Faculty Bibliography

PURPOSE: Goal-directed echocardiography (GDE) is used to answer specific clinical questions which can provide invaluable and timely information to the critical care physician. Studies that assess competency are lacking. We studied perception and ability of housestaff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated cardiac arrest scenarios, and we compared them to expert echocardiographers. METHODS: 14 housestaff subjects with prior GDE training were enrolled. Subjects answered a pre-study questionnaire and had time to familiarize themselves with the transthoracic echocardiography simulator. A baseline assessment was conducted whereby subjects obtained four standard cardiac windows (parasternal long, parasternal short, subcostal, and apical four chamber). Subjects were exposed to six simulated cardiac arrest scenarios. They were given relevant clinical information and were asked to perform a GDE during pulse checks which lasted ten seconds. Three GDE attempts were allowed and if no diagnosis was offered, a final twenty second interval was allowed. Subjects were debriefed and filled out a post-study questionnaire. All echocardiography views were graded on a scale of zero to three. Subject performance was compared to the performance of three expert echocardiographers. RESULTS: 21% of subjects reported comfort using GDE independently, while 71% preferred attending oversight. Baseline and scenario views by subjects were of good quality 93% and 79% of the time, respectively. Expert baseline and scenario views were of good quality 100% of the time. Subjects and experts made the correct diagnosis in 68% and 72% of cases, respectively. On average, subjects and experts required 1.5 pulse checks for the correct diagnosis. 93% of subjects perceived this study as an accurate assessment of ability and felt more comfortable with GDE at its conclusion. CONCLUSIONS: Housestaff with prior GDE training reach similar diagnostic conclusions in the same amount of tim!

Rationale Current methods available to assess rapid response management skills are subjective and variable. High-fidelity simulation (HFS), however, allows for objective and standardized measurement of these skills. Physicians-in-training can undergo the same simulation and be scored against one another to determine their level of proficiency when leading a rapid response. We created a critical care simulation scenario and corresponding checklist assessment tool to measure specific behaviors related to effective management of a rapid response. Methods Forty-four second-year internal medicine residents underwent HFS of a critically-ill patient with pulseless electrical activity. The simulation was designed to elicit leadership qualities, communication skills, decision-making and resource management during a rapid response. A comprehensive checklist was developed from expert consultation that itemized behaviors as having been "well done," "partially done," or "not done." Video-recordings of simulations were reviewed by two independent raters, each of which underwent extensive training in checklist use prior to project initiation. Results Composite scores from both raters revealed that 39% (103/264) and 55% (243/440) of resident scores were "well done" for leadership and communication skills during the rapid response, respectively. Twenty-six percent (46/176) of scores were "well done" for decision-making and 42% (37/88) of scores were "well done" for resource utilization skills. Cronbach's Alpha analysis of internal consistency of composite "well done" scores was good, with a value of 0.869. Conclusions HFS with use of a corresponding checklist assessment tool is an objective and effective way in which to measure rapid response management skills. During our simulation, a minority of residents received "well done" scores for leadership, decision-making and resource utilization. This may reflect residents' discomfort when placed in a supervisory role during rapid responses, a paucity of exposure to such situations, or inadequate training in running rapid responses. In order to better educate physicians-in-training, a standardized and objective measurement tool must be used. Our checklist assessment tool demonstrates good internal consistency. Therefore, it can be used to objectively measure behaviors that exemplify organization and management of rapid responses

PURPOSE: Current methods of measuring medical professionalism are subjective. They often do not account for high-pressure environments where professionalism can be strained, such as the intensive care unit (ICU). High-fidelity simulation (HFS) is a technology in which standardized, high-pressure patient scenarios are practiced. The standardization of HFS allows for objective measurement of professionalism-specific behaviors found in the ICU. METHODS: Forty-four second-year internal medicine residents underwent HFS of a critically-ill patient. Professionalism-specific behaviors pertaining to obtaining informed consent for central venous line (CVL) placement and disclosure of an iatrogenic complication secondary to the CVL were evaluated. A comprehensive checklist itemized pre-determined professionalism-specific behaviors as having been 'well done, ' 'partially done, ' or 'not done. ' The checklist was formulated from expert consultation, and items included objectively defined behaviors and excluded medical knowledge prerequisites. Video-recordings of simulations were reviewed by three independent raters, each of which underwent training prior to project initiation. RESULTS: Composite scores from three raters revealed that 74.2% (98/132) and 67.4% (89/132) of residents received 'well done ' scores for discussion of CVL benefits and risks, respectively. Sixteen percent (21/132) of residents received 'well done ' scores regarding discussion of alternatives to CVL placement. Concerning disclosure of the iatrogenic complication, 22% (29/132) of residents performed this task well. Cronbach's alpha analyses of internal consistency were .813 for obtaining informed consent and .709 for disclosure of the iatrogenic complication. CONCLUSIONS: During our ICU simulation, a majority of residents outlined benefits and risks to CVL placement well, though most neglected to discuss alternatives. Furthermore, a minority of residents disclosed the etiology of the iatrogenic complication. It is possible that the high-stress simulated ICU environment contributed to the low prevalence of these behaviors. CLINICAL IMPLICATIONS: Objective tools to evaluate medical professionalism are scarce. However, our assessment tool checklist demonstrates good internal consistency, and therefore HFS of a critically-ill patient can be used to reliably and objectively measure pre-determined professionalism-specific behaviors