Initiation and Assessment of Timekeeping Roles During In-Hospital Cardiac Arrests to Track Rhythm Checks and Epinephrine Dosing.

OBJECTIVES: Compliance to advanced cardiac life support algorithm is low and associated with worse outcomes from in-hospital cardiac arrests. This study aims to improve algorithm compliance by delegation of two separate code team members for timing rhythm check and epinephrine administration in accordance to the advanced cardiac life support algorithm. DESIGN: Prospective intervention with historical controls. SETTING: Single academic medical center. PATIENTS: Patients who suffered in-hospital cardiac arrest during study period were considered for inclusion. Patients in which the advanced cardiac life support algorithm or new timekeeper roles were not used were excluded. INTERVENTIONS: Two existing code team members were delegated to time epinephrine and rhythm checks. MEASUREMENTS AND MAIN RESULTS: Primary endpoint was deviations from the 2-minute rhythm check or 3- to 5-minute epinephrine administration. Each deviation outside allotted time intervals was counted as one deviation. However, instances in which multiple intervals passed were counted as multiple deviations. Algorithm adherence was analyzed before and after intervention. Secondary endpoints included return of spontaneous circulation rate, time until first dose of epinephrine, and anonymous survey data. Thirteen pre intervention in-hospital cardiac arrests were compared with 13 in-hospital cardiac arrests post. Prior to intervention, the median deviation per in-hospital cardiac arrest was 5 (interquartile range, 3-7) versus 1 post (interquartile range 0-1; p = 0.0003). The median time until first dose of epinephrine was administered pre intervention was 5 minutes (interquartile range, 0-4) versus post intervention median of 0 (interquartile range, 0-0; p = 0.02). Pre-intervention return of spontaneous circulation rate was 46.1% versus 69.2% post. Surveys demonstrated advanced cardiac life support providers felt time keeping roles made it easier to track epinephrine administration and rhythm checks and improved team communication. CONCLUSIONS: Two separate timekeeper roles during in-hospital cardiac arrests improved algorithm compliance, code team function, and was favored by code team members. Timekeeper roles may be associated with improved rates of return of spontaneous circulation and less time until the first dose of epinephrine was administered. This study is limited by small sample size and single-center design.

Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates.

Effective communication between providers and patients and their surrogates in the intensive care unit (ICU) is crucial for delivery of high-quality care. Despite the identification of communication as a key education focus by the American Board of Internal Medicine, little emphasis is placed on teaching trainees how to effectively communicate in the ICU. Data are conflicting on the best way to teach residents, and institutions vary on their emphasis of communication as a key skill. There needs to be a cultural shift surrounding the education of medical residents in the ICU: communication must be treated with the same emphasis, precision, and importance as placing a central venous catheter in the ICU. We propose that high-stakes communications between physicians and patients or their surrogates must be viewed as a medical procedure that can be taught, assessed, and quality controlled. Medical residents require training, observation, and feedback in specific communication skill sets with the goal of achieving mastery. It is only through supervised training, practice in real time, observation, and feedback that medical residents can become skillful practitioners of communication in the ICU.

Considering cognition. Current challenges and future directions in pulmonary and critical care fellowship training.

Fellowship training in pulmonary and critical care has evolved substantially over the past decade. Training programs are increasingly focused on a rigorous, multifaceted assessment of an individual trainee's progress toward achieving specific curricular milestones, and their ability to independently manage a series of entrustable professional activities. This new system has provided programs with an enormous amount of detailed information related to the specific goals and outcomes of training. However, it has not addressed the unmet need for fellowship programs to systematically assess and teach advanced clinical reasoning and judgment. Training programs must address these cognitive processes in a proactive and supportive way, and are challenged to develop novel approaches that encourage continuous self-evaluation. Only by addressing these critical deficiencies will programs enable trainees to progress beyond a level of clinical competence to one of true expertise. These efforts will also encourage physicians at all levels of training to embrace their commitment to lifelong learning.

Distinct and replicable genetic risk factors for acute respiratory distress syndrome of pulmonary or extrapulmonary origin.

BACKGROUND: The role of genetics in the development of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) from direct or indirect lung injury has not been specifically investigated. The aim of this study was to identify genetic variants contributing to ALI/ARDS from pulmonary or extrapulmonary causes. METHODS: We conducted a multistage genetic association study. We first performed a large-scale genotyping (50K ITMAT-Broad_CARe Chip) in 1717 critically ill Caucasian patients with either pulmonary or extrapulmonary injury, to identify single nucleotide polymorphisms (SNPs) associated with the development of ARDS from direct or indirect insults to the lung. Identified SNPs (p≤0.0005) were validated in two separated populations (Stage II), with trauma (Population I; n=765) and pneumonia/pulmonary sepsis (Population II; n=838), as causes for ALI/ARDS. Genetic variants replicating their association with trauma related-ALI in Stage II were validated in a second trauma-associated ALI population (n=224, Stage III). RESULTS: In Stage I, non-overlapping SNPs were significantly associated with ARDS from direct/indirect lung injury, respectively. The association between rs1190286 (POPDC3) and reduced risk of ARDS from pulmonary injury was validated in Stage II (p<0.003). SNP rs324420 (FAAH) was consistently associated with increased risk of ARDS from extrapulmonary causes in two independent ALI-trauma populations (p<0.006, Stage II; p<0.05, Stage III). Meta-analysis confirmed these associations. CONCLUSIONS: Different genetic variants may influence ARDS susceptibility depending on direct versus indirect insults. Functional SNPs in POPDC3 and FAAH genes may be driving the association with direct and indirect ALI/ARDS, respectively.

Simulation training and its effect on long-term resident performance in central venous catheterization.

INTRODUCTION: Simulation is a safe alternative to practicing procedural skills on patients. However, few published studies have examined the long-term effect of simulation technology on bedside procedures such as central venous catheter (CVC) insertion. METHODS: To determine whether simulation-based teaching improves procedural comfort, performance, and clinical events in CVC insertion, over traditional methods of procedural teaching, and to assess the long-term effect of this training, we conducted a prospective, randomized controlled trial with 53 postgraduate year-1 and postgraduate year-2 medical residents at a tertiary-care teaching hospital. At the start of the study, we assessed all residents' procedural comfort and previous training and experience with CVCs. We then measured their baseline performance in placing CVCs on simulators, using a validated assessment tool (pretest). For the intervention group, we reassessed performance immediately after simulation training (posttest). All subjects then placed actual CVCs as clinically indicated while on their medical intensive care unit rotations, under the supervision of critical care faculty. We measured clinical events associated with these CVCs. After their medical intensive care unit rotations, we reassessed CVC insertion skills on simulators and procedural comfort of all subjects (delayed posttest). RESULTS: Intervention subjects demonstrated a significant improvement in skills immediately after simulation training. At delayed posttesting, performance diminished somewhat in the intervention subjects and was not significantly different from control subjects; however, a significant increase over pretest scores persisted in both groups. CONCLUSIONS: A CVC insertion simulation course improves procedural skills. These skills decline over time, and simulation conferred no long-term additional benefit over traditional methods of procedural teaching.

Clinical characteristics and outcomes of sepsis-related vs non-sepsis-related ARDS.

BACKGROUND: ARDS may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS, but little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS: A total of 2,786 patients with ARDS-predisposing conditions were enrolled consecutively into a prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis and non-sepsis-related ARDS as ARDS developing after nonseptic injuries, such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS: Compared with patients with non-sepsis-related ARDS (n = 62), patients with sepsis-related ARDS (n = 524) were more likely to be women and to have diabetes, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (median, 78 vs 65, P < .0001). There were no differences in lung injury score, blood pH, Pao(2)/Fio(2) ratio, and Paco(2) on ARDS diagnosis. However, patients with sepsis-related ARDS had significantly lower Pao(2)/Fio(2) ratios than patients with non-sepsis-related ARDS patients on ARDS day 3 (P = .018), day 7 (P = .004), and day 14 (P = .004) (repeated-measures analysis, P = .011). Compared with patients with non-sepsis-related ARDS, those with sepsis-related had a higher 60-day mortality (38.2% vs 22.6%; P = .016), a lower successful extubation rate (53.6% vs 72.6%; P = .005), and fewer ICU-free days (P = .0001) and ventilator-free days (P = .003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality (hazard ratio, 1.26; 95% CI, 0.71-2.22). CONCLUSION: Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.

Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument.

PURPOSE: Despite mandates from accreditation bodies for programs to ensure procedural competence, standardized measures do not exist to assess residents' skills in performing central venous catheter (CVC) insertion. The objective of the present study was to develop an instrument to assess residents in subclavian (SC) CVC insertion, to set performance standards, and to validate the tool using performance data. METHOD: In 2007, the authors convened experts to create an assessment tool for CVC insertion using a modified Delphi method. They applied the Angoff method to a second set of experts to determine minimum passing scores (MPSs) for both the borderline trainee and the competent trainee. Two faculty evaluators then used the checklist to assess residents performing CVCs on simulators. RESULTS: The authors created and experts confirmed a 24-item checklist. Using the Angoff method, the MPS required completion of 10 major and 2 minor criteria for a trainee to show borderline proficiency with CVC insertion under supervision. This MPS was correlated with a global rating of 2 on a 5-point scale. The MPS for competence was 17 major and 5 minor criteria. None of the residents deemed competent on a global rating scale achieved the MPS for competence. CONCLUSIONS: The authors were able to create and validate a consensus-driven procedural assessment tool with data-driven standards for basic proficiency and competence that faculty can use to assess residents as they perform CVC insertion.