Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016.

BACKGROUND: The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown. OBJECTIVE: To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states. RESEARCH DESIGN: Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering. SUBJECTS: In total, 7058 census tracts across 10 states. RESULTS: FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents. CONCLUSION: Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.

Strengths and Challenges of Implementing a Learning Collaborative in the Ryan White HIV/AIDS Program.

Learning collaboratives (LCs) are a popular tool for supporting collaboration and shared learning among health programs. Many variations of LCs have been reported in the literature. However, descriptions of key LC components and implementation lack standardization, making it hard to compare and contrast different LC approaches. To advance the field's understanding of how primary elements of LCs are implemented, we describe the implementation of an LC in the Ryan White HIV/AIDS Program using a recently established taxonomy of four primary elements of LCs-innovation, social systems, communication, and time. Additionally, we explain the strengths and challenges we encountered with regard to each of these elements when implementing this LC. We then offer recommendations to others on how to leverage LC facilitators and mitigate challenges in future projects. This information can guide other programs to replicate beneficial practices and avoid pitfalls in future LC projects.

A Telesimulation Elective to Provide Medical Students With Pediatric Patient Care Experiences During the COVID Pandemic.

OBJECTIVES/INTRODUCTION: The Association of American Medical Colleges suggested that medical students not be involved in direct patient care activities in the United States because of the COVID pandemic. Our objectives are to (1) describe the rapid creation and implementation of a fully online simulation-based pediatric emergency medicine training intervention for medical student learners using existing simulation center staff (faculty, technicians, actors) and resources (simulation technology, scenario files) and (2) report student and faculty feedback on the intervention. METHODS: The sessions involved the use of our existing simulation center faculty, staff, and resources. Feedbacks on the sessions were collected via a survey from faculty and students at the end of each session. RESULTS: Sixteen simulation sessions were conducted (8 febrile infant, 8 anaphylactic toddler). Forty-eight students, 2 technicians, 2 actors, and 10 faculty participated. Ninety percent of the students agreed with the statements, "I am more comfortable with pediatrics after this session," "participating improved my pediatric knowledge/skills," "this session was more useful than other learning activities I am involved in at this time." Seventy percent of the students agreed with the statement, "I learned as much from observing as when I was actively involved." All faculty agreed with the statement, "this was an effective educational strategy compared to other distance learning." Most faculty (60%) disagreed with the statement, "virtual simulation was equal to or superior to in-person simulation." All students and faculty strongly agreed with the statement, "I would highly recommend this to others." CONCLUSIONS: A telesimulation intervention involving all medical students, staff, and facilitators interacting remotely for pediatric emergency training during COVID was associated with high levels of satisfaction by the majority of learners and faculty.

Patient-Centered Care in Primary Care Scale: Pilot Development and Psychometric Assessment.

BACKGROUND: Nurse contributions to patient-centered care in primary care clinics are all but ignored in standard patient experience surveys. PURPOSE: The purpose was to conduct a pilot study to develop and psychometrically assess a scale measuring nurses' and other providers' patient-centered care in Veteran Affairs primary care clinics. METHOD: We developed a patient experience survey composed of original items and previous studies' items and scales. The survey was field tested online with patients who had a recent clinic appointment. The nonrandom analytic sample comprised 221 patients. RESULTS: Exploratory factor analyses yielded a 36-item, 4-factor solution explaining 76% of the variance. The factors were: (1) Provider Knowing the Person/Individualizing Care (18 items; α = 0.98); (2) Nurse Knowing the Person (8; 0.95); (3) Nurse Individualizing Care (7; 0.94); and (4) Continuity of Care (3; not calculated). A short form with 23 items was created using stepwise regression. It had the same 4 factors as the long form with 76% of the variance explained. CONCLUSIONS: Patients reported distinctive nurse contributions that have not been routinely measured.

Expanding Medicaid Access without Expanding Medicaid: Why Did Some Nonexpansion States Continue the Primary Care Fee Bump?

Six states that have rejected the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion nonetheless extended the primary care "fee bump," by which the federal government increased Medicaid fees for primary care services up to 100 percent of Medicare fees during 2013-14. We conducted semistructured interviews with leaders in five of these states, as well as in three comparison states, to examine why they would continue a provision of the ACA that moderately expands access at significant state expense while rejecting the expansion and its large federal match, focusing on relevant economic, political, and procedural factors. We found that fee bump extension proposals were more successful where they were dissociated from major national policy debates, actionable with the input of relatively few stakeholder entities, and well aligned with preexisting policy-making structures and decision trends. Republican proposals to cap or reduce federal funding for Medicaid, if enacted, would compel states to contain program costs. In this context, states' established decision-making processes for updating Medicaid fee schedules, which we elucidate in this study, may shape the future of the Medicaid program.

Explication and Definition of Mental Health Recovery: A Systematic Review.

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope.

Hydrogen-limited growth of hyperthermophilic methanogens at deep-sea hydrothermal vents.

Microbial productivity at hydrothermal vents is among the highest found anywhere in the deep ocean, but constraints on microbial growth and metabolism at vents are lacking. We used a combination of cultivation, molecular, and geochemical tools to verify pure culture H(2) threshold measurements for hyperthermophilic methanogenesis in low-temperature hydrothermal fluids from Axial Volcano and Endeavour Segment in the northeastern Pacific Ocean. Two Methanocaldococcus strains from Axial and Methanocaldococcus jannaschii showed similar Monod growth kinetics when grown in a bioreactor at varying H(2) concentrations. Their H(2) half-saturation value was 66 µM, and growth ceased below 17-23 µM H(2), 10-fold lower than previously predicted. By comparison, measured H(2) and CH(4) concentrations in fluids suggest that there was generally sufficient H(2) for Methanocaldococcus growth at Axial but not at Endeavour. Fluids from one vent at Axial (Marker 113) had anomalously high CH(4) concentrations and contained various thermal classes of methanogens based on cultivation and mcrA/mrtA analyses. At Endeavour, methanogens were largely undetectable in fluid samples based on cultivation and molecular screens, although abundances of hyperthermophilic heterotrophs were relatively high. Where present, Methanocaldococcus genes were the predominant mcrA/mrtA sequences recovered and comprised ∼0.2-6% of the total archaeal community. Field and coculture data suggest that H(2) limitation may be partly ameliorated by H(2) syntrophy with hyperthermophilic heterotrophs. These data support our estimated H(2) threshold for hyperthermophilic methanogenesis at vents and highlight the need for coupled laboratory and field measurements to constrain microbial distribution and biogeochemical impacts in the deep sea.

A comprehensive, simulation-based approach to teaching clinical skills: the medical students' perspective.

The purpose of this study was to determine if third-year medical students participating in a mandatory 12-week simulation course perceived improvement in decision-making, communication, and teamwork skills. Students participated in or observed 24 acute emergency scenarios. At 4-week intervals, students completed 0-10 point Likert scale questionnaires evaluating the curriculum and role of team leader. Linear contrasts were used to examine changes in outcomes. P-values were Bonferroni-corrected for multiple pairwise comparisons. Student evaluations (n = 96) demonstrated increases from week 4 to 12 in educational value (p = 0.006), decision-making (p < 0.001), communication (p = 0.02), teamwork (p = 0.01), confidence in management (p < 0.001), and translation to clinical experience (p < 0.001). Regarding the team leader role, students reported a decrease in stress (p = 0.001) and increase in ability to facilitate team function (p < 0.001) and awareness of team building (p = <0.001). Ratings demonstrate a positive impact of simulation on both clinical management skills and team leadership skills. A simulation curriculum can enhance the ability to manage acute clinical problems and translates well to the clinical experience. These positive perceptions increase as the exposure to simulation increases.

Developing evaluation measures for health departments sharing and linking HIV and STI surveillance data.

Enhancing data sharing, quality, and use across siloed HIV and STI programs is critical for national and global initiatives to reduce new HIV infections and improve the health of people with HIV. As part of the Enhancing Linkage of STI and HIV Surveillance Data in the Ryan White HIV/AIDS Program initiative, four health departments (HDs) in the U.S. received technical assistance to better share and link their HIV and STI surveillance data. The process used to develop evaluation measures assessing implementation and outcomes of linking HIV and STI data systems involved six steps: 1) measure selection and development, 2) review and refinement, 3) testing, 4) implementation and data collection, 5) data quality review and feedback, and 6) dissemination. Findings from pilot testing warranted slight adaptations, including starting with a core set of measures and progressively scaling up. Early findings showed improvements in data quality over time. Lessons learned included identifying and engaging key stakeholders early; developing resources to assist HDs; and considering measure development as iterative processes requiring periodic review and reassessment to ensure continued utility. These findings can guide programs and evaluations, especially those linking data across multiple systems, in developing measures to track implementation and outcomes over time.

Overlooked advantages of interactive book reading in early childhood? A systematic review and research agenda.

Previous reviews of the nature and consequences of adult-child book reading have focused on seeking impacts of interactive reading on the acquisition of vocabulary and emergent literacy skills. In this systematic review we examined to what extent there has been systematic study of the effects of interactive reading on four less frequently studied developmental outcomes important to children's academic and life prospects: socio-emotional and socio-cognitive (SEL) skills, narrative skills, grammar, and world knowledge. We identified 67 studies of interactive reading that met the inclusion criteria and that examined the targeted outcomes, using either experimental, quasi-experimental, correlational, or single-group intervention methods. We found that studies of effects on grammar and world knowledge outcomes were very sparsely represented; though narrative was often studied as an outcome, the wide variation in conceptualizing and assessing the construct hampered any clear conclusion about book-reading effects. The most robust research strand focused on SEL skill outcomes, though here too the outcome assessments varied widely. We speculate that better instrumented approaches to assessing vocabulary and emergent literacy have led to the persistent emphasis on these domains, despite robust evidence of only modest associations, and argue that work to develop sound shared measures of narrative and SEL skills would enable cross-study comparison and the accumulation of findings. In addition, we note that the various studies implicated different explanatory principles for the value of reading with children: specific interactional features (open-ended questions, following the child's lead, expanding child utterances) or content features (emotion-enhanced books, talk about mental states, science topics), raising another topic for more focused study in the future.

Impact of the COVID-19 Pandemic on Social Service Organizations in a Clinical-Community Collaboration.

Increasingly, interventions are being developed to promote collaboration across health care and social service (such as food, housing, and transportation) sectors. During the COVID-19 pandemic, demand for social services grew while social service organizations' capacity declined due to constraints on staffing, funding, and operations. We used an organizational survey fielded from July through November 2020 and publicly available, county-level data to assess the pandemic's impact on 253 social service organizations in the Accountable Health Communities Model evaluation. Over half of surveyed organizations reported being severely impacted by the pandemic, and 92% reported being at least moderately impacted. Social service organizations without federal funding and those in counties with lower poverty (smaller proportion of residents in poverty) and higher COVID-19 case rates were most impacted by the pandemic. Understanding the pandemic's burden on social service organizations can inform planning for future collaborations across health care and social service sectors.

Improving preparedness of emergency medicine residents in the management of postpartum hemorrhage: A randomized controlled study of two pedagogical approaches.

OBJECTIVE: To evaluate a novel curriculum to enhance knowledge and preparedness of emergency medicine (EM) residents in the management of postpartum hemorrhage (PPH). METHODS: A randomized controlled trial examining two pedagogical approaches. Following baseline testing of knowledge and confidence in respect of PPH management, participants were randomized to receive a didactic lecture on PPH management (group A, n = 14) or a didactic lecture followed by simulation-based training on PPH management and debriefing (group B, n = 16). Post-intervention, proficiency in PPH management was evaluated by clinical skills simulation and post-intervention assessment for participants. The change in the mean test and clinical skills scores were compared using Student's t-test. Linear regression examined the effects of covariates. RESULTS: Both forms of intervention increased participants' knowledge of (group A: mean = 2.50, 95% confidence interval [CI] 1.63-3.37, P < 0.001; group B: mean = 1.56, 95% CI 0.89-2.24, P < 0.001) and confidence in PPH management (group A: mean = 1.00, 95% CI 0.46-1.54, P = 0.003; group B: mean = 1.00, 95% CI 0.52-1.48, P = 0.001), relative to baseline. However, addition of simulation and debriefing to the didactic session did not offer any advantage (knowledge: mean = -0.94, 95% CI -1.97 to 0.10, P = 0.074; confidence: mean = 0.00, 95% CI -0.66 to 0.66, P = 1.000). CONCLUSION: Delivery of a structured curriculum led to improvement of knowledge and confidence with regard to the management of PPH by EM residents.

Use of ultrasound guidance improves central venous catheter insertion success rates among junior residents.

OBJECTIVES: The purpose of this study was to determine whether junior residents had higher rates of first cannulation and overall success at central venous catheter insertions with the use of ultrasound (US) guidance compared to the landmark technique. METHODS: We conducted a secondary analysis of data from a prospective randomized controlled study of junior residents from January 2007 through September 2008, which assessed the impact of simulation training on central venous catheter insertion success rates. Blinded independent raters observed in-hospital central venous catheter insertions using a procedural checklist. Success at first cannulation and successful insertion were the primary outcomes. Secondary outcomes included rates of technical errors and mechanical complications. RESULTS: Independent raters observed 480 central venous catheter insertions by 115 residents. Successful first cannulation occurred in 27% of landmark compared to 49% of dynamic US-guided (P < .01), and 50% of static US-guided (P = .01) cannulations. Insertion success occurred for 55% of landmark compared to 80% of dynamic US-guided (P < .01) and 80% of static US-guided (P < .01) cannulations. Dynamic US guidance was associated with increased odds of first cannulation success compared to the landmark technique (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.37-3.67) and successful insertion (OR, 3.80; 95% CI, 2.34-6.19). Static US guidance was associated with increased odds of first cannulation success compared to the landmark technique (OR, 2.59; 95% CI, 1.25-5.39) and successful insertion (OR, 3.48; 95% CI, 1.54-7.87). The results were independent of central venous catheter insertion training, patient comorbidities, and resident specialties. There was no difference related to mechanical complications between the procedures. CONCLUSIONS: Dynamic and static US guidance during central venous catheter insertion was associated with improved in-hospital first cannulation rates and overall success rates of insertions by junior residents.

Creating a surgery clerkship in a changing environment: reality, simulation, and the rules of engagement.

This review describes the current challenges associated with creating a successful surgical clerkship and the ways in which teacher-focused and curriculum-focused initiatives can address these challenges. The challenges are both systemic (reflected by changes in our health care system and training programs) and institutional (reflected by factors that affect curriculum design and faculty advancement). Particular attention is paid to residents as teachers, faculty as mentors, the educational impact of the operating room, and the role of simulation. Strategies for engaging students, residents, and faculty are explored. The premise and impact of a comprehensive simulation course on the clinical education of medical students is detailed. Emphasis is placed on the educational validity of accountability and engagement of both the teachers and the learners.

Burnout and Post-traumatic Stress Disorder Symptoms Among Emergency Medicine Resident Physicians During the COVID-19 Pandemic.

INTRODUCTION: Emergency medicine is characterized by high volume decision-making while under multiple stressors. With the arrival of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in early 2020, physicians across the world were met with a surge of critically ill patients. Emergency physicians (EP) are prone to developing burnout and post-traumatic stress disorder (PTSD), due to experiencing emotional trauma as well as the cumulative stress of practice. Thus, calls have been made for attempts to prevent physician PTSD during this current pandemic. METHODS: From July 2019-January 2020, emergency medicine (EM) resident physicians at a large, academic healthcare system were surveyed for symptoms of burnout using the Maslach Burnout Inventory (MBI). In late April and early May 2020, during the outbreak surge of coronavirus disease 2019 (COVID-19) in the Northeast USA, these same residents and the whole EM residency at the institution were again surveyed for symptoms of burnout as well as post-traumatic stress using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5). A final survey was administered to the EM residents after the COVID-19 surge had largely subsided in June 2020. RESULTS: Twenty-two residents participated in the pre-pandemic study and completed the MBI. Twelve (55%) completed the two follow-up MBI surveys. In the larger EM residency cohort, 31/60 residents completed the MBI and PCL-5 survey during the pandemic peak and 30/60 (50%) completed the follow-up surveys. There were no significant differences in the three MBI burnout category measures of emotional exhaustion (P = 0.49), depersonalization (P = 0.13), and personal accomplishment (P = 0.70) pre-, during, and post-COVID. Of 31 participants, 11 (35%) scored greater than 31 on the PCL-5. Two residents had scores between 21-30, interpreted as "at risk." At greater than one month follow-up, 2/30 continued to meet criteria for a preliminary PTSD diagnosis, and five were "at risk." CONCLUSION: A significant proportion of residents (35%) experienced post-traumatic symptoms acutely during the COVID-19 pandemic crisis, potentially indicating a high prevalence of acute stress disorder in this population and increased risk of developing PTSD. However, there was no significant difference in burnout levels in this cohort before, during, or after the initial COVID-19 surge. Early screening for physicians at risk and referral for assessment and treatment may be important to mitigate pandemic-related PTSD.

Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.

INTRODUCTION: COVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19 increasingly return to the emergency department (ED) for care. This leads to new challenges and threats to patient and clinician safety as suspected patients with COVID-19 need to be quickly detected and isolated among other patients with non-COVID-19-related illnesses. At the front lines, emergency physicians also face continued personal safety concerns and increased work burden, which heighten stress and anxiety, especially given the prolonged course of the pandemic. Burnout, already a serious concern for emergency physicians due to the cumulative stresses of their daily practice, may present as a longer-term outcome of these acute stressors. METHODS AND ANALYSIS: We will implement a rapidly adaptive simulation-based approach to understand and improve physician preparedness while decreasing physician stress and anxiety. First, we will conduct semi-structured qualitative interviews and human factor observations to determine the challenges and facilitators of COVID-19 preparedness and mitigation of physician stress. Next, we will conduct a randomised controlled trial to test the effectiveness of a simulation preparedness intervention on physician physiological stress as measured by decreased heart rate variability on shift and anxiety as measured by the State-Trait Anxiety Inventory. ETHICS AND DISSEMINATION: The protocol was reviewed and approved by the Agency for Healthcare Research and Quality for funding, and ethics approval was obtained from the Yale University Human Investigation Committee in 2020 (HIC# 2000029370 and 2000029372). To support ongoing efforts to address clinician stress and preparedness, we will strategically disseminate the simulation intervention to areas most impacted by COVID-19. Using a virtual telesimulation and webinar format, the dissemination efforts will provide hands-on learning for ED and hospital administrators as well as simulation educators. TRIAL REGISTRATION NUMBER: NCT04614844.

All clinical stressors are not created equal: Differential task stress in a simulated clinical environment.

Background: A variety of stressors are encountered while working in the emergency department and are often recreated in simulation-based medical education. We seek to examine the physiologic and stress state response of participants in a simulated clinical environment to commonly encountered stressors. Methods: Emergency medicine (EM) residents participated in a randomized, controlled trial of six simulated patient encounters with one of three stressors, medical difficulty, interpersonal challenge, and technology/equipment failure, randomized into each scenario. Participants wore smart shirts to measure heart rate variability (HRV) at rest and just after the introduced stressor and completed the Short Stress State Questionnaire (SSSQ) before and after each scenario. Results: Twenty-seven EM residents participated in the study. Interpersonal challenge resulted in increased distress as measured by SSSQ compared to the other two stressors (one way ANOVA, F[2,144] = 9.95, p < 0.001). There was no difference in worry or task engagement across stressors. HRV decreased significantly from rest for all stressors (p = 0.0003, p = 0.0112, p = 0.0027 for medical difficulty, interpersonal challenge, and equipment failure, respectively), but there was no statistically significant difference between mean change in HRV across stressors (one way ANOVA, F[2,120] = 0.17, p = 0.8452). Conclusions: Interpersonal challenge stressor was significantly associated with an increase in distress in EM residents during the simulated encounters as compared to the other stressors. While heart rate variability decreased from rest for each stressor as expected following stressor introduction, differing stressors did not produce a differential change.

Just-in-time clinical video review improves successful placement of Sengstaken-Blakemore tube by emergency medicine resident physicians: A randomized control simulation-based study.

OBJECTIVE: Successful completion of life-saving procedures may benefit from a concise just-in-time (JIT) intervention. Video is an optimal medium for JIT training, but currently available video-based references are not optimized for a JIT format, especially in time-pressured situations prior to high-risk clinical contexts. We aimed to create and evaluate the efficacy of a brief video review of emergent Sengstaken-Blakemore tube (SBT) insertion for acutely decompensating variceal hemorrhage when used just prior to clinical performance in a simulated setting. METHODS: We created a less than 3-minute audio-optional JIT training video on SBT insertion. We recruited emergency medicine resident physicians to participate in a simulation scenario in which they had to quickly place an SBT. Participants were randomized to either a 3-minute procedure review by any media they chose (control) or review of the JIT video (intervention). Performance on a checklist created by a multidisciplinary group of SBT experts (passing score > 18 and maximum = 28) served as the primary outcome. We analyzed performance in checklist scores controlling level of training through a one-way analysis of covariance (ANCOVA). We analyzed rates of passing scores via a chi-square analysis. RESULTS: We randomized 32 participants to media review (control) or JIT video (intervention). The intervention group had an overall mean (±SD) performance of 19.8 (±9.0) and the control group had a mean (±SD) score of 6.6 (±7.4). After adjusting for postgraduate year, we found a significant difference in final checklist scores between the two groups (mean difference = 12.8, 95% confidence interval [CI] = 7.6 to 18.0). Percentages of participants reaching a minimum passing score were two of 16 (12.5%) in the control group and 10 of 16 (62.5%) in the intervention group (odds ratio = 11.7, 95% CI = 9.9 to 13.5). Cohen's kappa indicated substantial agreement (κ = 0.714) between reviewer scores. CONCLUSIONS: A readily available, focused, audio-optional JIT video increased performance for SBT insertion in a simulated setting. Future work may include testing of this format for more commonly performed emergency procedures and determination of effect on bedside performance in the clinical setting.

Virtual Telesimulation for Medical Students During the COVID-19 Pandemic.

PROBLEM: In March 2020, the novel coronavirus 2019 (COVID-19) became a global pandemic. Medical schools around the United States faced difficult decisions, temporarily suspending hospital-based clerkship rotations for medical students due to potential shortages of personal protective equipment and a need to social distance. This decision created a need for innovative, virtual learning opportunities to support undergraduate medical education. APPROACH: Educators at Yale School of Medicine developed a novel medical student curriculum converting high-fidelity, mannequin-based simulation into a fully online virtual telesimulation format. By using a virtual videoconferencing platform to deliver remote telesimulation as an immersive educational experience for widely dispersed students, this novel technology retains the experiential strengths of simulation-based learning while complying with needs for social distancing during the pandemic. The curriculum comprises simulated clinical scenarios that include live patient actors; facilitator interactions; and real-time assessment of vital signs, labs, and imaging. Each 90-minute session includes 2 sets of simulation scenarios and faculty-led teledebriefs. A team of 3 students performs the first scenario, while an additional team of 3 students observes. Teams reverse roles for the second scenario. OUTCOMES: The 6-week virtual telesimulation elective enrolled the maximum 48 medical students and covered core clinical clerkship content areas. Communication patterns within the virtual telesimulation format required more deliberate turn-taking than normal conversation. Using the chat function within the videoconferencing platform allowed teams to complete simultaneous tasks. A nurse confederate provided cues not available in the virtual telesimulation format. NEXT STEPS: Rapid dissemination of this program, including online webinars and live demonstration sessions with student volunteers, supports the development of similar programs at other universities. Evaluation and process improvement efforts include planned qualitative evaluation of this new format to further understand and refine the learning experience. Future work is needed to evaluate clinical skill development in this educational modality.

A Novel Application of the Modified Angoff Method to Rate Case Difficulty in Simulation-Based Research.

INTRODUCTION: Simulation use in research is often limited by controlling for scenario difficulty when using repeated measures. Our study assesses the feasibility of the Modified Angoff Method to reach expert consensus regarding difficulty of medical simulations. We compared scores with participant physiologic stress. METHODS: Emergency medicine physicians with expertise in simulation education were asked to review 8 scenarios and estimate the percentage of resident physicians who would perform all critical actions using the modified Angoff method. A standard deviation (SD) of less than 10% of estimated percentage correct signified consensus. Twenty-five residents then performed the 6 scenarios that met consensus and heart rate variability (HRV) was measured. RESULTS: During round 1, experts rated 4/8 scenarios within a 10% SD for postgraduate year 3 (PGY3) and 3/8 for PGY4 residents. In round 2, 6/8 simulation scenarios were within an SD of 10% points for both years. Intraclass correlation coefficient was 0.84 for PGY3 ratings and 0.89 for PGY4 ratings. A mixed effects analysis of variance showed no significant difference in HRV change from rest to simulation between teams or scenarios. Modified Angoff Score was not a predictor of HRV (multiple R2 = 0.0176). CONCLUSIONS: Modified Angoff ratings demonstrated consensus in quantifying the estimated percentage of participants who would complete all critical actions for most scenarios. Although participant HRV did decrease during the scenarios, we were unable to significantly correlate this with ratings. This modified Angoff method is a feasible approach to evaluate simulation difficulty for educational and research purposes and may decrease the time and resources necessary for scenario piloting.