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1.
Dimens Crit Care Nurs ; 40(6): 321-327, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34606222

RESUMO

BACKGROUND: Prone positioning has been used as an intervention to improve oxygenation in critically ill patients with acute respiratory distress syndrome. During the COVID-19 pandemic, resources were even more limited given a surge in acute respiratory distress syndrome patients, which outstripped intensive care unit (ICU) capacity at many institutions. LOCAL PROBLEM: The purpose of this article is to describe the development and implementation of a proning team during the surge in ICU patients with COVID-19 and to measure the impact of the program through surveys of staff involved. METHODS/INTERVENTIONS: A proning protocol and educational plan was developed. A proning team of redeployed staff was created. A survey of ICU registered nurses and proning team members was used to evaluate the benefits and challenges of the proning team. RESULTS: The proning team was successful in safely performing more than 300 proning and supinating maneuvers for critically ill patients. There is overwhelming support within the institution for a proning team for future COVID-19 surges. DISCUSSION: The development and implementation of the proning team happened quickly to assist with the surge of patients and off-load work from ICU registered nurses. Despite the success of the proning team, more clearly defined roles and expectations, as well as additional education, are needed to further enhance teamwork and workflow. CONCLUSIONS: Creation of the proning team was a creative use of resources that helped manage the large and medically complex patient population. This work may serve as a guide to other health care institutions.


Assuntos
COVID-19 , Pandemias , Humanos , Unidades de Terapia Intensiva , Decúbito Ventral , SARS-CoV-2
2.
J Crit Care ; 2021 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-34635389

RESUMO

The COVID-19 pandemic taxed critical care and its leaders in unprecedented ways. Medical directors, nursing directors, division chiefs and department chairs were forced to lead their staff through a pandemic wrought with personal and professional safety concerns, uncertainty, and more death than most critical care practitioners had ever seen. No leader was fully prepared for the COVID-19 pandemic. Herein, we describe what we believe are the three most important qualities of a leader in times of crisis: presence, transparency, and empathy.

3.
ATS Sch ; 2(3): 452-467, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34667993

RESUMO

The following is a concise review of the Pediatric Pulmonary Medicine Core reviewing pediatric pulmonary infections, diagnostic assays, and imaging techniques presented at the 2021 American Thoracic Society Core Curriculum. Molecular methods have revolutionized microbiology. We highlight the need to collect appropriate samples for detection of specific pathogens or for panels and understand the limitations of the assays. Considerable progress has been made in imaging modalities for detecting pediatric pulmonary infections. Specifically, lung ultrasound and lung magnetic resonance imaging are promising radiation-free diagnostic tools, with results comparable with their radiation-exposing counterparts, for the evaluation and management of pulmonary infections. Clinicians caring for children with pulmonary disease should ensure that patients at risk for nontuberculous mycobacteria disease are identified and receive appropriate nontuberculous mycobacteria screening, monitoring, and treatment. Children with coronavirus disease (COVID-19) typically present with mild symptoms, but some may develop severe disease. Treatment is mainly supportive care, and most patients make a full recovery. Anticipatory guidance and appropriate counseling from pediatricians on social distancing and diagnostic testing remain vital to curbing the pandemic. The pediatric immunocompromised patient is at risk for invasive and opportunistic pulmonary infections. Prompt recognition of predisposing risk factors, combined with knowledge of clinical characteristics of microbial pathogens, can assist in the diagnosis and treatment of specific bacterial, viral, or fungal diseases.

4.
ATS Sch ; 2(3): 468-483, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34667994

RESUMO

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.

5.
ATS Sch ; 2(3): 484-496, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34667995

RESUMO

The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year's sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

6.
Teach Learn Med ; : 1-11, 2021 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-34279167

RESUMO

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

8.
Acad Med ; 96(6): 869-875, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33735130

RESUMO

PURPOSE: Evaluation of the medical profession at all levels has exposed episodes of gender-based role misidentification whereby women physicians are disproportionately misidentified as nonphysicians. The authors of this study investigate this phenomenon and its repercussions, quantifying the frequency with which resident physicians experience role misidentification and the effect this has on their experience and behavior. METHOD: In 2018, the authors conducted a cross-sectional survey study of internal medicine, surgical, and emergency medicine residents at a single, large, urban, tertiary academic medical center. The survey tool captured both the self-reported frequency and effect of professional misidentification. The authors used a t test and linear multivariate regression to analyze the results. RESULTS: Of the 260 residents who received the survey, 186 (72%) responded, and the authors analyzed the responses of 182. All 85 of the women respondents (100%) reported being misidentified as nonphysicians at least once in their professional experience by patients or staff members, compared with 49% of the 97 men respondents. Of those 182 residents, 35% of women were misidentified more than 8 times per month by patients compared with 1% of men. Of the 85 women physicians responding to the survey, 38% felt angry and 36% felt less satisfied with their jobs as a result of misidentification compared with, respectively, 7% and 9% of men. In response to role misidentification, 51% of women changed their manner of attire and 81% changed their manner of introduction, compared with, respectively, 7% and 37% of men. CONCLUSIONS: These survey results demonstrate that women physicians are more likely than men physicians to be misidentified as nonphysicians and that role misidentification provokes gender-polarized psychological and behavioral responses that have potentially important professional ramifications.


Assuntos
Médicas , Sexismo , Centros Médicos Acadêmicos , Adulto , Estudos Transversais , Medicina de Emergência/educação , Feminino , Cirurgia Geral/educação , Humanos , Medicina Interna/educação , Internato e Residência , Masculino , Inquéritos e Questionários
10.
J Crit Care ; 63: 106-112, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33676795

RESUMO

PURPOSE: Acute Respiratory Distress Syndrome (ARDS) secondary to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has demonstrated variable oxygenation and respiratory-system mechanics without investigation of transpulmonary and chest-wall mechanics. This study describes lung, chest wall and respiratory-system mechanics in patients with SARS-CoV-2 and ARDS. METHODS: Data was collected from forty patients with confirmed SARS-CoV-2 and ARDS at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Esophageal balloons were placed to estimate pleural and transpulmonary pressures. Clinical characteristics, respiratory-system, transpulmonary, and chest-wall mechanics were measured over the first week. RESULTS: Patients had moderate-severe ARDS (PaO2/FiO2 123[98-149]) and were critically ill (APACHE IV 108 [94-128] and SOFA 12 [11-13]). PaO2/FiO2 improved over the first week (150 mmHg [122.9-182] to 185 mmHg [138-228] (p = 0.035)). Respiratory system (30-35 ml/cm H2O), lung (40-50 ml/cm H2O) and chest wall (120-150 ml/cm H2O) compliance remained similar over the first week. Elevated basal pleural pressures correlated with BMI. Patients required prolonged mechanical ventilation (14.5 days [9.5-19.0]), with a mortality of 32.5%. CONCLUSIONS: Patients displayed normal chest-wall mechanics, with increased basal pleural pressure. Respiratory system and lung mechanics were similar to known existing ARDS cohorts. The wide range of respiratory system mechanics illustrates the inherent heterogeneity that is consistent with typical ARDS.


Assuntos
COVID-19/complicações , Pulmão/fisiopatologia , Síndrome do Desconforto Respiratório/etiologia , Mecânica Respiratória , SARS-CoV-2/genética , APACHE , Idoso , Boston/epidemiologia , COVID-19/epidemiologia , COVID-19/terapia , COVID-19/virologia , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/virologia
12.
Med Teach ; : 1-4, 2020 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-33290669

RESUMO

Teaching in a learner-centred clinical setting requires clinical teachers trained in diagnosing and addressing learner needs and interests in order to create an optimal learning environment. These educational skills may not have been explicitly addressed in medical training in the past, when little to no focus was devoted to the learning environment and promoting learner-centredness. Thus, clinical teachers may be left without a model for their important and nuanced role as facilitators of learning in the current environment. We propose that clinical teachers frame their educational approach through the lens of teachers' perspectives. Not only does this model illustrate the factors that influence and modify clinical teachers' mindset, but it also demonstrates the impact that teachers' experiences may have upon creating the learning environment and determining educational outcomes. This model also identifies a feasible starting point for essential staff development: refining communication skills for use in the educational setting. With this training and model to frame understanding, clinical teachers may be better prepared to fulfill their essential role in the learner-centred educational clinical environment.

13.
Adv Med Educ Pract ; 11: 861-867, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33209072

RESUMO

Background: Many programs designed to improve feedback to students focus on faculty's ability to provide a safe learning environment, and specific, actionable suggestions for improvement. Little attention has been paid to improving students' attitudes and skills in accepting and responding to feedback effectively. Effective "real-time" feedback in the clinical setting is dependent on both the skill of the teacher and the learner's ability to receive the feedback. Medical students entering their clinical clerkships are not formally trained in receiving feedback, despite the significant amount of feedback received during this time. Methods: We developed and implemented a one-hour workshop to teach medical students strategies for effectively receiving and responding to "real-time" (formative) feedback in the clinical environment. Subjective confidence and skill in receiving real-time feedback were assessed in pre- and post-workshop surveys. Objective performance of receiving feedback was evaluated before and after the workshop using a simulated feedback encounter designed to re-create common clinical and cognitive pitfalls for medical students, called an objective structured teaching exercise (OSTE). Results: After a single workshop, students self-reported increased confidence (mean 6.0 to 7.4 out of 10, P<0.01) and skill (mean 6.0 to 7.0 out of 10, P=0.10). Compared to pre-workshop OSTE scores, post-workshop OSTE scores objectively measuring skill in receiving feedback were also significantly higher (mean 28.8 to 34.5 out of 40, P=0.0131). Conclusion: A one-hour workshop dedicated to strategies in receiving real-time feedback may improve effective feedback reception as well as self-perceived skill and confidence in receiving feedback. Providing strategies to trainees to improve their ability to effectively receive feedback may be a high-yield approach to both strengthen the power of feedback in the clinical environment and enrich the clinical experience of the medical student.

14.
Eur Respir Rev ; 29(157)2020 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-33020069

RESUMO

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research. METHODS: An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion. RESULTS: The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder. CONCLUSIONS: The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.


Assuntos
Comitês Consultivos/organização & administração , Betacoronavirus , Consenso , Infecções por Coronavirus/epidemiologia , Cooperação Internacional , Pneumonia Viral/epidemiologia , Pneumologia/normas , Sociedades Médicas , COVID-19 , Europa (Continente) , Humanos , Pandemias , SARS-CoV-2 , Estados Unidos
16.
Crit Care Explor ; 2(6): e0147, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32696010

RESUMO

Objectives: To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade. Design: Retrospective cohort study. Setting: Tertiary care teaching hospital in Boston, MA. Patients: All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours. Interventions: We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration. Measurements and Main Results: Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12-2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001). Conclusions: Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.

17.
PLoS One ; 15(6): e0234973, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32559244

RESUMO

BACKGROUND: On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial. METHODS: We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions. RESULTS: Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients. CONCLUSIONS: Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.


Assuntos
Diretivas Antecipadas/psicologia , Reanimação Cardiopulmonar/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Médicos/psicologia , Ordens quanto à Conduta (Ética Médica)/psicologia , Adulto , Diretivas Antecipadas/legislação & jurisprudência , Feminino , Hospitais Universitários/estatística & dados numéricos , Humanos , Masculino , Maryland , Relações Médico-Paciente , Ordens quanto à Conduta (Ética Médica)/legislação & jurisprudência , Inquéritos e Questionários
19.
PLoS One ; 15(5): e0233538, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32469920

RESUMO

INTRODUCTION: Simulation is a powerful tool for training and evaluating clinicians. However, few studies have examined the consistency of actor performances during simulation based medical education (SBME). The Simulated Communication with ICU Proxies trial (ClinicalTrials.gov NCT02721810) used simulation to evaluate the effect of a behavioral intervention on physician communication. The purpose of this secondary analysis of data generated by the quality assurance team during the trial was to assess how quality assurance monitoring procedures impacted rates of actor errors during simulations. METHODS: The trial used rigorous quality assurance to train actors, evaluate performances, and ensure the intervention was delivered within a standardized environment. The quality assurance team evaluated video recordings and documented errors. Actors received both timely, formative feedback and participated in group feedback sessions. RESULTS: Error rates varied significantly across three actors (H(2) = 8.22, p = 0.02). In adjusted analyses, there was a decrease in the incidence of actor error over time, and errors decreased sharply after the first group feedback session (Incidence Rate Ratio = 0.25, 95% confidence interval 0.14-0.42). CONCLUSIONS: Rigorous quality assurance procedures may help ensure consistent actor performances during SBME.


Assuntos
Feedback Formativo , Simulação de Paciente , Garantia da Qualidade dos Cuidados de Saúde/métodos , Idoso de 80 Anos ou mais , Humanos , Masculino
20.
JAMA Netw Open ; 3(5): e205188, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32427323

RESUMO

Importance: Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them. Objective: To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. Design, Setting, and Participants: A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. Main Outcomes and Measures: Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. Results: Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. Conclusions and Relevance: In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.


Assuntos
Cuidados Críticos , Tomada de Decisão Compartilhada , Médicos/psicologia , Relações Profissional-Família , Autoavaliação (Psicologia) , Adulto , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Inquéritos e Questionários
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