Faculty Bibliography

Deep exploration of a complex health care issue in pediatrics might be hindered by the sensitive or infrequent nature of a particular topic in pediatrics. Health care simulation builds on constructivist theories to guide individuals through an experiential cycle of action, self-reflection, and open discussion, but has traditionally been applied to the educational domain in health sciences. Leveraging the emotional activation of a simulated experience, investigators can prime participants to engage in open dialogue for the purposes of qualitative research. The framework of simulation-primed qualitative inquiry consists of 3 main iterative steps. First, researchers determine applicability by consideration of the need for an exploratory approach and potential to enrich data through simulation priming of participants. Next, careful attention is needed to design the simulation, with consideration of medium, technology, theoretical frameworks, and quality to create simulated reality relevant to the research question. Finally, data collection planning consists of a qualitative approach and method selection, with particular attention paid to psychological safety of subjects participating in the simulation. A literature review revealed 37 articles that used this newly described method across a variety of clinical and educational research topics and used a spectrum of simulation modalities and qualitative methods. Although some potential limitations and pitfalls might exist with regard to resources, fidelity, and psychological safety under the auspices of educational research, simulation-primed qualitative inquiry can be a powerful technique to explore difficult topics when subjects might experience vulnerability or hesitation.

INTRODUCTION: While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design. METHODS: Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs. RESULTS: One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training. CONCLUSION: A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

Background: Airway management skills are an essential part of EM resident training. They are recognized as a key ACGME competency milestone. All EM trainees must achieve mastery in performing basic support of oxygenation and ventilation until a definitive airway can be secured. Junior residents frequently overlook these important fundamental skills. In our residency, no formalized program was in place to assess first year residents' airway skill retention or identify potential skill improvement and remediation. Objectives: The goal of our study is to demonstrate improvements in PGY1 residents' comfort with basic airway management skills using an immersive simulation-based curriculum. Methods: Residents participated in three high fidelity simulations. The scenarios required identification of risk factors for a difficult airway, demonstration of effective BVM skills, patient repositioning, and use of nasal trumpets, oral airways and PEEP valve if necessary. The cases included a patient with methadone overdose where naloxone was not yet available, a patient with pulmonary edema requiring ventilatory support, and a MVC patient requiring maintenance of C-spine immobilization during airway management. We utilized a survey-based design with pre- and post-session distribution assessing trainees' comfort with basic airway skills. The survey consisted of 5-point Likertscale questions, and we employed the paired Student t-test for data analysis. Results: A total of 13 PGY1 residents completed the one-on-one didactic session. All residents universally chose "strongly agree" when asked if the simulations were helpful. Instructors responded that the residents' airway techniques improved at the completion of the scenarios. The trainees reported significantly higher confidence in basic airway skills after training (mean score +1.13, p<0.005). During subsequent feedback, residents identified how cognitive stress impaired information retrieval, decision-making, and in some, fine motor skills. Adherence to an airway checklist mitigated these potential safety threats. Conclusion: An immersive simulation-based curriculum significantly improved PGY1 residents in their comfort level toward basic airway skills. As a secondary objective, program leadership was also able to assess and complete the level 1 ACGME milestones for airway skills for all PGY1 session attendees

Background: While treating potentially violent patients in the ED, both patients and staff may be subject to unintentional injury. Preliminary studies have shown that a team-based approach with targeted staff training have significant positive outcomes in mitigating violence in health care settings. Objectives: The goal for our study was to show that a simulationbased interdisciplinary curriculum would improve attitudes and staff safety toward management of patient aggression in the ED. Methods: Formal roles and responsibilities for each member of the care team including positioning during restraint placement were predefined in conjunction with ED leadership. EM residents, nurses and hospital police officers were assigned to interdisciplinary teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement. Next, we conducted two simulation scenarios using standardized participants and structured debriefing. The study consisted of a survey-based design comparing pre- and postintervention responses to assess changes in staff attitudes. We utilized the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs and performed analysis with the Student paired t-test. Results: 162 ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/ interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively, Figure 479). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented including the creation of an ED-based interprofessional crisis management alert and response protocol. Conclusion: A structured interdisciplinary simulation-based intervention was successful in improving ED staff attitudes toward caring for agitated patients. Attitudes towards managing them remained conflicted. Ongoing work includes a follow-up qualitative study utilizing staff focus groups and tracking patient outcomes. (Figure Presented)

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!

BACKGROUND: The purpose of this study was to systematically examine the impact of insurance status on access to and utilization of elective specialty hand surgical care. We hypothesized that patients with Medicaid insurance or those without insurance would have greater difficulty accessing care both in obtaining local surgical care and in reaching a tertiary center for appointments. METHODS: This retrospective cohort study included all new patients with orthopaedic hand problems (n = 3988) at a tertiary center in a twelve-month period. Patient insurance status was categorized and clinical complexity was quantified on an ordinal scale. The relationships of insurance status, clinical complexity, and distance traveled to appointments were quantified by means of statistical analysis. An assessment of barriers to accessing care stratified with regard to insurance status was completed through a survey of primary care physicians and an analysis of both patient arrival rates and operative rates at our tertiary center. RESULTS: Increasing clinical complexity significantly correlated (p < 0.001) with increasing driving distance to the appointment. Patients with Medicaid insurance were significantly less likely (p < 0.001) to present with problems of simple clinical complexity than patients with Medicare and those with private insurance. Primary care physicians reported that 62% of local surgeons accepted patients with Medicaid insurance and 100% of local surgeons accepted patients with private insurance. Forty-four percent of these primary care physicians reported that, if patients who were underinsured (i.e., patients with Medicaid insurance or no insurance) had been refused by community surgeons, they were unable to drive to our tertiary center because of limited personal resources. Patients with Medicaid insurance (26%) were significantly more likely (p < 0.001) to fail to arrive for appointments than patients with private insurance (11%), with no-show rates increasing with the greater distance required to reach the tertiary center. CONCLUSIONS: Economically disadvantaged patients face barriers to accessing specialty surgical care. Among patients with Medicaid coverage or no insurance, local surgical care is less likely to be offered and yet personal resources may limit a patient's ability to reach distant centers for non-emergency care.

OBJECTIVE: To evaluate the prevalence and magnitude of sagittal plane deformity in bicondylar tibial plateau fractures. DESIGN: Retrospective radiographic review. SETTING: Two Level I trauma centers. MAIN OUTCOME MEASUREMENT: Sagittal inclination of the medial and lateral plateau measured in relation to the longitudinal axis of the tibia using computed tomographic reconstruction images. PATIENTS: Seventy-four patients (mean age, 49 years; range, 16-82 years; 64% male) with acute bicondylar tibial plateau fractures (Orthopaedic Trauma Association 41C, Schatzker VI) treated from October 2006 to July 2009. RESULTS: The average sagittal plane angulation of the lateral plateau was 9.8 degrees posteriorly (range, 17 degrees anteriorly to 37 degrees posteriorly). The medial plateau was angulated 4.1 degrees posteriorly on average (range, 16 degrees anteriorly to 31 degrees posteriorly). Forty-two lateral plateaus were angulated more than 5 degrees from the "normal" anatomic slope (defined as 5 degrees of posterior tibial slope). Of these, 76% were angulated posteriorly. Forty-three (58%) of the medial plateaus were angulated greater than 5 degrees from normal, of which only 47% were inclined posteriorly (P = 0.019 compared with lateral plateaus). In 68% of patients, the difference between medial and lateral plateaus was greater than 5 degrees ; the average intercondylar slope difference was 9 degrees (range, 0 degrees -31 degrees ; P < 0.001). Spanning external fixation did not affect the slope of either the medial or lateral tibial plateau. Intraobserver and interobserver correlations were high for both the medial and lateral plateaus (r > 0.81, P < 0.01). CONCLUSIONS: Considerable sagittal plane deformity exists in the majority of bicondylar tibial plateau fractures. The lateral plateau has a higher propensity for sagittal angulation and tends to have increased posterior slope. Most patients have a substantial difference between the lateral and medial plateau slopes. The identification of this deformity allows for accurate preoperative planning and specific reduction maneuvers to restore anatomic alignment.

BACKGROUND: The mechanisms underlying the interaction between the local mechanical environment and fracture healing are not known. We developed a mouse femoral fracture model with implants of different stiffness, and hypothesized that differential fracture healing would result. METHODS: Femoral shaft fractures were created in 70 mice, and were treated with an intramedullary nail made of either tungsten (Young's modulus = 410 GPa) or aluminium (Young's modulus = 70 GPa). Mice were then sacrificed at 2 or 5 weeks. Fracture calluses were analyzed using standard microCT, histological, and biomechanical methods. RESULTS: At 2 weeks, callus volume was significantly greater in the aluminium group than in the tungsten group (61.2 vs. 40.5 mm(3), p = 0.016), yet bone volume within the calluses was no different between the groups (13.2 vs. 12.3 mm(3)). Calluses from the tungsten group were stiffer on mechanical testing (18.7 vs. 9.7 N/mm, p = 0.01). The percent cartilage in the callus was 31.6% in the aluminium group and 22.9% in the tungsten group (p = 0.40). At 5 weeks, there were no differences between any of the healed femora. CONCLUSIONS: In this study, fracture implants of different stiffness led to different fracture healing in this mouse fracture model. Fractures treated with a stiffer implant had more advanced healing at 2 weeks, but still healed by callus formation. Although this concept has been well documented previously, this particular model could be a valuable research tool to study the healing consequences of altered fixation stiffness, which may provide insight into the pathogenesis and ideal treatment of fractures and non-unions.

BACKGROUND: Hip fractures in the elderly are associated with high 1-year mortality rates, but whether patients with other lower extremity fractures are exposed to a similar mortality risk is not clear. QUESTIONS/PURPOSES: We evaluated the mortality of elderly patients after distal femur fractures; determined predictors for mortality; analyzed the effect of surgical delay; and compared survivorship of elderly patients with distal femur fractures with subjects in a matched hip fracture group. PATIENTS AND METHODS: We included 92 consecutive patients older than 60 years with low-energy supracondylar femur fractures treated between 1999 and 2009. Patient, fracture, and treatment characteristics were extracted from operative records, charts, and radiographs. Data regarding mortality were obtained from the Social Security Death Index. RESULTS: Age-adjusted Charlson Comorbidity Index and a previous TKA were independent predictors for decreased survival. Congestive heart failure, dementia, renal disease, and history of malignant tumor led to shorter survival times. Patients who underwent surgery more than 4 days versus 48 hours after admission had greater 6-month and 1-year mortality risks. No differences in mortality were found comparing patients with native distal femur fractures with patients in a hip fracture control group. CONCLUSIONS: Periprosthetic fractures and fractures in patients with dementia, heart failure, advanced renal disease, and metastasis lead to reduced survival. The age-adjusted Charlson Comorbidity Index may serve as a useful tool to predict survival after distal femur fractures. Surgical delay greater than 4 days increases the 6-month and 1-year mortality risks. Mortality after native fractures of the distal femur in the geriatric population is high and similar to mortality after hip fractures. LEVEL OF EVIDENCE: Level II, prognostic study. See the guidelines online for a complete description of evidence.