds naturalistic learning into formal high school, college, and graduate school science class work. Our experience is based on work with hundreds of high school, college, and graduate students enrolled in traditional science classes in which mannequin simulators were used to teach physiological principles. Specific case scenarios were integrated into the curriculum as problem-solving exercises chosen to accentuate the basic science objectives of the course. This report also highlights the historic and theoretical basis for the use of mannequin simulators as an important physiology education tool and outlines how the authors' experience in healthcare education has been effectively translated to nonclinical student populations. Particular areas of focus include critical-thinking and problem-solving behaviors and student reflections on the impact of the teaching approach.

A Guide for Medical Educators: How to Design and Implement In Situ Simulation in an Academic Emergency Department to Support Interprofessional Education.

In situ simulation (ISS) put simulation training directly into the clinical practice environment. Although ISS creates opportunities to identify latent system threats, understand culture, and improve team dynamics, there are limited resources for medical educators to guide the development and implementation of ISS at academic (or community-based) emergency departments (EDs). We describe the implementation of ISS in a high-volume urban ED to help educators understand the requirements and limitations of successful program design. During an academic year, 66 individual learners participated in at least one of our 22 training sessions, a cohort that included 37 nurses, 17 physicians, eight physician assistants, and four allied health professionals. Feedback from these participants and case facilitators informed our iterative process of review and development of program guidelines and best practices. We share these key technical points and the themes we found to be essential to the successful implementation of an ISS program: consideration of session timing, participant buy-in, flexibility, and threats to professional identity. Overall, our report demonstrates the feasibility of implementing an ISS program in a high-volume urban ED and provides medical educators with a guide for creating an ISS program for interprofessional education.

Expansion of simulation and extended reality for undergraduate health professions education: A call to action.

In the spring of 2020, the COVID-19 pandemic limited access for many health professions students to clinical settings amid concerns about availability of appropriate personal protective equipment as well as the desire to limit exposure in these high-risk settings. Furthermore, the pandemic led to a need to cancel clinics and inpatient rotations, with a major impact on training for health professions and interprofessional health delivery, the long-term effects of which are currently unknown. While problematic, this also presents an opportunity to reflect on challenges facing the traditional clinical training paradigm in a rapidly changing and complex health care system and develop sustainable, high-quality competency-based educational models that incorporate rapidly progressing technologies. We call for pilot studies to explore specific simulation-based inpatient and outpatient clinical rotations for professional and interprofessional training.

Quality of care for acute asthma in 63 US emergency departments.

BACKGROUND: Little is known about the quality of acute asthma care in the emergency department (ED). OBJECTIVES: We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission. METHODS: We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance. RESULTS: The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (beta-coefficient, -8.2; 95% CI, -13.8 to -2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others. CONCLUSIONS: Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

Potent Tetrahydroquinolone Eliminates Apicomplexan Parasites.

Apicomplexan infections cause substantial morbidity and mortality, worldwide. New, improved therapies are needed. Herein, we create a next generation anti-apicomplexan lead compound, JAG21, a tetrahydroquinolone, with increased sp3-character to improve parasite selectivity. Relative to other cytochrome b inhibitors, JAG21 has improved solubility and ADMET properties, without need for pro-drug. JAG21 significantly reduces Toxoplasma gondii tachyzoites and encysted bradyzoites in vitro, and in primary and established chronic murine infections. Moreover, JAG21 treatment leads to 100% survival. Further, JAG21 is efficacious against drug-resistant Plasmodium falciparum in vitro. Causal prophylaxis and radical cure are achieved after P. berghei sporozoite infection with oral administration of a single dose (2.5 mg/kg) or 3 days treatment at reduced dose (0.625 mg/kg/day), eliminating parasitemia, and leading to 100% survival. Enzymatic, binding, and co-crystallography/pharmacophore studies demonstrate selectivity for apicomplexan relative to mammalian enzymes. JAG21 has significant promise as a pre-clinical candidate for prevention, treatment, and cure of toxoplasmosis and malaria.

A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds.

STUDY OBJECTIVE: We describe the frequency of undesirable events among patients boarding at a single, urban, tertiary, teaching emergency department (ED) through retrospective chart abstraction. METHODS: This was a chart review of all patients admitted during 3 randomly selected days in 2003 (n=162) to track the frequency of undesirable events such as missed relevant home medications, missed laboratory test results, arrhythmias, or other adverse events. RESULTS: One hundred fifty-one charts were abstracted (93.2%); 27.8% had an undesirable event, 17.9% missed a relevant home medication, and 3.3% had a preventable adverse event. There was a higher frequency of undesirable events among older patients (35.9%, aged >50 years; 7.3%, aged 20 to 49 years; 28.6%, aged 0 to 19 years) and those with more comorbidities (44.4% among Charlson score >or=3; 30.8% score 2; 36.1% score 1; 14.5% score 0). CONCLUSION: A substantial frequency of undesirable events occurs while patients board in the ED. These events are more frequent in older patients or those with more comorbidities. Future studies need to compare the rates of undesirable events among patients boarding in the ED versus inpatient units.

The safety of emergency care systems: Results of a survey of clinicians in 65 US emergency departments.

STUDY OBJECTIVE: Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety. METHODS: This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination. RESULTS: Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour. CONCLUSION: Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

Simulation-based Education to Ensure Provider Competency Within the Health Care System.

The acquisition and maintenance of individual competency is a critical component of effective emergency care systems. This article summarizes consensus working group deliberations and recommendations focusing on the topic "Simulation-based education to ensure provider competency within the healthcare system." The authors presented this work for discussion and feedback at the 2017 Academic Emergency Medicine Consensus Conference on "Catalyzing System Change Through Healthcare Simulation: Systems, Competency, and Outcomes," held on May 16, 2017, in Orlando, Florida. Although simulation-based training is a quality and safety imperative in other high-reliability professions such as aviation, nuclear power, and the military, health care professions still lag behind in applying simulation more broadly. This is likely a result of a number of factors, including cost, assessment challenges, and resistance to change. This consensus subgroup focused on identifying current gaps in knowledge and process related to the use of simulation for developing, enhancing, and maintaining individual provider competency. The resulting product is a research agenda informed by expert consensus and literature review.