Faculty Bibliography

INTRODUCTION: Health care providers must effectively function in highly skilled teams in a collaborative manner, but there are few interprofessional training strategies in place. Interprofessional education (IPE) using simulation technology has gained popularity to address this need because of its inherent ability to impact learners' cognitive frames and promote peer-to-peer dialog. Provider attitudes toward teamwork have been directly linked to the quality of patient care. Investigators implemented a simulation-enhanced IPE intervention to improve staff attitudes toward teamwork and interprofessional communication in the emergency department setting. METHODS: The 3-hour course consisted of a didactic session highlighting teamwork and communication strategies, 2 simulation scenarios on septic shock and cardiac arrest, and structured debriefing directed at impacting participant attitudes to teamwork and communication. This was a survey-based observational study. We used the TeamSTEPPS Teamwork Attitudes Questionnaire immediately before and after the session as a measurement of attitude change as well as the Hospital Survey on Patient Safety Culture before the session and 1 year after the intervention for program impact at the behavior level. RESULTS: Seventy-two emergency department nurses and resident physicians participated in the course from July to September 2012. Of the 5 constructs in TeamSTEPPS Teamwork Attitudes Questionnaire, 4 had a significant improvement in scores-6.4%, 2.8%, 4.0%, and 4.0% for team structure, leadership, situation monitoring, and mutual support, respectively (P < 0.0001, P = 0.029, P = 0.014, and P = 0.003, respectively). For Hospital Survey on Patient Safety Culture, 3 of 6 composites directly related to teamwork and communication showed a significant improvement-20.6%, 20.5%, and 23.9%, for frequency of event reporting, teamwork within hospital units, and hospital handoffs and transitions, respectively (P = 0.028, P = 0.035, and P = 0.024, respectively). CONCLUSIONS: A simulation-enhanced IPE curriculum was successful in improving participant attitudes toward teamwork and components of patient safety culture related to teamwork and communication.

Background: Bedside emergency procedures are often performed on high-acuity patients and frequently under time-sensitive conditions. Interns do not get many opportunities to learn about, observe, or perform procedures in medical school or during their first year of residency. Self-reported confidence is a poor predictor of performance, but studies have shown that low confidence and stress can inhibit or decrease performance, especially under time pressure or when stakes are high. Lack of familiarity with procedure or equipment can contribute to stress and performance anxiety. Objectives: We investigate the need, feasibility, and outcomes of a standardized, systematic, simulation-based emergency procedure curriculum for interns in an emergency medicine residency program. Methods: Common bedside procedures relevant to first year residents were identified using ACGME guidelines. Nine sessions were held over the intern year. Participants were surveyed at the end of their PGY-1 year (June) for curriculum and quality purposes to help inform the next iteration of the curriculum. Descriptive statistics were calculated and means were compared with one-tailed, paired t-tests. Results: 73% (11/15) of interns responded to the survey request. They had the opportunity to perform each of the procedures before, during, and after the workshop. Using a five-point Likert scale, the basic and advanced airway, central venous catheter, and chest tube sessions were most useful. Models used were deemed not very realistic (2.8-3.86). Self-reported comfort with the procedure improved significantly in all except incision and drainage and laceration repair. Conclusion: A monthly curriculum in bedside procedures is well received by interns and improves confidence. Rarer, more-invasive procedures might have a greater effect. (Table presented)

Background: High-fidelity simulation is widely used in medical education. Currently, there are no universally accepted metrics for evaluation of simulation case performance. Objectives: To test each of three evaluation metrics for assessment of EM resident performance on each of six advanced cardiac life support (ACLS) simulation cases. A secondary objective is to compare case performance between PGY-1 and PGY-3 EM residents at two separate institutions. Methods: Six ACLS-based high-fidelity simulation cases and the associated critical actions were developed by a group of EM faculty from multiple institutions and piloted by 35 residents (18=PGY-1 and 17=PGY-3) at two institutions. The cases were presented to each resident in random order and the sessions were videotaped. Two faculty reviewers independently scored the performance of the residents at each institution. All cases were scored by each of three metrics: 1) total number of critical actions achieved; 2) time to each critical action; and 3) a previously validated clinical performance evaluation (CPE) score. Statistical methods included descriptive statistics, Wilcoxon rank sum tests, and repeated measures analyses of variance using generalized estimating equations. A Spearman correlation coefficient (SCC) was calculated to assess reviewer agreement for the paired reviewers at each institution. Results: The overall CPE scores were significantly different between learner levels (p=0.0001), with no difference between institutions (p=0.1) [PGY-1 CPE scores of 5.62 (institution A), 5.72 (institution B); PGY-3 scores of 7.15 (A) and 6.38 (B)]. For all of the cases, the mean proportion of critical actions did not differ between learner levels (p=0.32), yet there was a difference between institutions (p=0.0001) [PGY-1 critical action scores of 0.85 (institution A), 0.94 (institution B); PGY-3 scores of 0.87 (A) and 0.91 (B)]. For the time to critical action, there was no significant difference for the majority of the critical actions, either bet!

Background: High-fidelity simulation is increasingly being used as a medical educational tool and research modality. Currently, there are no universally accepted metrics for evaluating clinician performance in the simulation environment. Furthermore, there are no baseline data characterizing the expected performance on specific cases according to training level. Objectives: The objective of this pilot study is to develop a set of six ACLS-based cases and compare clinician performance using three different evaluation metrics. A secondary objective is to compare case performance between PGY-1 and PGY-3 EM residents. Methods: Six cases with critical actions were developed by a multiinstitutional EM faculty group. Each of the cases was piloted by 25 residents at the lead institution (13 PGY-1s and 12 PGY-3s) in random order. Sessions were videotaped for independent review by two faculty observers. Data included the total number of critical actions (CA) achieved, time to each critical action (TCA), and a previously validated clinical performance evaluation (CPE) score. The CPE score is comprised of eight criteria, each with an eight-point possible score, with 8 being "excellent" and a 1 being "poor". The reported case scores are the average of the eight values. Descriptive statistics, Wilcoxon rank sum tests, and repeated measures analyses of variance using generalized estimating equations are reported. Results: For all of the cases, the mean proportion of CAs performed was 0.94 by the PGY-1s and 0.91 by the PGY-3s (p>0.05). For TCA, 11 CAs were analyzed and only two were found to have a significant difference: the PGY-1s had a time to second defibrillation attempt of 236 seconds compared with 291 seconds for the PGY-3s, and the PGY-3s had a time to epinephrine of 112 seconds compared to 164 for the PGY- 1s (p<0.05). The overall mean CPE scores were 5.72 for PGY-1s and 6.38 for PGY-3s (p<0.05). The mean difference in CPE scores between the faculty observers was -0.39 (95%CI -0.55 to -0.23). Mean pro!

Background: Team training initiatives have been implemented in hospitals nationwide in response to patient safety reports citing teamwork and communication failures as the most frequent contributors of errors. TeamSTEPPSTM is an evidence-based teamwork training system designed to improve patient outcomes by enhancing communication and skills of health care professionals. We developed a novel ED team training course based on TeamSTEPPSTM principles as a pilot curriculum for the Bellevue Hospital ED. Objectives: This study's purpose was to address the gap in current health care education at the Bellevue ED, by creating an interprofessional curriculum for nursing and residents focused on teamwork and communication utilizing simulation based education. We hypothesized that there would be a significant improvement in the staff's attitudes toward teamwork after the intervention. Methods: The team T\training course was conducted via a simulation center based training session over three hours consisting of an introductory didactic session, two simulation scenarios, video and self-observed evaluation utilizing the TeamSTEPPSTM Team Performance Observation Tool. Subjects consisted of EM nurses and residents organized into teams of six participants. We used the previously validated TeamSTEPPSTM Teamwork Attitudes Questionnaire with a five-point Likert scale model, designed to measure individual attitudes related to core components of teamwork, and distributed them in person pre- and post-session. Data analysis was performed using the Student's t-test to compare scores. Results: Over seven sessions from July to September 2012, a total of 76 nurses and residents participated in the course with 100% survey response. Seven of the pre-session and ten of the post-session surveys were disqualified as dictated in the protocol. Four of the five teamwork construct question groups had significant improvements in scores: 6.4%, 2.8%, 4.0%, and 4.0% for Team Structure, Leadership, Situation Monitoring, and Mutual Suppo!

Although mutations in multiple genes are associated with inherited demyelinating neuropathies, the molecular components and pathways crucial for myelination remain largely unknown. To approach this question, we performed genome-wide expression analysis in several paradigms where the status of peripheral nerve myelination is dynamically changing. Anchor gene correlation analysis, a form of microarray analysis that integrates functional information, using correlation-based clustering, with a statistically rigorous test, the Westfall and Young step-down algorithm, was applied to this data set. Biological pathways active in myelination, genes encoding proteins involved in myelin synthesis, and genes whose mutation results in myelination defects were identified. Many known genes and previously uncharacterized ESTs not heretofore associated with myelination were also identified. One of these ESTs, MASR (myelin-associated SUR4 protein), encodes a member of the SUR4 family of fatty acid desaturases, enzymes involved in elongation of very long chain fatty acids. Its specific localization in myelinating Schwann cells indicates a crucial role for MASR in normal myelin lipid synthesis.