Faculty Bibliography

In situ simulation has frequently been used to improve team performance and provide an opportunity for the practice of critical skills and identify latent safety threats, which are undetected risks that may lead to adverse outcomes. However, the use of known quality improvement tools to prioritize and mitigate these safety threats is an area requiring further study. Over the course of 9 in situ simulations of a pediatric shock case, postcase debriefs were held to identify latent safety threats in an emergency department and a mixed pediatric and adult inpatient unit. Latent safety threats identified included structure-related threats such as inability to locate critical equipment, knowledge-based threats relating to rapid intravenous fluid administration, and communication-based threats such as lack of role designation. Identification of latent safety threats in the health care environment may assist clinician leaders in mitigating risk of patient harm. The protocol described may be adopted and applied to other critical event simulations, with structured debriefing used as a tool to identify and mitigate threats before they affect the patient.

OBJECTIVE/UNASSIGNED:Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols. METHODS/UNASSIGNED:An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings. RESULTS/UNASSIGNED: = 0.427). DISCUSSION/UNASSIGNED:Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields. IMPLICATIONS FOR PRACTICE/UNASSIGNED:Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.

OBJECTIVE:To evaluate the tolerance, overall experience, procedure discomfort, and patient anxiety using different routes in office-based laryngeal procedures. SUBJECTS AND METHODS/METHODS:We performed a retrospective analysis of patients undergoing office-based laryngeal procedures for the treatment or diagnosis of laryngeal lesions via transnasal, transoral, or percutaneous routes. Tolerability, overall experience, procedure discomfort, and patient's anxiety were evaluated and reported on a custom scale over 5. RESULTS:A total 178 procedures performed on 154 patients were reviewed. The video-recordings and data on 15 procedures were missing. A total of 163 procedures were included in this study. These were stratified as follows; 128 procedures via the transnasal fiberoptic approach, 16 procedures via the transoral fiberoptic approach, and 19 procedures via the percutaneous approach. There was no significant difference in the mean score of overall experience across the three different approaches (P= 0.926). The mean overall experience score for the transnasal approach was 1.85, vs 1.93 and 1.94 for the transoral and percutaneous approach, respectively. Similarly, there was no significant difference in the mean score of tolerability across the three different approaches. The mean tolerability score was 1.68 using the transnasal approach, compared to 1.6 using the transoral approach, and 1.84 using the percutaneous approach (P= 0.77). Anxiety scores, and procedure discomfort scores did not differ either among the three groups (P= 0.138 and P= 0.656, respectively). CONCLUSIONS:There was no significant difference in tolerability, anxiety, procedure discomfort, and overall experience regarding the different approaches employed.

OBJECTIVE/UNASSIGNED:To report patient tolerance in office-based blue laser therapy for vocal fold lesions. METHODS/UNASSIGNED:A retrospective review of the medical records of patients who underwent office-based blue laser therapy for lesions of the vocal folds between November 2021 and February 2023 was conducted. A total of 48 patients were included. Patient tolerance was assessed using the Iowa Satisfaction with Anesthesia Scale (IOWA). Patient tolerance was analyzed in relation to patients' demographic characteristics, disease type and severity, and procedure-related factors. RESULTS/UNASSIGNED:value .041). There was a moderate and significant negative correlation between vocal fold movement VAS, swallowing VAS, and tolerance score. The mean total duration of the procedures was 10.38 ± 4.8 min. There was a mild negative correlation between the duration of the procedure and tolerance. CONCLUSION/UNASSIGNED:Office-based blue laser therapy for vocal fold lesions is a well-tolerated procedure. Patient should be instructed how to breathe quietly and avoid swallows to improve tolerance to surgery. LEVEL OF EVIDENCE/UNASSIGNED:4.

IMPORTANCE:Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement. OBJECTIVE:To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events. DESIGN, SETTING, AND PARTICIPANTS:A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022. EXPOSURES:Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS). MAIN OUTCOMES AND MEASURES:The primary outcome was overall interrater agreements using Fleiss κ. RESULTS:Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios. CONCLUSION AND RELEVANCE:This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

STUDY OBJECTIVE/OBJECTIVE:Assess the prevalence of and risk factors for pediatric pulmonary hypertension (PH) in the 2016 Kids' Inpatient Database (KID), including obstructive sleep apnea (OSA) and obesity. METHODS:Retrospective cross-sectional cohort study utilizing 6,081,132 weighted pediatric discharges from the 2016 KID. Study variables included age, length of stay, mortality, gender, hospital region, primary payer, race, median household income for patient's ZIP code, OSA, central sleep apnea (CSA), obesity, Down syndrome, sickle cell disease (SCD), thalassemia, congenital heart disease (CHD), hypertension, asthma and chronic lung disease of prematurity (CLDP). PH was the primary outcome of interest. Bivariate and multivariable logistic regression models were utilized with odds ratios and 95 % confidence intervals. RESULTS:The mean age was 3.76 years, the mean hospital length of stay was 3.85 days, 48.9 % were male, 52.6 % had government health insurance, 51.0 % were White, 16.1 % were Black, 21.1 % were Hispanic, 5.0 % were Asian or Pacific Islander, 0.80 % were Native American and 6.1 % identified as "other". The prevalence of PH was 0.21 % (12,777 patients). There were 37,631 patients with OSA and the prevalence of PH among this cohort was 3.3 %, over 10x greater than the overall prevalence of PH in the 2016 KID (0.21 %). Risk factors associated with PH included CLDP, CHD, Down syndrome, asthma, OSA, CSA, hypertension, SCD, obesity, race/ethnicity, government insurance, age, male gender (p < 0.0001), and hospital region (p = 0.0002). CONCLUSIONS:Several risk factors were independently associated with PH, such as OSA, CSA, obesity, asthma, and insurance status. Prospective multi-institutional studies are needed to assess the relationships between these risk factors, severity metrics, and causative links in the development of PH; in addition to identifying children with OSA who are most likely to benefit from cardiopulmonary screening prior to adenotonsillectomy. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND/UNASSIGNED:The 2016 WHO classification described a subtype of midline gliomas harboring histone 3 (H3) K27M alterations, and the 2021 edition added a new subtype of hemispheric diffuse gliomas with H3 G34R/V mutations. The incidence and clinical behavior of leptomeningeal disease (LMD) in these patients is not well defined. METHODS/UNASSIGNED:Retrospective study of patients with H3-altered gliomas diagnosed from 01/2012 to 08/2021; histone mutations were identified through next-generation sequencing (NGS) of tumor biopsy and/or cerebrospinal fluid (CSF). RESULTS/UNASSIGNED:< .0001). CONCLUSIONS/UNASSIGNED:In our cohort, 50% of patients developed LMD. Although further studies are needed, CSF ctDNA characterization may aid in identifying molecular tumor profiles in glioma patients with LMD, and neuroaxis imaging and CSF NGS should be considered for early LMD detection.

PURPOSE/OBJECTIVE:Patients with EGFR-mutated NSCLC represent a unique subset of lung cancer patients with distinct clinical and molecular characteristics. Previous studies have shown a higher incidence of brain metastases (BM) in this subgroup of patients, and neurologic death has been reported to be as high as 40% and correlates with leptomeningeal disease (LMD). METHODS:Between 2012 and 2021, a retrospective review of our prospective registry identified 606 patients with BM from NSCLC, with 170 patients having an EGFR mutation. Demographic, clinical, radiographic, and treatment characteristics were correlated to the incidence of LMD and survival. RESULTS:LMD was identified in 22.3% of patients (n = 38) at a median follow-up of 19 (2-98) months from initial SRS. Multivariate regression analysis showed targeted therapy and a cumulative number of metastases as significant predictors of LMD (p = 0.034, HR = 0.44), (p = .04, HR = 1.02). The median survival time after SRS of the 170 patients was 24 months (CI 95% 19.1-28.1). In a multivariate Cox regression analysis, RPA, exon 19 deletion, and osimertinib treatment were significant predictors of overall survival. The cumulative incidence of neurological death at 2 and 4 years post initial stereotactic radiosurgery (SRS) was 8% and 11%, respectively, and correlated with LMD. CONCLUSION/CONCLUSIONS:The study shows that current-generation targeted therapy for EGFR-mutated NSCLC patients may prevent the development and progression of LMD, leading to improved survival outcomes. Nevertheless, LMD is associated with poor outcomes and neurologic death, making innovative strategies to treat LMD essential.