A shared point of care ultrasound curriculum for graduate medical education.

BACKGROUND: Point of care ultrasound (POCUS) education has grown significantly over the past two decades. Like most curricular items, POCUS education is siloed within individual graduate medical education (GME) programs. The purpose of this study was to evaluate the effectiveness of a shared GME POCUS curriculum between five GME programs at a single institution. METHODS: Post-graduate-year-1 (PGY-1) residents from emergency medicine (EM), family medicine (FM), internal medicine (IM), combined internal medicine-pediatrics (IM-Peds) and combined emergency medicine-pediatrics (EM-Peds) residency programs were enrolled in a core POCUS curriculum. The curriculum included eleven asynchronous online learning modules and ten hands-on training sessions proctored by sonographers and faculty physicians with POCUS expertise. Data was gathered about the curriculum's effectiveness including participation, pre- and post-curricular surveys, pre- and post-knowledge assessments, and an objective skills assessment. RESULTS: Of the 85 residents enrolled, 61 (72%) participated in the curriculum. Engagement varied between programs, with attendance at hands-on sessions varying the most (EM 100%, EM-Peds 100%, FM 40%, IM 22%, Med-Peds 11%). Pre- and post-knowledge assessment scores improved for all components of the curriculum. Participants felt significantly more confident with image acquisition, anatomy recognition, interpreting images and incorporating POCUS findings into clinical practice (p < 0.001) after completing the curriculum. CONCLUSION: In this shared GME POCUS curriculum, we found significant improvement in POCUS knowledge, attitudes, and psychomotor skills. This shared approach may be a viable way for other institutions to provide POCUS education broadly to their GME programs.

Closing the gender gap in medicine: the impact of a simulation-based confidence and negotiation course for women in graduate medical education.

BACKGROUND: Currently, 75-80% of the medical workforce worldwide consists of women. Yet, women comprise 21% of full professors and less than 20% of department chairs and medical school deans. Identified causes of gender disparities are multifactorial including work-life responsibilities, gender discrimination, sexual harassment, bias, lack of confidence, gender differences in negotiation and leadership emergence, and lack of mentorship, networking, and/or sponsorship. A promising intervention for the advancement of women faculty is the implementation of Career Development Programs (CDPs). Women physician CDP participants were shown to be promoted in rank at the same rate as men by year five, and more likely to remain in academics after eight years compared to both men and women counterparts. The objective of this pilot study is to investigate the effectiveness of a novel, simulation-based, single-day CDP curriculum for upper-level women physician trainees to teach communication skills identified as contributing to medicine's gender advancement gap. METHODS: This was a pilot, pre/post study performed in a simulation center implementing a curriculum developed to educate women physicians on 5 identified communication skills recognized to potentially reduce the gender gap. Pre- and post-intervention assessments included confidence surveys, cognitive questionnaires, and performance action checklists for five workplace scenarios. Assessment data were analyzed using scored medians and descriptive statistics, applying Wilcoxon test estimation to compare pre- versus post-curriculum intervention scores, with p < 0.05 considered statistically significant. RESULTS: Eleven residents and fellows participated in the curriculum. Confidence, knowledge, and performance improved significantly after completion of the program. Pre-confidence: 28 (19.0-31.0); Post-confidence: 41 (35.0-47.0); p < 0.0001. Pre-knowledge: 9.0 (6.0-11.00); Post knowledge: 13.0 (11.0-15.0); p < 0.0001. Pre-performance: 35.0 (16.0-52.0); Post-performance: 46.0 (37-53.00); p < 0.0001. CONCLUSION: Overall, this study demonstrated the successful creation of a novel, condensed CDP curriculum based on 5 identified communication skills needed for women physician trainees. The post-curriculum assessment demonstrated improved confidence, knowledge, and performance. Ideally, all women medical trainees would have access to convenient, accessible, and affordable courses teaching these crucial communication skills to prepare them for careers in medicine to strive to reduce the gender gap.

Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS: A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS: A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS: This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.

Pediatric Emergency Medicine Faculty Response to Point-of-Care Ultrasound Credentialing Curriculum.

OBJECTIVES: As point-of-care ultrasound (POCUS) continues to evolve in pediatric emergency medicine (PEM), new protocols and curricula are being developed to help establish the standards of practice and delineate training requirements. New suggested guidelines continue to improve, but a national standard curriculum for training and credentialing PEM providers is still lacking. To understand the barriers and perception of curriculum implementation for PEM providers, we created an ultrasound program at our institution and observed attitudes and response to training. METHODS: Fourteen PEM-fellowship-trained faculty with limited to no previous experience with POCUS underwent training within a 12-month time frame using a modified practice-based training that included didactics, knowledge assessment, and hands-on practice. As part of the curriculum, the faculty completed a 3-phase survey before, after, and 6 months after completion of the curriculum. RESULTS: There was a 100%, 78.6%, and 71.4% response rate for the presurvey, postsurvey, and 6 months postsurvey, respectively. Lack of confidence with using POCUS went from 100% on the presurvey to 57% on the postsurvey and down to 30% on the 6th month postsurvey. All other barriers also decreased from precurriculum to postcurriculum, except for length of time to perform POCUS. Participants rated the curriculum highly, with a mean Likert score and standard error of the mean at 3.9 ± 0.73, respectively. The average rating for whether POCUS changed clinical practice was low (2.6 ± 1.34). CONCLUSION: These results show that a simplified structured curriculum can improve perception of POCUS and decrease barriers to usage while helping to understand obstacles for implementation of POCUS among PEM-fellowship-trained faculty.

Immunization Status and the Management of Febrile Children in the Pediatric Emergency Department: What Are We Doing?

OBJECTIVES: Widespread Haemophilus influenzae and Streptococcus pneumoniae immunization has decreased occult bacteremia and bacterial meningitis rates. Practice has evolved in pediatric emergency departments (PEDs) to favor fewer diagnostic tests for and empiric treatment of invasive bacterial infection. We lack evidence-based guidance on evaluation and treatment of unimmunized (UnI) or underimmunized (UnderI) febrile children. This study aims to determine how parental report of immunization status in febrile PED patients impacts rates of diagnostic testing, interventions, and hospital admissions. METHODS: This is a retrospective cohort study with chart review of encounters of children aged 3 to 36 months presenting to an academic, tertiary care PED in 2019 using International Classification of Diseases-10 code for fever (R50.9). Inclusion criteria were documented fever of 38°C and higher and well appearance. Encounters were excluded if there was a history of chronic illness or documentation of ill appearance or hemodynamic instability. Encounters were grouped by provider-documented immunization status. Fischer exact test and logistic regression compared rates of diagnostic testing (serum, urine or cerebrospinal fluid laboratory studies, and chest radiographs), interventions (intravenous fluid bolus, intravenous antibiotic or steroid administration, respiratory support, or breathing treatment), and hospital admissions between UnderI, UnI, and fully immunized (FI) groups. RESULTS: Of the 1813 encounters reviewed, 1093 (60%) included provider-documented immunization status and 788 (43%) met final inclusion criteria: 23 (2.1%) UnI, 44 (5.8%) UnderI, and 721 (92.1%) FI. The UnderI and UnI children experienced significantly higher rates of laboratory evaluation including complete blood count and blood culture, medical intervention, and antibiotic prescriptions while in the PED. No significant differences were observed for rates of chest radiographs, hospital admissions, or 72-hour PED return visits. CONCLUSIONS: Higher rates of laboratory testing and interventions were observed in UnderI and UnI versus FI febrile patients at a PED, likely demonstrating increased clinical suspicion for invasive bacterial infection in this group despite lacking national guidelines. Given continued vaccine hesitancy, further studies are needed for guiding management of febrile UnI and UnderI children presenting for emergency care.

Reuse of Personal Protective Equipment: Results of a Human Factors Study Using Fluorescence to Identify Self-Contamination During Donning and Doffing.

BACKGROUND: At least 115,000 health and care workers (HCWs) are estimated to have lost their lives to COVID-19, according to the the chief of the World Health Organization (WHO). Personal protective equipment (PPE) is the first line of defense for HCWs against infectious diseases. At the height of the pandemic, PPE supplies became scarce, necessitating reuse, which increased the occupational COVID-19 risks to HCWs. Currently, there are few robust studies addressing PPE reuse and practice variability, leaving HCWs vulnerable to accidental contamination and harm. OBJECTIVE: The objective of this study was to assess potential HCW contamination during PPE donning, doffing, and reuse. METHODS: The study included 28 active acute care physicians, nurses, and nurse practitioners that evaluated 5 simulated patients with COVID-like symptoms while donning and doffing PPE between each patient encounter. An N95 mask was contaminated with a transparent fluorescent gel applied to the outside of the N95 mask to simulate contamination that might occur during reuse. Participants were evaluated after PPE doffing for each encounter using a black light to assess for face and body contamination. RESULTS: All participants had multiple sites of contamination, predominantly on their head and neck. None of the participants were able to don and doff PPE without contaminating themselves during five consecutive simulation cycles. CONCLUSIONS: The current Centers for Disease Control and Prevention PPE guidelines for donning and doffing fall short in protecting HCWs. They do not adequately protect HCWs from contamination. There is an urgent need for PPE and workflow redesign.

Performance of Pediatric Emergency Medicine Faculty After Point-of-Care Ultrasound Credentialing Implementation.

OBJECTIVE: As point-of-care ultrasound (POCUS) continues to evolve, a national standardized curriculum for training and credentialing pediatric emergency medicine (PEM) physicians is still lacking. The goal of this study was to assess PEM faculty in performing and interpreting POCUS during implementation of a training curriculum. METHODS: Sixteen full-time PEM faculty with either limited or no prior POCUS experience were trained to perform 4 ultrasound studies. Twelve of the 16 completed the training with a goal of credentialing within 12 months of implementation. For each faculty, we assessed competency by comparing precurriculum and postcurriculum test assessments and by evaluating quality of POCUS acquisition and accuracy of interpretation. We also monitored the amount of continuing medical education (CME) hours completed to ensure a minimum didactic component. RESULTS: We found a significant improvement in POCUS competency comparing precurriculum to postcurriculum test assessments (55.4% vs 75.6%, P < 0.0002). One thousand two hundred seventy images were submitted over the course of the curriculum. Accuracy, sensitivity, and specificity were 98.23% (confidence interval [CI] = 97.18-98.97), 97.01% (CI = 92.53-99.81), and 98.43% (CI = 97.33-99.81), respectively. Faculty self-rating of image quality was significantly higher than expert reviewer rating of image quality (3.4 ± 0.86 vs 3.2 ± 0.56, P < 0.0001). We found no change in expert reviewer rating of image quality over time. Faculty completed a combined 232.5 CME hours (average, 17.4 ± 10.8), with the majority of hours coming from an institutional POCUS CME workshop. CONCLUSIONS: These results show that a structured curriculum can improve PEM faculty POCUS competency.

Frequency of safety net errors in the emergency department: Effect of patient handoffs.

OBJECTIVES: The objective of this study was to determine physician awareness of abnormal vital signs and key clinical interventions (oxygen provision, intravenous access) in the emergency department, and to measure the effect of patient handoffs on this awareness. METHODS: This was a prospective observational study at two large, urban, academic emergency departments. Emergency department physicians were asked the following about each of the physician's patients: 1) the number of IV lines, 2) whether the patient was on supplemental oxygen, and 3) whether the patient had any abnormal vital signs. Physicians were blind to the nature of the study prior to enrollment. Error rates between physician responses and actual patient status were calculated, and logistic regression, adjusted for physician clustering, was used to calculate association of errors with multiple situational factors, including handoff status. RESULTS: We analyzed 463 patient encounters from 74 physicians. Physicians missed abnormal vital signs in 19.4% of encounters. They made errors in oxygen status and number of IV lines in 16.6% and 35.8% of encounters, respectively. Physicians were significantly more likely to make all types of errors on patients who had undergone handoff as opposed to their primary patients. CONCLUSION: Emergency physicians make frequent errors regarding awareness of their patients' vital signs, oxygen and vascular status and patient handoffs are associated with an increased frequency of such errors.

Prospective study of emergency medicine provider wellness across ten academic and community hospitals during the initial surge of the COVID-19 pandemic.

BACKGROUND: While COVID-19 has had far-reaching consequences on society and health care providers, there is a paucity of research exploring frontline emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (e.g., nurse practitioners and physician assistants; APPs) during the initial phase of the COVID-19 pandemic. METHODS: A descriptive, prospective, cohort survey study of EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher's Exact, and logistic regression was performed. RESULTS: Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85 to 61% (p < 0.001). Impact on basic self-care declined from 66 to 32% (p < 0.001). Symptoms of stress, anxiety, or fear was initially 83% and reduced to 66% (p = 0.009). Reported strain on relationships and feelings of isolation affected > 50% of respondents initially without significant change (p = 0.05 and p = 0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95% CI 1.82-5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10-5.47). Baseline resilience was normal to high. Provider well-being improved over the four weeks (30 to 14%; p = 0.01), but burnout did not significantly change (30 to 22%; p = 0.39). CONCLUSION: This survey of frontline EM providers, including physicians and APPs, during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, putting many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.

How to HEEAL: A Patient and Peer-Centric Simulation Curriculum for Medical Error Disclosure.

Introduction: Medical errors are an unfortunate certainty with emotional and psychological consequences for patients and health care providers. No standardized medical curriculum on how to disclose medical errors to patients or peers exists. The novel HEEAL (honesty/empathy/education/apology-awareness/lessen chance for future errors) curriculum addresses this gap in medical education through a multimodality workshop. Methods: This 6-hour, two-part curriculum incorporated didactic and standardized patient (SP) simulation education with rapid cycle deliberate practice (RCDP). The morning focused on provider-patient error disclosure; the afternoon applied the same principles to provider-provider (peer) discussion. Summative simulations with SPs evaluated learners' skill baseline and improvement. Formative simulations run by expert simulation educators used RCDP to provide real-time feedback and opportunities for adjustment. Medical knowledge was measured through pre- and postintervention multiple-choice questions. Learners' confidence and attitude towards medical errors disclosure were surveyed pre- and postintervention with assistance of the Barriers to Error Disclosure Assessment tool, revised with the addition of several questions related to provider-provider disclosure. Results: Fourteen medical students participated in this pilot curriculum. Statistical significance was demonstrated in medical knowledge (p = .01), peer-disclosure skills (p = .001), and confidence in medical error disclosure (p < .001). Although there was improvement in patient-disclosure skills, this did not reach statistical significance (p = .05). Discussion: This curriculum addresses the need for designated training in medical error disclosure. Learners gained knowledge, skills, and confidence in medical error disclosure. We recommend this curriculum for medical students preparing for transition to residency.

Assessment of Gender Bias During Paramedic-Physician Handoffs.

Objective Gender bias against female physicians has been frequently demonstrated and associated with negative feelings toward their careers. Gender bias has also been demonstrated in prehospital clinical care. However, potential gender bias during paramedic-physician handoffs has not been studied. This study aimed to identify gender bias during interactions between prehospital personnel and emergency physicians at the time of patient handoff. Methods An observational study was conducted at an urban academic emergency department. Observers were trained to record information from paramedic-physician handoffs but were blind to the nature of the study. The primary outcome was to whom paramedics initially directed the focus of their handoff report based on physician gender, with secondary outcomes of to whom paramedics directed most of their report and whether they asked about further questions based on physician gender. Results There were 784 observed handoffs. There was no significant association between the gender of the physician and which physician received first attention (χ2 {1, N = 782} = 0.9736, p = 0.3238) or majority attention (χ2 {1, N = 780} = 1.9414, p = 0.1635). Paramedics were more likely to ask questions to male attendings than female attendings (χ2 {1, N = 784} = 4.4319, p = 0.0353). Conclusion We identified limited differences in communication based on gender between paramedics and physicians during emergency department patient handoffs.

Demographics, Diagnoses, Drugs, and Adjuvants in Patients on Chronic Opioid Therapy vs. Intermittent Use in a Tertiary Pediatric Chronic Pain Clinic.

Anywhere from 11.6% to 20% of pediatric and adolescent patients treated for chronic pain are prescribed opioids, but little is known about these patients. The purpose of this study was to determine the characteristics of patients on chronic opioid therapy (COT) and what therapies had been utilized prior to or in conjunction with COT. The study was a retrospective chart review of all chronic pain patients seen during 2020 with those patients on COT separated for analysis. A total of 346 unique patients were seen of which 257 were female (74.3%). The average age was 15.5 years. A total of 48 patients (13.9%) were identified as being on COT with an average age of 18.1 years. Of these, 23 (47.9%) were male which was significantly more than expected. The most common reason for patients to be receiving COT was palliative (13/48), and the second most common was sickle cell anemia (10/48). Patients on COT were significantly more likely to be male, be older, and to be concurrently prescribed benzodiazepines. Concurrent opioid and benzodiazepine therapy is a risk factor for respiratory depression and overdose. Further investigation into the increased proportion of males and benzodiazepine usage in patients on COT is warranted.

Disparities in outcomes among patients diagnosed with cancer in proximity to an emergency department visit.

A suspected diagnosis of cancer in the emergency department (ED) may be associated with poor outcomes, related to health disparities, however data are limited. This is a retrospective observational cohort of the Indiana State Department of Health Cancer Registry, and the Indiana Network for Patient Care. First time cancer diagnoses appearing in the registry between January 2013 and December 2017 were included. Cases identified as patients who had an ED visit in the 6 months before their cancer diagnosis; controls had no preceding ED visits. The primary outcome was mortality, comparing ED-associated mortality to non-ED-associated. 134,761 first-time cancer patients were identified, including 15,432 (11.5%) cases. The mean age was same at 65, more of the cases were Black than the controls (12.4% vs 7.4%, P < .0001) and more were low income (36.4%. vs 29.3%). The top 3 ED-associated cancer diagnoses were lung (18.4%), breast (8.9%), and colorectal cancers (8.9%), whereas the controls were breast (17%), lung (14.9%), and prostate cancers (10.1%). Cases observed an over three-fold higher mortality, with cumulative death rate of 32.9% for cases vs 9.0% for controls (P < .0001). Regression analysis predicting mortality, controlling for many confounders produced an odds ratio of 4.12 (95% CI 3.72-4.56 for cases). This study found that an ED visit within 6 months prior to the first time of ICD-coded cancer is associated with Black race, low income and an overall three-fold increased adjusted risk of death. The mortality rates for ED-associated cancers are uniformly worse for all cancer types. These data suggest that additional work is needed to reduce disparities among ED-associated cancer diagnoses.

Effect of a point-of-care ultrasound (POCUS) curriculum on emergency department soft tissue management.

BACKGROUND: Pediatric emergency department (ED) visits for superficial skin and soft tissue infections (SSTI) have steadily been increasing and point-of-care ultrasound (POCUS) continues to be an effective modality to improve management and shorter ED length of stays (LOS). OBJECTIVE: We sought to determine the impact of a soft tissue POCUS curriculum on POCUS utilization, ED LOS, and cost-effectiveness. METHODS: This was a retrospective pre- and post-interventional study of pediatric patients aged 0 to 17 years. Patients presenting to ED with international classification of disease 9 or 10 code for abscess or cellulitis were included. Data were collected a year before and after curriculum implementation with a 1-year washout training period. Training included continuing medical education, greater than 25 quality assured examinations, and a post-test. We compared diagnostic imaging type, ED LOS, and mean charges in patients with SSTI. RESULTS: We analyzed data on 119 total patients, 38 pre- and 81 post-intervention. We found a significant increase in the total number of POCUS examinations performed pre- to post-curriculum intervention, 26 vs. 59 (p = 0.0017). Mean total charges were significantly decreased from $3,762 (± 270) to $2,622 (± 158; p = 0.0009). There was a significant trend towards a decrease in average ED LOS 282 (standard error of mean [SEM] ± 19) vs 185 (± 13) minutes (p = 0.0001). CONCLUSIONS: Implementation of a soft tissue POCUS curriculum in a pediatric ED was associated with increased POCUS use, decreased LOS, and lower cost. These findings highlight the importance of POCUS education and implementation in the management of pediatric SSTI.

Identification of Bias in Ordering Further Imaging in Ethnic Groups With Indeterminate Ultrasound for Appendicitis.

Background Recent studies have shown a higher incidence of complications from acute appendicitis in Hispanic populations. Hispanic ethnicity alone has been shown to be a risk factor. In contrast, one study found little evidence of racial disparities in complication rates. The objective of this study was to identify physician bias regarding whether ethnicity drives further testing after initial radiologic imaging has been obtained in the evaluation of appendicitis in our pediatric emergency department (PED). The use of computed tomography (CT) scan in the diagnosis of appendicitis was compared between Hispanic versus non-Hispanic populations when ultrasound (US) was indeterminate. Methodology This is a retrospective cohort study of Hispanic and non-Hispanic patients aged 2-18 who presented to the PED with right lower quadrant abdominal pain over a one-year period (January 1, 2017 to December 29, 2017). Both groups were subdivided into positive, negative, or indeterminate US findings for appendicitis. Each subgroup was analyzed based on those who had CT imaging done. Results A total of 471 ultrasounds were performed, 162 Hispanic and 309 non-Hispanic patients. Indeterminate US scans were documented in 90/162 (56%) Hispanic versus 155/309 (50%) non-Hispanic patients. Of those with indeterminate US scans, 30% Hispanic versus 32% non-Hispanic patients received CT scans. Negative US scans were documented in 54/162 (33%) Hispanic versus 102/309 (33%) non-Hispanic patients. Of those with negative US scans, 7% Hispanic versus 5% non-Hispanic patients received CT scans. Chi-square analysis comparing both the proportion of CT scans received for indeterminate US scans (p=0.71) and negative US scans (p=0.52) showed no statistical significance. Conclusions There was no significant difference in the number of CT scans ordered for indeterminate US scans between Hispanic and non-Hispanic patients. One can infer that there is no inherent bias toward ordering advanced imaging in Hispanic children based on ethnicity alone.

Adaptive change in simulation education: Comparison of effectiveness of a communication skill curriculum on death notification using in person methods versus a digital communication platform.

Background: Mandates to social distance and "shelter in place" during the COVID-19 pandemic necessitated the exploration of new academic content delivery methods. Digital communication platforms (DCP; e.g., Zoom) were widely used to facilitate content delivery, yet little is known about DCP's capacity or effectiveness, especially for simulation. Objective: The objective was to compare the experience, outcomes, and resources required to implement a simulation-based communication skill curriculum on death notification to a cohort of learners using in-person versus DCP delivery of the same content. Methods: We used the GRIEV_ING mnemonic to train students in death notification techniques either in person or utilizing a DCP. For all learners, three measures were collected: knowledge, confidence, and performance. Individual learners completed knowledge and confidence assessments pre- and postintervention. All performance assessments were completed by standardized patients (SPs) in real time. Wilcoxon rank-sum test was used to identify differences in individual and between-group performances. Results: Thirty-four learners participated (N = 34), 22 in person and 12 via DCP. There was a statistically significant improvement in both groups for all three measures: knowledge, confidence, and performance. Between-group comparisons revealed a difference in pretest confidence but no differences between groups in knowledge or performance. More preparation and prior planning were required to set up the DCP environment than the in-person event. Conclusions: The in-person and DCP delivery of death notification training were comparable in their ability to improve individual knowledge, confidence, and performance. Additional preparation time, training, and practice with DCPs may be required for SPs, faculty, and learners less familiar with this technology.

B-line quantification: comparing learners novice to lung ultrasound assisted by machine artificial intelligence technology to expert review.

BACKGROUND: The goal of this study was to assess the ability of machine artificial intelligence (AI) to quantitatively assess lung ultrasound (LUS) B-line presence using images obtained by learners novice to LUS in patients with acute heart failure (AHF), compared to expert interpretation. METHODS: This was a prospective, multicenter observational study conducted at two urban academic institutions. Learners novice to LUS completed a 30-min training session on lung image acquisition which included lecture and hands-on patient scanning. Learners independently acquired images on patients with suspected AHF. Automatic B-line quantification was obtained offline after completion of the study. Machine AI counted the maximum number of B-lines visualized during a clip. The criterion standard for B-line counts was semi-quantitative analysis by a blinded point-of-care LUS expert reviewer. Image quality was blindly determined by an expert reviewer. A second expert reviewer blindly determined B-line counts and image quality. Intraclass correlation was used to determine agreement between machine AI and expert, and expert to expert. RESULTS: Fifty-one novice learners completed 87 scans on 29 patients. We analyzed data from 611 lung zones. The overall intraclass correlation for agreement between novice learner images post-processed with AI technology and expert review was 0.56 (confidence interval [CI] 0.51-0.62), and 0.82 (CI 0.73-0.91) between experts. Median image quality was 4 (on a 5-point scale), and correlation between experts for quality assessment was 0.65 (CI 0.48-0.82). CONCLUSION: After a short training session, novice learners were able to obtain high-quality images. When the AI deep learning algorithm was applied to those images, it quantified B-lines with moderate-to-fair correlation as compared to semi-quantitative analysis by expert review. This data shows promise, but further development is needed before widespread clinical use.

Statin Use is Associated with Reduced Risk of Recurrence in Patients with Venous Thromboembolism.

BACKGROUND: Statin therapy appears to reduce incidence of venous thromboembolism in secondary analyses of non-venous thromboembolism trials, but no evidence has shown effect of statins in large population samples. The objective of this study was to examine the magnitude of the effect of statin therapy on venous thromboembolism recurrence across a large statewide population. METHODS: This was a retrospective analysis of the Indiana Network for Patient Care database. All patients with an International Classification of Diseases-defined diagnosis of either deep vein thrombosis or pulmonary embolism from 2004-2017 were included. We collected Generic Product Identifier codes to determine whether patients had been prescribed a statin medication and divided patients into 2 groups: + or - statin. We then performed a propensity-matching analysis to balance covariates and created a final logistic regression model with statin use as the predictor variable and venous thromboembolism recurrence as the dependent variable. RESULTS: This study included a total of 192,908 patients with documented statin use in 13.5%. Venous thromboembolism recurrence occurred in 16% of all patients over the study period. After propensity matching, patients not on a statin were found to have significantly higher rates of venous thromboembolism recurrence (20% vs 16%, P < .0001). Logistic regression yielded an odds ratio of 0.75 (95% confidence interval, 0.72-0.79) for venous thromboembolism recurrence for those on statin therapy. CONCLUSIONS: We found that a statin prescription reduced risk of venous thromboembolism recurrence by approximately 25% after adjusting for risk factors, supporting the adjunctive role of statins in the prevention of venous thromboembolism recurrence.

Qualities Important in the Selection of Chief Residents.

Background Chief resident selection occurs by numerous methods. Chief residents also fulfill multiple roles, requiring a broad skill set. However, there is little literature on which qualities various stakeholders value in chief resident selection. The objective of this study was to identify the qualities that residents and faculty believe are important for chief residents. Methods Following a literature review, educational experts conducted a multi-institutional survey that asked participants to name the qualities they felt were most important in chief residents and to rank-order a predefined list of 10 qualities. Associations were calculated between rank-order and participant age, gender, institutional position, and history of serving as a chief resident. Results The response rate for the survey was 43.9% (385/877). Leadership, organization, and communication skills were named by all participants among the most common responses. Residents additionally named approachability, advocacy, and listening skills among their most valued qualities, whereas faculty named strong clinical skills and integrity. Dependability and trustworthiness were the most valued qualities in the rank-order list, whereas strong clinical skills and self-reflection were the least valued. Females valued the ability to manage multiple demands more whereas males valued dependability more. The faculty valued strong clinical skills more than residents. Conclusion A variety of qualities are seen as being valuable in chief residents. Additional research is needed to understand what qualities are associated with effective chief resident performance.

Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage.

INTRODUCTION: Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. METHODS: We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. RESULTS: A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93). CONCLUSION: This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.