Development of Learning Curves for Bronchoscopy: Results of a Multicenter Study of Pulmonary Trainees.

BACKGROUND: There are currently no reference standards for the development of competence in bronchoscopy. RESEARCH QUESTION: The aims of this study were to (1) develop learning curves for bronchoscopy skill development and (2) estimate the number of bronchoscopies required to achieve competence. STUDY DESIGN AND METHODS: Trainees from seven North American academic centers were enrolled at the beginning of their pulmonology training. Performance during clinical bronchoscopies was assessed by supervising physicians using the Ontario Bronchoscopy Assessment Tool (OBAT). Group-level learning curves were modeled using a quantile regression growth model, where the dependent variable was the mean OBAT score and the independent variable was the number of bronchoscopies performed at the time the OBAT was completed. RESULTS: A total of 591 OBAT assessments were collected from 31 trainees. The estimated regression quantiles illustrate significantly different learning curves based on trainees' performance percentiles. When competence was defined as the mean OBAT score for all bronchoscopies rated as being completed without need for supervision, the mean OBAT score associated with competence was 4.54 (95% CI, 4.47-4.58). Using this metric, the number of bronchoscopies required to achieve this score varied from seven to 10 for the 90th percentile of trainees and from 109 to 126 for the lowest 10th percentile of trainees. When competence was defined as the mean OBAT score for the first independent bronchoscopy, the mean was 4.40 (95% CI, 4.20-4.60). On the basis of this metric, the number of bronchoscopies required varied from one to 11 for the 90th percentile of trainees and from 83 to 129 for the lowest 10th percentile of trainees. INTERPRETATION: We were able to generate learning curves for bronchoscopy across a range of trainees and centers. Furthermore, we established the average number of bronchoscopies required for the attainment of competence. This information can be used for purposes of curriculum planning and allows a trainee's progress to be compared with an established norm.

Family Meeting Training Curriculum: A Multimedia Approach With Real-Time Experiential Learning for Residents.

Introduction: Effective communication skills are widely recognized as an important aspect of medical practice. Several tools and curricula for communications training in medicine have been proposed, with increasing attention to the need for an evidence-based curriculum for communication with families of patients in the intensive care unit (ICU). Methods: We developed a curriculum for internal medicine residents rotating through the medical ICU that consisted of a didactic session introducing basic and advanced communication skills, computer-based scenarios exposing participants to commonly encountered dilemmas in simulated family meetings, and experiential learning through the opportunity to identify potential communication challenges prior to facilitating actual family meetings, followed by structured peer debriefing. Seventeen residents participated in the study. Results: We administered the Communication Skills Attitude Scale to participants before and after participation in the curriculum, as well as a global self-efficacy survey, with some items based on the Common Ground rating instrument, at the end of the academic year. There were no significant changes in either positive or negative attitudes toward learning communication skills. Resident self-perceived efficacy in several content domains improved but did not reach statistical significance. Discussion: Our curriculum provided interactive preparatory training and an authentic experience for learners to develop skills in family meeting facilitation. Learners responded favorably to the curriculum. Use of the Family Meeting Behavioral Skills (FMBS) tool helped residents and educators identify and focus on specific skills related to the family meeting. Next steps include gathering and analyzing data from the FMBS tool.

Iatrogenic tracheal laceration in the setting of chronic steroids.

We report the case of a 71-year-old woman with end-stage chronic obstructive pulmonary disease who presented with a 10-cm tracheal laceration from a presumed traumatic intubation in the setting of respiratory distress and chronic obstructive pulmonary disease exacerbation and subsequently developed significant subcutaneous emphysema along her neck and mediastinum in addition to her peritoneum and mesentery. We were successfully able to treat this patient conservatively up until the time that tracheostomy was warranted. We discuss and review tracheobronchial injuries with respect to etiology, risk factors, and management and hope to benefit health care providers managing airways in patients at risk for tracheal injury.

ICU family communication and health care professionals: A qualitative analysis of perspectives.

OBJECTIVES: Although ineffective communication is known to influence patient and family satisfaction with care in intensive care unit [ICU] settings, there has been little systematic analysis of the features of the perceived problem from a communication theory perspective. This study was undertaken to understand perceptions of miscommunication and the circumstances in which they present. RESEARCH METHODOLOGY AND DESIGN: Semi-structured interviews were conducted with 22 health care professionals [HCPs] in five adult ICUs at an academic medical centre in the United States. FINDINGS: From qualitative analysis of the transcribed interviews, four themes emerged, each containing multiple subthemes. Person factors are problems that originate within individuals, related to education, cultural background and emotion. Structural factors are associated with boundaries and coordination of institutional roles. Information management problems result from social and psychological processes by which HCPs and family members seek, distribute and understand information. Relationship management problems arise from difficulties in interpersonal interactions. CONCLUSIONS: Ineffective communication is not a single problem, but rather several distinct problems that exist at different levels of abstraction and vary in over-time stability. These findings provide a framework for designing interventions to improve the well-being of patients and family members.

Looks like a stroke, acts like a stroke, but it's more than a stroke: a case of cerebral mucormycosis.

Mucormycosis is a fungus that exhibits angiocentric growth and can cause a thrombotic arteritis. Infection with this organism is uncommon and cerebral involvement is most often secondary to direct invasion through the paranasal sinuses. Here, we present a case of mucormycosis with cerebral involvement without sinus disease, which resulted in ischemic stroke with rapid progression resulting in death.

Short-term mortality prediction for acute lung injury patients: external validation of the Acute Respiratory Distress Syndrome Network prediction model.

OBJECTIVE: An independent cohort of patients with acute lung injury was used to evaluate the external validity of a simple prediction model for short-term mortality previously developed using data from Acute Respiratory Distress Syndrome Network (ARDSNet) trials. DESIGN: Data for external validation were obtained from a prospective cohort study of patients with acute lung injury. SETTING: Thirteen intensive care units at four teaching hospitals in Baltimore, MD. PATIENTS: Five hundred and eight nontrauma patients with acute lung injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 508 patients eligible for this analysis, 234 (46%) died inhospital. Discrimination of the ARDSNet prediction model for inhospital mortality, evaluated by the area under the receiver operator characteristic curves, was 0.67 for our external validation data set vs. 0.70 and 0.68 using Acute Physiology and Chronic Health Evaluation II and the ARDSNet validation data set, respectively. In evaluating calibration of the model, predicted vs. observed inhospital mortality for the external validation data set was similar for both low-risk (ARDSNet model score = 0) and high-risk (score = 3 or 4+) patient strata. However, for intermediate-risk (score = 1 or 2) patients, observed inhospital mortality was substantially higher than predicted mortality (25.3% vs. 16.5% and 40.6% vs. 31.0% for score = 1 and 2, respectively). Sensitivity analyses limiting our external validation data set to only those patients meeting the ARDSNet trial eligibility criteria and to those who received mechanical ventilation in compliance with the ARDSNet ventilation protocol did not substantially change the model's discrimination or improve its calibration. CONCLUSIONS: Evaluation of the ARDSNet prediction model using an external acute lung injury cohort demonstrated similar discrimination of the model as was observed with the ARDSNet validation data set. However, there were substantial differences in observed vs. predicted mortality among intermediate-risk patients with acute lung injury. The ARDSNet model provided reasonable, but imprecise, estimates of predicted mortality when applied to our external validation cohort of patients with acute lung injury.