The utility of bandemia in prognostication and prediction of mortality in sepsis.

Background: Bandemia, defined as a band count >10%, is indicative of underlying infection and is increasingly being used for early detection of sepsis. While an absolute band level has been linked to worse outcomes, its trend has not been extensively studied as a prognostic marker. In this study, we assessed patients admitted to the ICU with sepsis or septic shock and evaluated the correlation between bandemia trends and clinical trajectory among these patients. Methods: This study was a retrospective chart review. Band counts, serum lactate levels, and SOFA scores at 0 and 72 h after admission to the ICU were collected. Patients were risk stratified into groups depending on their SOFA trends, and corresponding band trends and serum lactate levels were compared. Results: 134 patients were included for analysis. There was a statistically significant decrease in bandemia trends for patients with a reduction in SOFA scores [median (IQR)-4.5 (-11, 0); p < 0.0001], and a statistically significant increase in bandemia trends for patients with worsening SOFA scores [median (IQR) 4 (0, 8); p = 0.0007]. Conclusion: Early trends of serum band levels in patients with sepsis or septic shock may help to predict a clinical trajectory and overall prognosis. More investigation is warranted as to whether incorporating bandemia trends, when used in conjunction with other known markers such as lactate levels, may help to guide bedside clinical decisions such as risk stratification, tailored therapies, and ultimately improve outcomes.

Hospital-Based Health Care Worker Perceptions of Personal Risk Related to COVID-19.

BACKGROUND: Health care workers treating Coronavirus disease 2019 (COVID-19) patients face significant stressors such as caring for critically ill and dying patients, physically demanding care requiring new degrees of personal protective equipment use, risk of contracting the disease, and putting loved ones at risk. This study investigates the stress impact from COVID-19 exposure and how nurses and medical providers (eg, physicians, nurse practitioners, physician assistants) experience these challenges differently. METHODS: An electronic, self-administered questionnaire was sent to all hospital staff over 6 weeks surveying exposure to COVID-19 patients and degree of stress caused by this exposure. Responses from medical providers and nurses were analyzed for significant contributors to stress levels, as well as comparing responses from medical providers versus nurses. RESULTS: Stress levels from increased risk of disease contraction while on the job, fear of transmitting it to family or friends, and the resulting social stigma were highest in medical staff during the COVID-19 pandemic. Compared with medical providers, nurses had nearly 4 times the odds of considering job resignation due to COVID-19. However, most health care workers (77.4% of medical providers and 52.9% of nurses) strongly agreed or agreed with the statements indicating high levels of altruism in their desire to treat COVID-19 patients. CONCLUSION: The significant stress burden placed on nurses likely contributes to increased thoughts of job resignation. However, health care providers displayed high levels of altruism during this time of extreme crisis, despite their personal risks of caring for COVID-19 patients.

Overcoming Communication Barriers: An evaluation of communication devices for healthcare providers wearing powered air-purifying respirators (PAPRs).

Introduction: The COVID-19 pandemic has resulted in an increased use of Powered Air Purifying Respirators (PAPRs), by health care providers to mitigate the risk of viral transmission, especially for aerosol-generating procedures. In this study, we evaluate communication devices that could be used concurrently with PAPRs to promote improved communication. Methods: We tested two devices, a Bluetooth earpiece and a throat microphone that operated over mobile networks, against a control scenario in a simulated operating room environment with participants donning PAPRs. Participants read a short paragraph to each other, transcribed short phrases, and evaluated the scenarios according to speech intelligibility, ease of use, and comfort. Results: There were 30 participants of varying PAPR experience. The Bluetooth headset had the most accurate transcriptions, followed by control, and lastly the neckpiece (94.7%vs 88.4%vs 76%, p<0.001). Conclusion: Communication devices have the potential to bridge but also worsen communications barriers between providers donning PAPRs.

Virtual Residency Interviews: A Survey of Anesthesiology Program Director Perspectives Amidst the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic caused a rapid pivot from in-person to virtual residency interviews across the United States. We present a survey we conducted about the attitudes and opinions of anesthesiology program directors with regard to the 2021 virtual interview process. METHODS: This was a 13-question online survey disseminated to 142 anesthesiology residency program directors in February 2021, asking them to compare the most recent interview cycle to their experience with prior cycles. RESULTS: There were 46 (37%) respondents. Generally, respondents saw an increase in applicants and reported perceiving worse interpersonal relationships with applicants, significantly so in programs with small resident classes. CONCLUSIONS: Past research has focused on the benefits of virtual interviews for the applicant, but these should be evaluated in tandem with increased difficulties for the interviewers.

COVID-19 Intubation Safety: A Multidisciplinary, Rapid-Cycle Model of Improvement.

The COVID-19 pandemic has forced the health care industry to develop dynamic protocols to maximize provider safety as aerosolizing procedures, specifically intubation, increase the risk of contracting SARS-CoV-2. The authors sought to create a quality improvement framework to ensure safe practices for intubating providers, and describe a multidisciplinary model developed at an academic tertiary care facility centered on rapid-cycle improvements and real-time gap analysis to track adherence to COVID-19 intubation safety protocols. The model included an Intubation Safety Checklist, a standardized documentation template for intubations, obtaining real-time feedback, and weekly multidisciplinary team meetings to review data and implement improvements. This study captured 68 intubations in suspected COVID-19 patients and demonstrated high personal protective equipment compliance at the institution, but also identified areas for process improvement. Overall, the authors posit that an interdisciplinary workgroup and the integration of standardized processes can be used to enhance intubation safety among providers during the COVID-19 pandemic.

A Novel, Web-Based Quality Improvement Platform to Address ACGME CLER Requirements.

BACKGROUND: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) formally mandated trainee (resident and fellow) participation in health care quality improvement (QI) projects as one of the Clinical Learning Environment Review (CLER) Pathways to Excellence. Subsequent national reviews showed large variations in how QI education is conducted, as well as a significant mismatch between educational and organizational goals. OBJECTIVE: We developed a web-based platform to engage trainees in QI that better aligned with best practice methodology and matched identified institutional priorities. METHODS: A needs assessment survey was distributed to trainees to understand the obstacles to compliance with ACGME QI requirements. Based on the results, a web-based clearinghouse, called the QI Platform, was developed and launched in July 2016, and utilization was analyzed in February 2019. RESULTS: A total of 196 of 440 needs assessment surveys (45%) were completed. Themes extracted from surveys to identify barriers in QI participation included difficulties designing projects, lack of mentorship or expert support, and difficulty engaging an interprofessional team. Over 2.5 years, 151 projects were registered on the platform. Of these, 17 (11%) were collaborative entries. At the time of analysis, 166 of 437 trainees (38%) were listed as participants in active QI projects. A total of 22 projects were archived as complete, and 68 incomplete projects were reassigned to the "Ideas" section as works in progress after lead trainee graduation. CONCLUSIONS: An institutional QI Platform clearinghouse for GME QI projects was feasible to develop and maintain, and it appeared acceptable to most GME programs and trainees for recording and tracking QI projects, and linking these to hospital QI priorities.

Integrating Adverse Event Reporting Into a Free-Text Mobile Application Used in Daily Workflow Increases Adverse Event Reporting by Physicians.

Adverse event (AE) reporting is a key component of patient safety and physicians are known to underreport. The authors hypothesized that integrating AE reporting into a mobile application used in daily physician workflow would increase physician reporting of AEs. After integrating AE reporting into a free-text mobile application used for daily workflow, the change in AE reporting by physicians was analyzed using Mann-Whitney U tests. AE reporting by physicians increased more than 37-fold (21 to 806; U = 7.5, P < .0001). AE reporting by physicians as a proportion of all AE reports received increased 120-fold (from 0.1% to 12% of all reports, U = 10, P < .0001). Integrating AE reporting into a free-text mobile application used in daily physician workflow markedly increased their reporting of AEs. This approach shifted time burden from physicians to quality officers. Implementation should be coupled with physician education about identifying AEs and content to include in reports.

Evaluation of Knowledge Acquisition with a Practice Management Course for Anesthesiology Residents: A Pilot Study.

Physicians routinely rely on nontechnical skills-including leadership ability, managerial skills and financial considerations-when delivering patient care. Efficient practice management is a commonplace expectation of attending anesthesiologists, but there is no uniform residency training to foster the expertise required to succeed in this endeavor. The purpose of this study is to evaluate a novel practice management course for anesthesiology residents. METHODS: Senior anesthesiology residents (Clinical Anesthesia-3) at The George Washington University were eligible to participate in a 1-month Ambulatory Anesthesiology-Practice Management Rotation focusing on the acquisition of nontechnical skills and knowledge applicable to becoming an effective clinical leader. The rotation included 1-week service as operating room manager, completion of an online module, assigned readings with follow-up discussions, and completion of a billing and reimbursement exercise. The interventions, in aggregate, were measured with a preknowledge and a postknowledge test. RESULTS: Twelve residents out of 14 (86%) completed the preknowledge and postknowledge tests. Residents scored significantly higher on the postcourse exam (61.49%, SD 18.65%) than the pretest (42.7%, SD 12.7%) (P < .004). CONCLUSION: A curriculum designed to develop the practice management skills required of a physician anesthesiologist is feasible and effective at improving knowledge within a 1-month, senior resident rotation.

Sustained Attention in Auditory and Visual Monitoring Tasks: Evaluation of the Administration of a Rest Break or Exogenous Vibrotactile Signals.

OBJECTIVE: Performance and mental workload were observed for the administration of a rest break or exogenous vibrotactile signals in auditory and visual monitoring tasks. BACKGROUND: Sustained attention is mentally demanding. Techniques are required to improve observer performance in vigilance tasks. METHOD: Participants (N = 150) monitored an auditory or a visual display for changes in signal duration in a 40-min watch. During the watch, participants were administered a rest break or exogenous vibrotactile signals. RESULTS: Detection accuracy was significantly greater in the auditory than in the visual modality. A short rest break restored detection accuracy in both sensory modalities following deterioration in performance. Participants experienced significantly lower mental workload when monitoring auditory than visual signals, and a rest break significantly reduced mental workload in both sensory modalities. Exogenous vibrotactile signals had no beneficial effects on performance, or mental workload. CONCLUSION: A rest break can restore performance in auditory and visual vigilance tasks. Although sensory differences in vigilance tasks have been studied, this study is the initial effort to investigate the effects of a rest break countermeasure in both auditory and visual vigilance tasks, and it is also the initial effort to explore the effects of the intervention of a rest break on the perceived mental workload of auditory and visual vigilance tasks. Further research is warranted to determine exact characteristics of effective exogenous vibrotactile signals in vigilance tasks. APPLICATION: Potential applications of this research include procedures for decreasing the temporal decline in observer performance and the high mental workload imposed by vigilance tasks.

Novel use of videolaryngoscopy to remove a foreign body.

We present a case where a C-MAC video laryngoscope was used to remove a duodenal stent that was inadvertently dislodged in the patient's proximal oesophagus during an interventional radiology procedure, causing upper airway obstruction. Using the C-MAC and a pair of Magill forceps, we were able to successfully remove the stent. Video feed allowed for further communication between us and the ENT (ear, nose and throat) surgeons.

Strategies to combat auditory overload during vehicular command and control.

Strategies to combat auditory overload were studied. Normal-hearing males were tested in a sound isolated room in a mock-up of a military land vehicle. Two tasks were presented concurrently, in quiet and vehicle noise. For Task 1 dichotic phrases were delivered over a communications headset. Participants encoded only those beginning with a preassigned call sign (Baron or Charlie). For Task 2, they agreed or disagreed with simple equations presented either over loudspeakers, as text on the laptop monitor, in both the audio and the visual modalities, or not at all. Accuracy was significantly better by 20% on Task 2 when the equations were presented visually or audiovisually. Scores were at least 78% correct for dichotic phrases presented over the headset, with a right ear advantage of 7%, given the 5 dB speech-to-noise ratio. The left ear disadvantage was particularly apparent in noise, where the interaural difference was 12%. Relatively lower scores in the left ear, in noise, were observed for phrases beginning with Charlie. These findings underscore the benefit of delivering higher priority communications to the dominant ear, the importance of selecting speech sounds that are resilient to noise masking, and the advantage of using text in cases of degraded audio.

Diversity is what you want it to be: how social-dominance motives affect construals of diversity.

We propose that diversity is a malleable concept capable of being used either to attenuate or to enhance racial inequality. The research reported here suggests that when people are exposed to ambiguous information concerning an organization's diversity, they construe diversity in a manner consistent with their social-dominance motives. Specifically, anti-egalitarian individuals broaden their construal of diversity to include nonracial (i.e., occupational) heterogeneity when an organization's racial heterogeneity is low. By contrast, egalitarian individuals broaden their construal of diversity to include nonracial heterogeneity when an organization's racial heterogeneity is high. The inclusion of occupational heterogeneity in perceptions of diversity allows people across the spectrum of social-dominance orientation to justify their support for or opposition to hierarchy-attenuating affirmative-action policies. Our findings suggest that diversity may not have a fixed meaning and that, without a specific delineation of what the concept means in particular contexts, people may construe diversity in a manner consistent with their social motivations.

The Independent LifeStyle Assistant: lessons learned.

The Independent LifeStyle Assistant (I.L.S.A.) is an agent-based monitoring and support system to help elderly people live longer in their homes by reducing caregiver burden. I.L.S.A. is a multiagent system that incorporates a unified sensing model, situation assessments, response planning, real-time responses, and machine learning. This paper describes the six-month study of the system we fielded in elders' homes and the major lessons we learned during development.

Varied-mapping conjunction search: evidence for rule-based learning.

Five experiments were carried out to examine whether top-down processes can aid search, even when targets and distractors are variably mapped. Experiments 1a and 1b determined that effortless VM search can be obtained in Contrast Polarity X Orientation and Color X Orientation conjunction search when one feature dimension remains consistently mapped across blocks. Experiment 2 showed that efficient VM search is possible when both dimensions are variably mapped. In Experiment 3, efficient VM search was found when target-distractor reversals occurred on a trial-wise basis. Experiments 4 and 5 found that VM search deteriorates when target identity is not known prior to display onset. These studies demonstrate the role of top-down mechanisms in the development of efficient VM search and present several challenges to strength-theoretic views on the mechanisms underlying automaticity.

Age differences in feature selection in triple conjunction search.

Younger and older participants were trained in a triple conjunction visual search task to examine age differences in the development of proficient performance. For the first 8 days, participants searched for a target defined by its contrast polarity, shape, and orientation. On Days 9 through 16, the target identity was switched to one defined by opposing feature values. On Day 17, the target was returned to the original feature values. Results indicated that, after training, younger adults reduced their display size effects more than elderly adults. Disruption occurred after the first but not after the second transfer. However, each time the target was switched, there were no age differences in disruption. Eye movement data suggest that older adults use a similar feature selection strategy as younger adults but may be more susceptible to distraction. The results are discussed in terms of current models of attention and search.

Age differences in visual search for traffic signs during a simulated conversation.

The effects of divided attention were examined in younger adults (M = 23 years) and older adults (M = 64 years) who searched for traffic signs in digitized images of traffic scenes. Sign search was executed under single-task and dual-task conditions in scenes containing either small or large amounts of visual clutter. For both age groups, clutter and the secondary task had additive effects on search accuracy, speed, and oculomotor involvement. Compared with the younger adults, older adults were less accurate, especially with high-clutter scenes, were slower to decide that a target sign was not present, and exhibited a marginally greater divided-attention effect on reaction times. They exhibited longer fixations in the divided-attention condition, in which they also showed a disproportionate reduction in recognition memory for the content of the secondary task. Actual or potential applications of this research include methods for evaluating the distraction of conversations and safety implications of conversation on visual search behavior.

Plasticity of feature-based selection in triple-conjunction search.

Two experiments examined the disruption of feature-based selection in triple-conjunction search at multiple target transfers. In Experiment 1, after 10 training sessions, a new target possessing previous distractor features was introduced. This produced disruption in RT and fixation number, but no disruption in feature-based selection. Specifically, there was a tendency to fixate objects sharing the target's contrast polarity and shape and this did not change even upon transfer to the new target. In Experiment 2, 30 training sessions were provided with three target transfers. At the first transfer, the results replicated Experiment 1. Subsequent transfers did not produce disruption on any measure. These findings are discussed in terms of strength theory, Guided Search, rule-based approaches to perceptual learning, and the area activation model.

Age, skill transfer, and conjunction search.

Ten younger and ten older adults were provided with 16 sessions of conjunction search under consistent mapping, where target and distractors remain constant in identity. The target and one distractor were reversed after every fourth session. After the first four training sessions, on target-present trials, display size slopes were near zero for both age groups. However, on target-absent trials, older adults continued to show significantly larger display size effects than younger adults. There were no systematic age differences in either the probability of fixating objects that possess the target's features or in the amount of disruption at any reversal. Thus, although older adults exhibited more conservative criteria in visual search, they developed proficient and flexible search skill to the same degree as their younger counterparts. These data have implications for models of visual attention, skill acquisition, and cognitive aging.