Mobilizing an institutional supportive response for healthcare workers and other staff in the context of COVID-19: The Yale experience.

The burden of the COVID-19 pandemic upon healthcare workers necessitates a systematic effort to support their resilience. This article describes the Yale University and Yale New Haven Health System effort to unite several independent initiatives into a coherent integrated model for institutional support for healthcare workers. Here, we highlight both opportunities and challenges faced in attempting to support healthcare workers during this pandemic.

Acute care surgery survey: opinions of surgeons about a new training paradigm.

HYPOTHESIS: The acute care surgery (ACS) 2-year training model, incorporating surgical critical care (SCC), trauma surgery, and emergency general surgery, was developed to improve resident interest in the field. We believed that analysis of survey responses about the new training paradigm before its implementation would yield valuable information on current practice patterns and on opinions about the ACS model. DESIGN: Two surveys. PARTICIPANTS: Members of the Surgery Section of the Society of Critical Care Medicine and SCC program directors. INTERVENTIONS: One survey was sent to SCC program directors to define the practice patterns of trauma and SCC surgeons at their institutions, and another survey was sent to all Surgery Section of the Society of Critical Care Medicine members to solicit opinions about the ACS model. MAIN OUTCOME MEASURES: Practice patterns of trauma and SCC surgeons and opinions about the ACS model. RESULTS: Fifty-seven of 87 SCC program directors responded. Almost all programs are associated with level I trauma centers with as many as 15 trauma surgeons. Most of these trauma surgeons cover SCC and emergency general surgery. Sixty-six percent of surgical intensive care units are semiclosed; 89.0% have surgeons as directors. Seventy percent of the staff in surgical intensive care units are surgeons. One hundred fifty-five of approximately 1100 Surgery Section of the Society of Critical Care Medicine members who responded to the other survey did not believe that the ACS model would compromise surgical intensive care unit and trauma care or trainee education yet would allow surgeons to maintain their surgical skills. Respondents were less likely to believe that the ACS fellowship would be important financially, increase resident interest, or improve patient care. CONCLUSIONS: In academic medical centers, surgical intensivists already practice the ACS model but depend on many nonsurgeons. Surgical intensivists believe that ACS will not compromise care or education and will help maintain the field, although the effect on resident interest is unclear.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines.

INTRODUCTION: Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment "bundle" may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve "bundle" compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance. METHODS: Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered. RESULTS: Individual participants' pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge. CONCLUSION: Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.

A two-tiered quality management program: Morbidity and Mortality conference data applied to resident education.

The ACGME mandates a competency-based resident education curriculum. The Joint Commission (TJC) requires a quality improvement (QI) program in all hospitals with residency training programs. Our QI program, based on M&M conference data, provided the operational framework for peer review and resolution of adverse events. However, the conference focused on only three of the six ACGME core competencies (patient care, medical knowledge, practice-based learning and improvement) but not specifically on interpersonal and communication skills, professionalism or systems-based practice. To address this issue, we devised a two-tiered QI process that meets the reporting mandate of TJC and addresses all six ACGME core competencies. Adverse events are reported and discussed in the Department of Surgery's divisional M&M conferences. If an issue involving the ACGME core competencies is identified that requires nonconference discussion, ie, communication, professionalism or systems-based practice, the case is referred to the Department of Surgery Subcommittee for Quality Improvement (SCQI). A report is then returned to the divisional M&M for discussion and possible incorporation into the Resident Core Curriculum. Resident and attending surgeon surveys demonstrated the new format to be effective in addressing all six ACGME competencies.

Midlevel practitioner workforce analysis at a university-affiliated teaching hospital.

OBJECTIVE: To quantify midlevel practitioner (MLP) staffing requirements based on the volume and complexity of patient care and the duty-hour constraints of the Accreditation Council for Graduate Medical Education 80-hour workweek. DESIGN: Data extracted from Eclipsys Sunrise Decision Support Manager, the hospital financial budget, and census reports; and MLP, resident, and subspecialty fellow clinical, operative, and on-call schedules, and educational curriculum. Fiscal year 2005 patient census and hours of required care were defined by attending physician service and/or patient care location. Volume of patient care activity for MLPs, residents, and subspecialty fellows were established by verified self-reporting methodology. SETTING: Urban teaching hospital with 867 beds, of which 116 are surgical beds (which include 36 intensive care unit beds and 12 step-down beds). PARTICIPANTS: Attending physicians, MLPs, residents, and subspecialty fellows. MAIN OUTCOME MEASURES: Coverage index (available staffing hours [residents, subspecialty fellows, and MLPs] divided by the clinical coverage schedule), and the workload staffing efficiency index (number of clinical hours of patient care activities divided by the hours of available staff for a specific clinical service). RESULTS: The workload staffing efficiency index and the coverage index identified 4 services that benefited from the addition of new MLPs. CONCLUSION: We developed a quantitative MLP staffing methodology based on patient volume and the type and complexity of direct and indirect patient care activities, encompassing the roles and availability of residents, subspecialty fellows, and MLPs.

Resident work hours: the five stages of grief.

The authors describe their reactions, as surgical educators, to the mandate of the Accreditation Council for Graduate Medical Education to reduce resident work hours. They explain these reactions in terms of Dr. Elizabeth Kübler-Ross's five stages of grief: denial, anger, bargaining, depression, and finally acceptance ("which should not be mistaken for a happy stage"). The authors describe each stage of grief and use it to make specific comments on the difficulties that the mandate imposes. They then reveal that their views about the work-hours regulations differ: Dr. Ivy now sees them as an opportunity to grow and improve, and likens the resistance to the new restrictions to that of Europeans to the printing press. But Dr. Barone ("the older of the coauthors and a known curmudgeon") is not so sure, and shares many of the concerns described earlier in the five stages of grief, even though he has outwardly accepted the work-hours rules and insists on full compliance by his residents and faculty. In particular, he is saddened that some residents feel they have the absolute right to go home regardless of the situation on the surgery service, and this feeling is validated by the work-hours rules.

Guidelines for critical care medicine training and continuing medical education.

OBJECTIVE: Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care. PARTICIPANTS: A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine. SCOPE: Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization. DATA SOURCES AND SYNTHESIS: Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline. CONCLUSIONS: Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

The role of advance directives and family in end-of-life decisions in critical care units.

PURPOSE: To define the extent and nature of the End-of-Life (EOL) decision-making process in critically ill patients. MATERIALS AND METHODS: Retrospective review of all deaths in adult medical and surgical intensive care units of a tertiary care hospital over a one-year period. RESULTS: There were sixty-one deaths in the study period. The mean age was 68 years, and 30 patients (49%) were female. Nearly one-third of patients had advance directives: eight patients presented advance directives on hospital admission, and 10 families produced advance directives at EOL. Seventy-six percent were admitted to the ICU as Code I (full care) and 24% were Code II (selective modification of care). At EOL, 10 patients were Code I, 14 were Code II, and 38 were transitioned to Code III (comfort care only). In the Code III population, the change in code status was initiated by the family in 12 cases. CONCLUSIONS: In a substantial number of instances transitioned to comfort care at EOL, the family initiated the code-status change. Interestingly, in several cases the family initially withheld advance directives. Critically ill patients and their families are assuming an active role in EOL care.

Renal artery to inferior vena cava fistula following gunshot wound to the abdomen.

Traumatic fistula involving the renal artery and IVC is a rare event, and typically is a result of penetrating injury. A case of right renal artery to IVC fistula following a gunshot wound to the abdomen is reported, and illustrates the significant hemodynamic changes that accompany these fistulae. We also emphasize the importance of thorough initial exploration of retroperitoneal hematomas following penetrating trauma, and review management options in the treatment of renal arteriovenous fistulae.