An Approach to Leadership Development and Patient Safety and Quality Improvement Education in the Context of Professional Identity Formation in Pre-Clinical Medical Students.

Objectives: Leadership and patient safety and quality improvement (PSQI) are recognized as essential parts of a physician's role and identity, which are important for residency training. Providing adequate opportunities for undergraduate medical students to learn skills related to these areas, and their importance, is challenging. Methods: The Western University Professional Identity Course (WUPIC) was introduced to develop leadership and PSQI skills in second-year medical students while also aiming to instill these topics into their identities. The experiential learning portion was a series of student-led and physician-mentored PSQI projects in clinical settings that synthesized leadership and PSQI principles. Course evaluation was done through pre/post-student surveys and physician mentor semi-structured interviews. Results: A total of 108 of 188 medical students (57.4%), and 11 mentors (20.7%), participated in the course evaluation. Student surveys and mentor interviews illustrated improved student ability to work in teams, self-lead, and engage in systems-level thinking through the course. Students improved their PSQI knowledge and comfort levels while also appreciating its importance. Conclusion: The findings from our study suggest that undergraduate medical students can be provided with an enriching leadership and PSQI experience through the implementation of faculty-mentored but student-led groups at the core of the curricular intervention. As students enter their clinical years, their first-hand PSQI experience will serve them well in increasing their capacity and confidence to take on leadership roles.

A Systematic Review of Interventions to Reduce Computed Tomography Usage in the Emergency Department.

STUDY OBJECTIVE: Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety. METHODS: Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted. RESULTS: A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen's κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low. CONCLUSION: Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.

Realist inquiry: a new way to think about overcrowding interventions.

OBJECTIVES: Physician-focused throughput initiatives are intended to mitigate the effects of emergency department (ED) overcrowding. Our tertiary care academic hospital recently piloted an emergency physician leader role intended to improve throughput. Although a separate experimental evaluation of this initiative was undertaken, it was expected that such an evaluation could not alone provide the necessary information to inform 'how' the emergency physician leader intervention worked. The objective of this study was to conduct a realist evaluation of the emergency physician leader. Realist inquiry utilizes Context Mechanism Outcome configurations to determine the impacts of interventions that are often missed by quantitative analysis. Using a realist perspective, this study aimed to evaluate the emergency physician leader initiative's effects on throughput with the goal of building transferable lessons to the implementation of future interventions. METHODS: Semi-structured interviews with key stakeholders in the intervention were conducted and analyzed using thematic and template techniques specifically aimed at identifying Context Mechanism Outcomes. RESULTS: 13 interviews were conducted with physicians and nurses who identified contexts and mechanisms which promoted or impeded ED throughput. For example, in situations where there was a clear indication for imaging or management that could not be initiated within the scope of a nursing protocol, the emergency physician leader initiating these orders was felt to promote ED throughput. Conversely, in contexts where there was no nurse available to fulfill early orders, the emergency physician leader's initiation of orders was perceived to impede throughput. CONCLUSION: This evaluation provides insights into the reasoning and behaviour of individuals involved in the emergency physician leader initiative and provides a systematic approach to unraveling its complex causal pathway. Knowledge of context-mechanism-outcome relationships may help implementers design and measure the impact of future physician-focused throughput interventions.

RéSUMé: OBJECTIFS: Les initiatives de débit axées sur les médecins visent à atténuer les effets du surpeuplement des urgences. Notre hôpital universitaire de soins tertiaires a récemment mis à l'essai un rôle de chef de file des médecins d'urgence visant à améliorer le débit. Bien qu'une évaluation expérimentale distincte de cette initiative ait été entreprise, on s'attendait à ce qu'une telle évaluation ne puisse à elle seule fournir les informations nécessaires pour déterminer "comment" l'intervention du chef de file des médecins urgentistes a fonctionné. L'objectif de cette étude était de procéder à une évaluation réaliste du chef du médecin d'urgence. L'enquête réaliste utilize les configurations Contexte Mécanisme Effet pour déterminer les impacts des interventions qui sont souvent manqués par l'analyse quantitative. En utilisant une perspective réaliste, cette étude visait à évaluer les effets de l'initiative du leader des médecins d'urgence sur le débit dans le but de tirer des leçons transférables pour la mise en œuvre de futures interventions. MéTHODES: Des entretiens semi-structurés avec les principales parties prenantes de l'intervention ont été menés et analysés à l'aide de techniques thématiques et de modèles visant spécifiquement à identifier les effets du contexte et du mécanisme. RéSULTATS: 13 entretiens ont été menés avec des médecins et des infirmières qui ont identifié les contextes et les mécanismes qui favorisaient ou entravaient le débit des urgences. Par exemple, dans les situations où il y avait une indication claire d'imagerie ou de prise en charge qui ne pouvait pas être initiée dans le cadre d'un protocole infirmier, le médecin chef des urgences initiant ces commandes était considéré comme favorisant le débit des urgences. À l'inverse, dans les contextes où aucune infirmière n'était disponible pour répondre aux premières commandes, l'initiation des commandes par le médecin chef des urgences était perçue comme une entrave au débit. CONCLUSION: Cette évaluation donne un aperçu du raisonnement et du comportement des personnes impliquées dans l'initiative des chefs de file des médecins d'urgence et fournit une approche systématique pour démêler son cheminement causal complexe. La connaissance des relations contexte-mécanisme-résultat peut aider les exécutants à concevoir et à mesurer l'impact des futures interventions de débit axées sur les médecins.

A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department.

This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.

Data Driven Competitive Motivation Strategies in a Longitudinal Simulation Curriculum for Trauma Team Training.

OBJECTIVE: A novel approach to trauma team simulation was used to enhance team performance in a cohort of general surgical residents. We implemented data driven debriefing using performance report cards and video footage of the simulations. We wanted to evaluate the technical and nontechnical skills developed by teams using this approach. DESIGN: All surgical residents in an academic program were divided into 5 equal "trauma teams". Throughout the academic year, each team took part in 4 standardized, high fidelity trauma simulations. Rubrics to assess technical efficiency were scored. Each team received individualized feedback in the form of report cards following each simulation. Video recordings of each simulation were analyzed by blinded raters using a validated instrument to assess nontechnical skills/Crisis Resource Management (CRM) skills. SETTING: An academic level 1 trauma hospital in Canada. RESULTS: Five teams comprising five residents participated in four simulations each. Learner feedback was universally positive and learning during simulation was rated higher than learning during didactic lecture. The effect of data driven report cards and anonymized ranking was cited by trainees as a motivating factor to improve. CRM scores improved over the course of the academic year for all teams but without reaching statistical significance. A strong positive correlation was measured between technical and CRM skills for all teams. CONCLUSIONS: Adding data driven debriefing using performance report cards that assess both technical and CRM skills to a trauma team curriculum is a feasible and acceptable way to influence trainee performance using positive competitive motivation. More data are required to confirm the early patterns of improvement uncovered in CRM scoring. A positive correlation between technical skills and CRM skills raises important questions for future research.

PEMT, Δ6 desaturase, and palmitoyldocosahexaenoyl phosphatidylcholine are increased in rats during pregnancy.

DHA is important for fetal neurodevelopment. During pregnancy, maternal plasma DHA increases, but the mechanism is not fully understood. Using rats fed a fixed-formula diet (DHA as 0.07% total energy), plasma and liver were collected for fatty acid profiling before pregnancy, at 15 and 20 days of pregnancy, and 7 days postpartum. Phosphatidylethanolamine methyltransferase (PEMT) and enzymes involved in PUFA synthesis were examined in liver. Ad hoc transcriptomic and lipidomic analyses were also performed. With pregnancy, DHA increased in liver and plasma lipids, with a large increase in plasma DHA between day 15 and day 20 that was mainly attributed to an increase in 16:0/DHA phosphatidylcholine (PC) in liver (2.6-fold) and plasma (3.9-fold). Increased protein levels of Δ6 desaturase (FADS2) and PEMT at day 20 and increased Pemt expression and PEMT activity at day 15 suggest that during pregnancy, both DHA synthesis and 16:0/DHA PC synthesis are upregulated. Transcriptomic analysis revealed minor changes in the expression of genes related to phospholipid synthesis, but little insight on DHA metabolism. Hepatic PEMT appears to be the mechanism for increased plasma 16:0/DHA PC, which is supported by increased DHA biosynthesis based on increased FADS2 protein levels.