Faculty Bibliography

BACKGROUND:Crisis Standards of Care (CSC) may require rationing of life-sustaining resources, such as mechanical ventilation, during public health emergencies. Simulation modeling offers a scalable, transparent method to evaluate triage frameworks before implementation. While ventilator triage frameworks vary in their use of exclusion criteria, comorbidity adjustments, and reassessment frequency, few have been rigorously compared using real-world data under realistic surge conditions. Robust platforms that simulate both front-end (initiation) and back-end (reassessment or reallocation) triage are critical for evaluating clinical, operational, and ethical performance. METHODS:We developed a computational simulation platform using retrospective real-world data from intubated adults during the Spring 2020 COVID-19 surge across a large New York City health system. The simulated surge cohort included all patients mechanically ventilated between March 1 and June 30, 2020. A crisis cohort was defined as those patients receiving ventilation once 95% of the health system's pre-pandemic ventilator supply was in use. Eight CSC strategies were evaluated, including policies from New York, Pennsylvania, Maryland, Canada, two academic frameworks, a lottery-based system, and first-come first-served. Strategies varied in their use of exclusion criteria, comorbidity modifiers, reassessment intervals, and prioritization for special populations. Daily ICU census and ventilator availability were used to simulate resource strain and drive triage decision-making. Patients simulated for ventilator rationing were simulated to expire. Manual abstraction of comorbidities and structured rules for imputing missing SOFA subscores were applied uniformly. RESULTS:The platform simulated 10,000 iterations per strategy and included 2,365 intubated patients. Final analyses will be published separately. CONCLUSION:This platform provides a scalable, reproducible framework for evaluating ventilator triage strategies under pandemic-like conditions. By integrating both initial triage and serial reassessment (front- and back-end) logic, operational constraints, and clinical trajectories, it enables detailed comparisons of survival, resource utilization, and prognostic accuracy. The simulation also supports ethical evaluation by testing the practical impact of exclusion and comorbidity-based criteria. Such models can assist governments, health systems, and public health agencies in designing triage protocols that are evidence-informed, ethically defensible, and operationally feasible. This work demonstrates how computational modeling can strengthen health system preparedness and support public trust.

BACKGROUND:Ischemic/anoxic brain injury is often assumed to occur within minutes of severe cerebral ischemia. However, emerging evidence suggests brain tissue may be more resilient, with important implications for resuscitation. We hypothesized that during prolonged cardiac arrest, cortical electrical activity may be restorable if cerebral oxygenation thresholds are met and may be associated with return of spontaneous circulation (ROSC). METHODS:) during cardiopulmonary resuscitation (CPR). RESULTS:≥16%, and alpha at >40%. Alpha activity was seen up to 35 min, and delta/theta up to 60 min into CPR. Suppression reverted to near-normal in 12% of transitions. Alpha activity was associated with ROSC (OR 5.4; 95% CI 1.08-29.20; p = 0.045), while suppression predicted lower ROSC odds (OR 0.12; 95% CI 0.02-0.53; p = 0.002). Survival analysis was limited by small sample size. CONCLUSION/CONCLUSIONS:Near-physiologic brain activity may be restored during prolonged CPR if oxygenation thresholds are met and is associated with ROSC. Further research is needed to evaluate survival outcomes.

BACKGROUND:Current CPR guidelines recommend 10 breaths/min in adult cardiac arrest patients with an advanced airway, though this is largely based on animal studies. We evaluated the association between ventilation rate and return of spontaneous circulation (ROSC) in in-hospital cardiac arrest (IHCA). METHODS:) monitoring. Patients were enrolled from 25 tertiary centers in the U.S. and U.K. A subset had intra-arrest arterial blood gases collected per routine care. RESULTS:did not differ significantly, suggesting a hemodynamic mechanism. CONCLUSIONS:monitors. Thus, more studies are needed to determine the need to re-evaluate current ventilation targets during CPR in intubated patients.

Critical care ultrasound (CCUS) is a tool enabling providers to deliver bedside care to the sickest patients in the hospital. Competency in CCUS involves understanding its indications, acquiring and interpreting images, and integrating this information for clinical decision-making. Core examinations include focused transthoracic echo (basic and/or advanced), thoracic ultrasound, abdominal ultrasound, vascular diagnostic, and procedural guidance. Certification, provided by an external professional society or certifying body, and credentialing, conducted internally by an individual provider's health care organization, are both processes designed to ensure competency. This article clearly defines these concepts, reviews relevant literature, and offers guidance on best practices.

BACKGROUND:Although technology is rapidly advancing in immersive virtual reality (VR) simulation, there is a paucity of literature to guide its implementation into health professions education, and there are no described best practices for the development of this evolving technology. OBJECTIVE:We conducted a qualitative study using semi-structured interviews with early adopters of immersive VR simulation technology to investigate utilization and motivations behind employing this technology in educational practice, and to identify the educational needs that this technology can address. METHODS:We conducted 16 interviews with VR early adopters. Data were analyzed via Directed Content Analysis through the lens of the Unified Theory of Acceptance and Use of Technology (UTAUT). RESULTS:The main themes that emerged included Focus on Cognitive Skills, Access to Education, Resource Investment, and Balancing Immersion. These findings help to clarify the intended role of VR simulation in health professions education. Based on our data, we synthesize a set of research questions that may help define best practices for future VR development and implementation. CONCLUSIONS:Immersive VR simulation technology primarily serves to teach cognitive skills, to expand access to educational experiences, to act as a collaborative repository of widely relevant and diverse simulation scenarios, and to foster learning through deep immersion. By applying the UTAUT theoretical framework to the context of VR simulation, we not only collected validation evidence for this established theory, but also proposed several modifications to better explain use behavior in this specific setting.

BACKGROUND/UNASSIGNED:Advanced critical care echocardiography comprises a specific set of qualitative and quantitative point-of-care echocardiography skills, including a reliable, noninvasive method to measure cardiac output. This technique requires echocardiographic measurement of left ventricular outflow tract (LVOT) diameter and LVOT velocity time integral (VTI). Although there is a demand among critical care fellows to learn these advanced techniques, there are no data describing the acquisition of mastery in these skills. OBJECTIVE/UNASSIGNED:This pilot study aims to describe the accuracy of echocardiographic measurement of LVOT diameter and LVOT VTI obtained by critical care fellows after an educational intervention, as well as to enhance validation evidence for an image scoring assessment that is applicable to these measurements. METHODS/UNASSIGNED:We implemented a brief mastery learning intervention to teach the measurement of LVOT diameter and VTI. Fellow measurements of these parameters, along with the corresponding echocardiographic images, were compared with a gold standard of measurements obtained by professional echocardiography technicians and interpreted by cardiologists. RESULTS/UNASSIGNED: = 0.004), with a mean percent difference of 8.05 ± 7.0%. The sensitivity for fellows to detect an abnormal LVOT VTI was 91%, with a specificity of 43%. CONCLUSION/UNASSIGNED:Critical care fellow measurement of LVOT VTI and LVOT diameter demonstrated strong and moderate positive correlations with cardiologist-reported values, respectively, with acceptable clinical agreement. However, interrater reliability and percent differences showed room for improvement. Education in these advanced skills is resource intensive, and additional research is needed to determine the most effective approach to training fellows.

INTRODUCTION/UNASSIGNED:Mounting evidence indicates that an individual's humoral adaptive immune response plays a critical role in the setting of SARS-CoV-2 infection, and that the efficiency of the response correlates with disease severity. The relationship between the adaptive immune dynamics in the lower airways with those in the systemic circulation, and how these relate to an individual's clinical response to SARS-CoV-2 infection, are less understood and are the focus of this study. MATERIAL AND METHODS/UNASSIGNED:We investigated the adaptive immune response to SARS-CoV-2 in paired samples from the lower airways and blood from 27 critically ill patients during the first wave of the pandemic (median time from symptom onset to intubation 11 days). Measurements included clinical outcomes (mortality), bronchoalveolar lavage fluid (BALF) and blood specimen antibody levels, and BALF viral load. RESULTS/UNASSIGNED:While there was heterogeneity in the levels of the SARS-CoV-2-specific antibodies, we unexpectedly found that some BALF specimens displayed higher levels than the paired concurrent plasma samples, despite the known dilutional effects common in BALF samples. We found that survivors had higher levels of anti-spike, anti-spike-N-terminal domain and anti-spike-receptor-binding domain IgG antibodies in their BALF (p<0.05), while there was no such association with antibody levels in the systemic circulation. DISCUSSION/UNASSIGNED:Our data highlight the critical role of local adaptive immunity in the airways as a key defence mechanism against primary SARS-CoV-2 infection.

IMPORTANCE:The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented. OBJECTIVES:To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities. DESIGN, SETTING, AND PARTICIPANTS:This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized. EXPOSURES:The NYVAG protocol for triage ventilators. MAIN OUTCOMES AND MEASURES:Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing. RESULTS:The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities. CONCLUSIONS AND RELEVANCE:In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.