Effective Behaviors of Leaders During Clinical Emergencies: A Qualitative Study of Followers' Perspectives.

BACKGROUND: To effectively manage a clinical emergency, physicians need well-developed leadership skills, yet there is limited structured leadership training available for critical care trainees. In order to develop an effective curriculum, leadership competencies must first be defined. RESEARCH QUESTION: During clinical emergencies, what leadership behaviors do followers value? STUDY DESIGN AND METHODS: We conducted qualitative interviews with members of multidisciplinary critical care teams at a large academic health system, with participants including resident physicians, nurses, and respiratory therapists (N=15). Thematic analysis was used to categorize leadership behaviors that followers perceived to be effective. RESULTS: We identified three themes related to leadership during clinical emergencies: "control," "collaboration," and "common understanding." Participants described behaviors they felt resulted in both effective and ineffective leadership. For effective leaders, control, the most dominant theme, included behaviors that clearly established roles for the leader and followers, allowing the leader to guide care during a clinical emergency. Collaboration referenced the ability of a leader to maintain a collegial environment. Finally, common understanding reflected a leader's ability to manage communication in a way that fostered a shared mental model across team members. INTERPRETATION: During clinical emergencies, followers value leaders who assert themselves while also maintaining positive team interaction and encouraging an organized flow of information. Our findings provide a potential framework to develop a leadership curriculum for critical care trainees.

Point of care ultrasound for all by all: A multidisciplinary survey across a large quaternary care medical system.

PURPOSE: We sought to understand current POCUS practices and comfort as well as assess opinions about POCUS across our medical system via a survey to guide program development. METHODS: This study was conducted as a 19 question RedCap survey with multiple parts. Respondents were queried for demographics as well as experience with, attitudes toward, and clinical use of POCUS in common critical care scenarios. RESULTS: The survey was completed by 343 individuals, a response rate of 30%. Most respondents "agreed" that POCUS is a needed skill and helped them provide safer care (78% and 86% agreement). Most faculty and trainees reported some POCUS training (62% and 88%) and at least weekly use. Trainees rated themselves more comfortable than faculty for most exam types. The majority of faculty rated their POCUS education as inadequate while trainees had mixed responses. CONCLUSIONS: POCUS is a frequently used tool, yet users are less confident in their skills than expected. POCUS applications are viewed as needed for future practice but there is a substantial need for improved education among faculty and trainees. Pooling resources and sharing educational initiatives across multiple specialties may help improve POCUS implementation.

Crisis Leadership Education for Critical Care Fellows. A Longitudinal Curriculum Using Simulation.

Background: Leadership and teamwork are critical to the performance of a multidisciplinary team responding to emergencies in the intensive care unit; yet, these skills are variably taught to pulmonary and critical care trainees. Currently, there is no standardized leadership curriculum in critical care training. Objective: We developed a longitudinal crisis leadership curriculum for first-year pulmonary and critical care fellows using high-fidelity simulation as a medium to practice and solidify skills. The goal was to improve leadership skills and trainee confidence when leading a team during life-threatening emergencies. Methods: Guided by a needs assessment of current and recently graduated fellows, we developed a leadership curriculum from a review of the available literature and local expert opinion. Four sessions were conducted over the academic years of 2016 to 2017 and 2017 to 2018, each including small-group teaching on effective leadership behaviors, followed by simulation with postsession leadership debriefing to review performance. Fellows were surveyed regarding their experiences with the curriculum. Results: Over two academic years, 100% of targeted fellows (N = 13) completed every session. Participants reported improved understanding of key elements of effective leadership, greater confidence in leading a multidisciplinary team, and increased preparedness to lead during a crisis. Simulation with debriefing was viewed as an effective medium for learning leadership skills, and fellows provided positive feedback regarding the experience. Conclusion: Implementation of a longitudinal crisis leadership curriculum within the first year of pulmonary and critical care fellowship was feasible and highly valued by learners. More research is needed to determine effective methods for teaching and assessing leadership skills.

Just-In-Time Tools for Training Non-Critical Care Providers. Troubleshooting Problems in the Ventilated Patient.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for non-intensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to managing complications that can arise in patients receiving invasive mechanical ventilation.

Just-In-Time Tools for Training Non-Critical Care Providers. Basics of Respiratory Failure.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for nonintensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to the evaluation and management of patients with hypoxemic respiratory failure and the basics of invasive mechanical ventilation.

Communication Training in Adult and Pediatric Critical Care Medicine. A Systematic Review.

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention (n = 15), cross-sectional survey (n = 5), and instrument validation (n = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention.

ICU Emergencies Simulation Curriculum for Critical Care Fellows: Neurologic Emergencies.

Introduction: The management of neurologic emergencies is an important component of critical care fellowship training. Additional training in neurocritical care has been demonstrated to improve clinical outcomes, though exposure to these emergencies during training can be limited. Methods: Three simulation cases are presented as part of a comprehensive neurologic emergencies curriculum for critical care trainees. The cases represent neurologic catastrophes encountered in the intensive care unit consisting of symptomatic hyponatremia, severe alcohol withdrawal syndrome, and brain herniation syndrome. The case descriptions are complete with learning objectives, critical actions checklists, and debriefing material for facilitators, as well as all necessary personnel briefs and required equipment. Results: The scenarios were completed over the course of the 2016-2017 academic year by first-year critical care fellows. Following curriculum implementation, there was an improvement in self-perceived confidence of fellows in neurologic emergency management skills. Discussion: The cases were felt to be realistic and beneficial and led to perceived improvement in management of neurologic emergencies and leadership during clinical crises.

ICU Emergencies Simulation Curriculum for Critical Care Fellows: The Difficult Airway.

Introduction: Management of airway emergencies is a core skill for critical care fellows. There is no standardized training mechanism for difficult airway management among critical care fellowships, although fellows frequently cite management of airway catastrophes as an area of educational need. Methods: Three simulation cases that are each approximately 15 minutes in length are presented. The cases represent airway emergencies encountered in the intensive care unit consisting of angioedema, endotracheal tube dislodgement, and endotracheal tube occlusion. Incorporated into the scenarios are planned incidents of interpersonal conflict requiring negotiation by the learner during a crisis event. The case descriptions are complete, with learning objectives and critical actions as well as all necessary personnel briefs and required equipment. Results: The cases were completed over multiple simulation sessions on different days by 11 first-year critical care fellows during the 2016-2017 academic year. All participants demonstrated improvement in self-perceived confidence in airway management skills. Discussion: The cases were felt to be realistic and beneficial and led to perceived improvement in management of airway emergencies and leadership during crisis scenarios.