Publications by authors named "Patrick G Hughes"

38 Publications

Supporting the Quadruple Aim Using Simulation and Human Factors During COVID-19 Care.

Am J Med Qual 2021 Mar-Apr 01;36(2):73-83

Department of Emergency Medicine, Yale School of Medicine, New Haven, CT Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN Department of Internal Medicine, Central Michigan University College of Medicine, Mount Pleasant, MI Department of Emergency Medicine, Florida Atlantic University College of Medicine, Boca Raton, FL Department of Emergency Medicine, University of California, Irvine, Irvine, CA Department of Pediatrics, Yale School of Medicine, New Haven, CT Department of Emergency Medicine, Yale School of Medicine, New Haven, CT Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI College of Population Health, Thomas Jefferson University, Philadelphia, PA.

The health care sector has made radical changes to hospital operations and care delivery in response to the coronavirus disease (COVID-19) pandemic. This article examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the COVID-19 era. First, patient safety is enhanced through development and testing of new technologies, equipment, and protocols using laboratory-based and in situ simulation. Second, population health is strengthened through virtual platforms that deliver telehealth and remote simulation that ensure readiness for personnel to deploy to new clinical units. Third, prevention of lost revenue occurs through usability testing of equipment and computer-based simulations to predict system performance and resilience. Finally, simulation supports health worker wellness and satisfaction by identifying optimal work conditions that maximize productivity while protecting staff through preparedness training. Leveraging simulation and human factors will support a resilient and sustainable response to the pandemic in a transformed health care landscape.
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http://dx.doi.org/10.1097/01.JMQ.0000735432.16289.d2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8030878PMC
April 2021

Nineteen-Year Trends in Mortality of Patients Hospitalized in the United States with High-Risk Pulmonary Embolism.

Am J Med 2021 Feb 22. Epub 2021 Feb 22.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.

Background: Several advanced treatments of high-risk patients with pulmonary embolism have been used in recent decades. We assessed the 19-year national trend in mortality of high-risk patients with pulmonary embolism to determine what impact, if any, advanced therapy might have had on mortality.

Methods: Mortality (case fatality rate) was assessed in patients with a primary (first-listed) diagnosis of high-risk pulmonary embolism who were hospitalized during the period from 1999 to 2014 and in 2016 and 2017. High-risk was defined as patients with pulmonary embolism who were in shock or suffered cardiac arrest. International Classification of Diseases, 9th revision, Clinical Modification codes were used for data on the period from 1999 to 2014, and version 10 codes were used for data on the years 2016 and 2017. Trends in mortality were assessed according to treatment.

Results: From 1999 to 2017 (excluding 2015), 58,784 patients were hospitalized in United States with a primary diagnosis of pulmonary embolism that was high risk. Mortality in all high-risk patients decreased from 72.7% in 1999 to 49.8% in 2017 (P < .0001). Most high-risk patients (60.3%) were treated with anticoagulants alone and did not receive an inferior vena cava filter. Mortality in these patients decreased from 79.0% in 1999 to 55.7% in 2017 (P < .0001). Thrombolytic therapy was administered to 16.1% of high-risk patients, open pulmonary embolectomy alone was used in 4.3%, and extracorporeal membrane oxygenation was used in 0.4%.

Conclusions: Mortality of high-risk patients with pulmonary embolism has decreased. This decrease can be attributed to improved treatment of patients with shock and with cardiac arrest, and does not reflect advances in therapy for pulmonary embolism.
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http://dx.doi.org/10.1016/j.amjmed.2021.01.026DOI Listing
February 2021

Usefulness of ancillary findings on CT pulmonary angiograms that are negative for pulmonary embolism.

Thromb Res 2021 Apr 26;200:48-50. Epub 2021 Jan 26.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States of America; Department of Emergency Medicine, Sparrow Health System, East Lansing, MI, United States of America.

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http://dx.doi.org/10.1016/j.thromres.2021.01.018DOI Listing
April 2021

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness.

Pediatr Emerg Care 2021 Jan;37(1):48-53

Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN.

Objective: We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States.

Methods: We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network.

Results: We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%).

Conclusions: This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.
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http://dx.doi.org/10.1097/PEC.0000000000002307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780930PMC
January 2021

National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic.

World J Crit Care Med 2020 Dec 18;9(5):74-87. Epub 2020 Dec 18.

Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, Jefferson College of Population Health, Philadelphia, PA, 19107, United States.

Background: The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections.

Aim: To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.

Methods: A cross-sectional multi-center national survey of PICU medical director(s) from children's hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation.

Results: We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children's hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives.

Conclusions: A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.
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http://dx.doi.org/10.5492/wjccm.v9.i5.74DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754533PMC
December 2020

Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries.

Trauma Surg Acute Care Open 2020 25;5(1):e000520. Epub 2020 Nov 25.

Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.

Background: Antiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.

Methods: A retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals' trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians' discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.

Results: Of 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.

Conclusions: Patients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.

Level Of Evidence: Level III, prognostic.
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http://dx.doi.org/10.1136/tsaco-2020-000520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689589PMC
November 2020

Rescue Intubation in the Emergency Department After Prehospital Ketamine Administration for Agitation.

Prehosp Disaster Med 2020 Dec 14;35(6):651-655. Epub 2020 Sep 14.

Division of Emergency Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FloridaUSA.

Objective: Prehospital intramuscular (IM) ketamine is increasingly used for chemical restraint of agitated patients. However, few studies have assessed emergency department (ED) follow-up of patients receiving prehospital ketamine for this indication, with previous reports suggesting a high rate of post-administration intubation. This study examines the rate of and reasons for intubation and other airway interventions in agitated patients who received ketamine by Emergency Medical Services (EMS).

Methods: This retrospective cohort study included patients who received prehospital ketamine for agitation and were transported to two community hospital EDs. Charts were reviewed for demographics, ketamine dose, and airway intervention by EMS or in the ED. Characteristics of patients who were intubated versus those who did not receive airway intervention were analyzed.

Results: Over 28 months, 86 patients received ketamine for agitation. Fourteen (16.3%) underwent endotracheal intubation. Patients with a higher temperature and a lower Glasgow Coma Score (GCS) were more likely to require intubation. There was no age or dose-dependent association on intubation rate. Intubated patients averaged 39 years old versus 44 for patients not intubated (negative five-year difference; 95% CI, -16 to 6). The mean ketamine dose was 339.3mg in patients intubated versus 350.7mg in patients not (-11.4mg difference; 95% CI, -72.4 to 49.6). The mean weight-based ketamine dose was 4.44mg/kg in patients intubated versus 4.96mg/kg in patients not (-0.53mg/kg difference; 95% CI, -1.49 to 0.43).

Conclusions: The observed rate of intubation in patients receiving prehospital ketamine for agitation was 16.3%. Study data did not reveal an age or dose-dependent rate of intubation. Further research should be conducted to compare the airway intervention rate of agitated patients receiving ketamine versus other sedatives in a controlled fashion.
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http://dx.doi.org/10.1017/S1049023X20001168DOI Listing
December 2020

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum.

J Vis Exp 2020 08 5(162). Epub 2020 Aug 5.

Indiana University School of Medicine.

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners' confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the "right way." The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.
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http://dx.doi.org/10.3791/61646DOI Listing
August 2020

Creation and Implementation of a Large-Scale Geriatric Interprofessional Education Experience.

Curr Gerontol Geriatr Res 2020 25;2020:3175403. Epub 2020 Jul 25.

Department of Geriatrics, Summa Health System, Akron, OH, USA.

The care of the older adult requires an interprofessional approach to solve complex medical and social problems, but this approach is difficult to teach in our educational silos. We developed an interprofessional educational session in response to national requests for innovative practice models that use collaborative interprofessional teams. We chose geriatric fall prevention as our area of focus as our development of the educational session coincided with the development of an interprofessional Fall Risk Reduction Clinic. Our aim of this study was to evaluate the number and type of students who attended a pilot and 10 subsequent educational sessions. We also documented the changes that occurred due to a Plan-Do-Study-Act (PDSA) rapid-cycle improvement model to modify our educational session. The educational session evolved into an online presession self-study didactic and in-person educational session with a poster/skill section, an interprofessional team simulation, and simulated patient experience. The simulated patient experience included an interprofessional fall evaluation, team meeting, and presentation to an expert panel. The pilot session had 83 students from the three sponsoring institutions (hospital system, university, and medical university). Students were from undergraduate nursing, nurse practitioner graduate program, pharmacy, medicine, social work, physical therapy, nutrition, and pastoral care. Since the pilot, 719 students have participated in various manifestations of the online didactic plus in-person training sessions. Ten separate educational sessions have been given at three different institutions. Survey data with demographic information were available on 524 participants. Students came from ten different schools and represented thirteen different health care disciplines. A large-scale interprofessional educational session is possible with rapid-cycle improvement, inclusion of educators from a variety of learning institutions, and flexibility with curriculum to accommodate learners in various stages of training.
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http://dx.doi.org/10.1155/2020/3175403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397430PMC
July 2020

Adjunctive Therapy and Mortality in Patients With Unstable Pulmonary Embolism.

Am J Cardiol 2020 06 4;125(12):1913-1919. Epub 2020 Apr 4.

Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan.

Mortality with adjunctive therapy in patients with unstable pulmonary embolism, defined as those in shock or on ventilator support, is sparsely studied and requires further investigation. This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016. In-hospital all-cause mortality in unstable patients with acute pulmonary embolism was assessed according to treatment. Patients were identified by International Classification of Diseases-10-Clinical Modification Codes. Most unstable patients, 85%, received only anticoagulants. Their mortality was 3,080 of 6,635 (46%) without an inferior vena cava (IVC) filter, and mortality was much less with an IVC filter, 285 of 1,185 (24%) (p <0.0001). Mortality with catheter-directed thrombolysis alone, 70 of 235 (30%), did not differ significantly from mortality with anticoagulants plus an IVC filter, p = 0.07, although a trend favored the latter. Intravenous thrombolytic therapy without an IVC filter showed a mortality of 295 of 695 (42%) which tended to be lower than mortality with anticoagulants alone (p = 0.06). The addition of an IVC filter to intravenous thrombolytic therapy resulted in a mortality of 20 of 165 (12%), which was the lowest mortality with any combination of adjunctive treatments. Intravenous thrombolytic therapy, however, was associated with more adverse effects of therapy than catheter-directed thrombolysis or anticoagulants.
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http://dx.doi.org/10.1016/j.amjcard.2020.03.014DOI Listing
June 2020

Does my personal protective equipment really work? A simulation-based approach.

Med Educ 2020 08 26;54(8):759-760. Epub 2020 May 26.

Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1111/medu.14188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267359PMC
August 2020

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine.

AEM Educ Train 2020 Feb 27;4(Suppl 1):S22-S39. Epub 2019 Dec 27.

Kaiser Permanente Central Valley/Kaiser Permanente School of Medicine Pasadena CA.

Objectives: Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.

Methods: The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.

Results And Analysis: Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.

Conclusions/implications For Educators: We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.
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http://dx.doi.org/10.1002/aet2.10418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011411PMC
February 2020

Ancillary Findings on CT Pulmonary Angiograms that are Negative for Pulmonary Embolism.

Spartan Med Res J 2020 Jan 30;4(2):11769. Epub 2020 Jan 30.

Sparrow Health System.

Context: One advantage of computed tomographic pulmonary angiograms (CTPA) is that they often show pathology in patients in whom pulmonary embolism (PE) has been excluded. In this investigation, we identified the ancillary findings on CTPAs that were negative for PE to obtain an impression of the type of findings shown.

Methods: This was a retrospective analysis of findings on CTPAs that were negative for PE obtained in nine emergency departments between January 2016 - February 2018. Ancillary findings were assessed by review of the radiographic reports.

Results: Ancillary findings were identified in N=338 (40.9%) of 825 patients with CTPAs that were negative for PE. Most ancillary findings, 254 (75.1%) of 338 were pulmonary or pleural abnormalities. Liver, gall bladder, kidney, or pancreatic abnormalities were shown in 26 (7.7%) cases, and abnormalities of the heart or great vessels were shown in 23 (6.8%) of cases. Abnormalities of the esophagus or intestine were shown in 12 (3.6%), abnormalities of the thyroid in 10 (3.0%) and abnormalities of bone or soft tissue lesions were shown in three (0.9%) cases. Inferential statistical procedures demonstrated that the occurrence of ancillary findings in patients with negative CTPAs was proportionately greater in patients who were 50 years and older (p < 0.001), although not between genders (p = 0.145).

Conclusions: Ancillary findings on CTPAs that were negative for PE were frequently reported. Future studies might focus of the extent to which ancillary findings on CTPA assisted physicians in management of the patient.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746057PMC
January 2020

Iatrogenic Critical Care Procedure Complication Boot Camp: A Simulation-based Pilot Study.

AEM Educ Train 2019 Apr 19;3(2):188-192. Epub 2019 Feb 19.

Indiana University School of Medicine Indianapolis IN.

Background: Traditional medical education strategies teach learners how to correctly perform procedures while neglecting to provide formal training on iatrogenic error management. Error management training (EMT) requires active exploration as well as explicit encouragement for learners to make and learn from errors during training. Simulation provides an excellent methodology to execute a curriculum on iatrogenic procedural complication management. We hypothesize that a standardized simulation-based EMT curriculum will improve learner's confidence, cognitive knowledge, and performance in iatrogenic injury management.

Methods: This was a pilot, prospective, observational study performed in a simulation center using a curriculum developed to educate resident physicians on iatrogenic procedural complication management. Pre- and postintervention assessments included confidence surveys, cognitive questionnaires, and critical action checklists for six simulated procedure complications. Assessment data were analyzed using medians and interquartile ranges (IQRs), and the paired change scores were tested for median equality to zero via Wilcoxon signed rank tests with p < 0.05 considered statistically significant.

Results: Eighteen residents participated in the study curriculum. The median (IQR) confidence increased significantly by a summed score of 12.5 (8.75-17.25; p < 0.001). Similarly, the median (IQR) knowledge significantly increased by 6 (3-8) points from the pre- to postintervention assessment (p < 0.001). For each of the simulation cases, the number of critical actions performed increased significantly (p < 0.001 to p = 0.002).

Conclusion: We demonstrated significant improvement in the confidence, clinical knowledge, and performance of critical actions after the completion of this curriculum. This pilot study provides evidence that a structured EMT curriculum is an effective method to teach management of iatrogenic injuries.
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http://dx.doi.org/10.1002/aet2.10317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457349PMC
April 2019

Setup and Execution Of the Blindfolded Code Training Exercise.

J Vis Exp 2019 03 29(145). Epub 2019 Mar 29.

Department of Emergency Medicine, Indiana University School of Medicine;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.
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http://dx.doi.org/10.3791/59248DOI Listing
March 2019

Carbon monoxide poisoning at a Florida Hospital following Hurricane Irma.

Am J Emerg Med 2019 09 8;37(9):1800-1801. Epub 2019 Mar 8.

Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2019.03.009DOI Listing
September 2019

Pacemaker-associated Phlegmasia Cerulea Dolens Treated with Catheter-directed Thrombolysis.

Clin Pract Cases Emerg Med 2018 Nov 5;2(4):316-319. Epub 2018 Sep 5.

Florida Atlantic University, Charles E. Schmidt College of Medicine, Department of Emergency Medicine, Boca Raton, Florida.

Phlegmasia cerulea dolens (PCD) is a rare and severe form of deep venous thrombosis that is classically associated with the lower extremities. We report a case of upper extremity PCD developing abruptly in a 37-year-old female with an indwelling cardiac pacemaker who presented to the emergency department complaining of pain and paresthesias in her left arm, adjoining left chest wall, and inferior neck. Her condition was promptly diagnosed and successfully treated with intravenous unfractionated heparin and balloon venoplasty with catheter-directed thrombolysis without any known residual signs or symptoms at hospital discharge.
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http://dx.doi.org/10.5811/cpcem.2018.8.39444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6230348PMC
November 2018

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies.

Int J Health Care Qual Assur 2018 Oct;31(8):935-949

Northeastern Ohio Medical University , Rootstown, Ohio, USA.

Purpose: The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED).

Design/methodology/approach: A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications.

Findings: This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries.

Originality/value: Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.
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http://dx.doi.org/10.1108/IJHCQA-08-2017-0157DOI Listing
October 2018

Sleep and Lifestyle Habits of Osteopathic Emergency Medicine Residents During Training.

J Am Osteopath Assoc 2018 Aug;118(8):e45-e50

Context: Duty hours were enacted in 2003 with the intent to improve patient safety and resident well-being. However, limited data exist regarding improvements in residents' well-being since the implementation of these restrictions.

Objective: To examine osteopathic emergency medicine (EM) resident characteristics regarding sleep and lifestyle habits and duty hour reporting.

Method: A convenience sample of osteopathic EM residents was surveyed at a statewide conference in May 2014. The conference included 177 residents from 15 osteopathic EM residencies. Data regarding demographics, sleep and lifestyle habits (including work-related motor vehicle incidents [MVIs] and chemical aid use for sleep/wakefulness), and duty hour reporting were collected. The Epworth Sleepiness Scale (ESS) score was calculated, with a score greater than 10 indicating sleep disturbance.

Results: Of the 128 residents (72%) who returned the survey, approximately two-thirds were female, were currently on an EM rotation, and were training in suburban emergency departments with more than 60,000 annual visits. Only 35% of respondents slept 8 or more hours per night during an EM rotation, and 63% admitted to weight change during residency. Forty-two percent of respondents had a work-related MVI, which was more likely to occur if their ESS score was greater than 11 (P<.03). Mean (SD) ESS score was 9.9 (4.8; range, 0-24). Respondents reported using chemical aids for staying awake or going to sleep on a mean (SD) of 6.9 (9.3) days per month (range, 0-30). The majority of respondents (84%) reported strict duty hour enforcement policies, few (17%) had ever been asked to falsify reports, and more than half (56%) had ever voluntarily reported false hours.

Conclusion: Most residents surveyed slept fewer than 8 hours per night and had a weight change during EM residency training. The majority of residents used a chemical aid for sleep or wakefulness. Nearly half of residents surveyed met criteria for disordered sleep, which was associated with a higher occurrence of MVIs.
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http://dx.doi.org/10.7556/jaoa.2018.113DOI Listing
August 2018

Training the trainers: a survey of simulation fellowship graduates.

Can Med Educ J 2017 Jun 30;8(3):e81-e89. Epub 2017 Jun 30.

Summa Akron City Hospital, Department of Emergency Medicine, Department of Medical Education, Ohio, US.

Background: Coupled with the expansion of simulation has been the development and growth of medical simulation fellowships. These non-accredited fellowships do not have a standardized curriculum and there are currently no studies investigating the simulation fellowship experience. The purpose of this study was to explore the simulation fellowship experience of graduates throughout North America and how it prepared them for their post-fellowship career.

Methods: A web-based survey was developed by Emergency Medicine attending physicians both of whom completed one-year fellowships in medical simulation. Prior to distribution, the survey was reviewed and tested by three simulation fellowship graduates and a PhD researcher. Feedback was integrated into the survey prior to distribution. The survey consisted of a maximum of 29 multiple choice questions including two step-logic questions and two open response questions. The survey was distributed to simulation fellowship directors in multiple disciplines and the directors were asked to forward the survey to graduates. Additionally, the Society for Academic Emergency Medicine Simulation Academy list-serve was utilized for distribution of the survey.

Results: The survey had 35 responses. The majority of respondents completed fellowship within the last two years (66%, 23/35). Fellowship graduates strongly agreed or agreed that their fellowship adequately prepared them for their post-fellowship simulation career (88%). Graduates report that research design/reporting (53%) and administration (18%) were areas of their fellowship curriculum that needed the most improvement.

Conclusion: The majority of simulation fellowship graduates agreed that their fellowship experience adequately prepared them for their post-fellowship simulation career. Graduates also felt that training in research and administration are areas that could be improved.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661740PMC
June 2017

Development, Validation, and Implementation of a Medical Judgment Metric.

MDM Policy Pract 2017 Jan-Jun;2(1):2381468317715262. Epub 2017 Jun 19.

Summa Health, Akron, Ohio (RAA, MLM, SSA, PGH, JRCB, LA, RLG).

Medical decision making is a critical, yet understudied, aspect of medical education. To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss's Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen's Kappa 0.851 to 0.880). : The MJM demonstrated preliminary evidence of reliability and validity.
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http://dx.doi.org/10.1177/2381468317715262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6125013PMC
June 2017

Simulation Fellowship Programs in Graduate Medical Education.

Acad Med 2017 Aug;92(8):1214

associate professor and director, Simulation Fellowship, Summa Akron City Hospital research program director, Department of Emergency Medicine, Summa Akron City Hospital associate director, Simulation Fellowship, Summa Akron City Hospital professor and director, International Affairs, University of Illinois at Chicago.

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http://dx.doi.org/10.1097/ACM.0000000000001780DOI Listing
August 2017

Neonatal Resuscitation Program Rolling Refresher: Maintaining Chest Compression Proficiency Through the Use of Simulation-Based Education.

Adv Neonatal Care 2017 Oct;17(5):354-361

Summa Health System, Akron, Ohio (Drs Cepeda Brito, Hughes, Figueroa, and Ahmed); Akron Children's Hospital, Akron, Ohio (Mss Firestone, Johnson, Ruthenburg, McKinney); and BIOSTATS, Data Analysis for Clinical Research Studies (Dr Gothard).

Background: Structured training courses have shown to improve patient outcomes; however, guidelines are inconsistently applied in up to 50% of all neonatal resuscitations. This is partly due to the fact that psychomotor skills needed for resuscitation decay within 6 months to a year from the completion of a certification course. Currently, there are no recommendations on how often refresher training should occur to prevent skill decay.

Purpose: Improve provider proficiency and confidence in the performance of neonatal resuscitation with a focus on chest compression effectiveness.

Methods: The study recruited neonatal intensive care unit providers (n = 25). A simulation-based Neonatal Resuscitation Program (NRP) curriculum was developed and executed. Training sessions were delivered utilizing in situ simulations at varying time intervals. Pre- and postconfidence surveys and practicum skill scores were collected and evaluated by a content expert. Categorical data were summarized by frequency and percentage and tested for distributional equality via Pearson chi-square tests or Fisher exact tests depending on cell sample size distribution. All statistical tests were 2-sided with P < .05 considered statistically significant.

Results: Provider overall confidence and rate of chest compressions improved; however, there was no statistically significant difference between groups. Rolling refresher training at varied time intervals did not demonstrate statistically significant differences in chest compression quality among NRP providers.

Implications For Practice: Rolling refresher training more frequently than every 6 months may not provide added benefit to NRP providers.

Implications For Research: Additional research is needed to determine optimal refresher training frequency to prevent skill decay.
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http://dx.doi.org/10.1097/ANC.0000000000000384DOI Listing
October 2017

SIMULATION DIRECTORS AS IMPROVEMENT LEADERS.

Physician Leadersh J 2017 Jan;4(1):44-47

Physician leaders who oversee simulation labs play vital roles in the advancement of efficiency and effectiveness of their organizations.
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January 2017

Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study.

Crit Care Res Pract 2016 31;2016:5283765. Epub 2016 Jul 31.

Summa Health System, Department of Medical Education, Virtual Care Medical Simulation Laboratory, Akron, OH 44304, USA.

Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: 58.9 ± 8.9 versus post: 72.8 ± 6.1, p = 0.01) and CS total scores (pre: 22.2 ± 6.4 versus post: 29.9 ± 3.4, p = 0.007). Significant differences were noted in airway management, p = 0.008; appropriate cycles of drug/shock-CPR, p = 0.008; left uterine displacement, p = 0.008; and identifying causes of cardiac arrest, p = 0.008. Nonsignificant differences were noted for administration of appropriate drugs/doses, p = 0.074; chest compressions, p = 0.074; bag-mask ventilation before intubation, p = 0.074; and return of spontaneous circulation identification, p = 0.074. Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.
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http://dx.doi.org/10.1155/2016/5283765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4983319PMC
August 2016