American Journal of Obstetrics and Gynecology, Dec 1, 2016
BACKGROUND: More than a decade ago, researchers described a survey of Maternal Fetal Medicine fel... more BACKGROUND: More than a decade ago, researchers described a survey of Maternal Fetal Medicine fellows that showed that chorionic villus sampling training was limited for Maternal Fetal Medicine fellows in the United States. Prenatal screening and diagnosis have rapidly evolved since then and include the introduction of noninvasive aneuploidy screening that uses cell-free fetal DNA. Yet, chorionic villus sampling remains the only method available for first-trimester genetic diagnosis. OBJECTIVE: This study evaluated the chorionic villus sampling training of Maternal Fetal Medicine fellows with respect to availability, competency standards, and education methods. STUDY DESIGN: In November 2015, an electronic survey was sent to Maternal Fetal Medicine fellows and fellowship directors of accredited Maternal Fetal Medicine fellowship programs in the United States. RESULTS: Fifty-eight percent of fellows (179/310) and 46% of program directors (35/76) responded. Ninety-five percent of Maternal Fetal Medicine fellows think that invasive diagnostic testing is essential to their training; 100% of fellows have amniocentesis training; and 65% have chorionic villus sampling training. The median number of chorionic villus sampling procedures that are expected during a fellowship in those who trained was 10. Eighty-eight percent of fellows and 89% of program directors state that chorionic villus sampling training could be better; 89% of fellows and 97% of directors would like access to simulated models. Barriers to training included lack of patients (71%) and lack of proficient attending supervisors (43%). CONCLUSION: Since the last survey, >10 years ago, chorionic villus sampling training has declined further. A decrease in the number of procedures that are performed is the leading barrier to this training.
In situ simulation (ISS) programs deliver patient safety benefits to healthcare systems, however,... more In situ simulation (ISS) programs deliver patient safety benefits to healthcare systems, however, face many challenges in both implementation and sustainability. Prebriefing is conducted immediately prior to a simulation activity to enhance engagement with the learning activity, but is not sufficient to embed and sustain an ISS program. Longer-term and broader change leadership is required to engage colleagues, secure time and resources, and sustain an in situ simulation program. No framework currently exists to describe this process for ISS programs. This manuscript presents a framework derived from the analysis of three successful ISS program implementations across different hospital systems. We describe eight change leadership steps adapted from Kotter’s change management theory, used to sustainably implement the ISS programs analyzed. These steps include the following: (1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision...
Historically simulation was used as an education and training technique in healthcare, but now ha... more Historically simulation was used as an education and training technique in healthcare, but now has an emerging role in improving quality and safety. Simulation-based techniques can be applied to help understand healthcare settings and the practices and behaviours of those who work in them. Simulation-based interventions can help to improve care and outcomes – for example, by improving readiness of teams to respond effectively to situations or to improve skill and speed. Simulation can also help test planned interventions and infrastructural changes, allowing possible vulnerabilities and risks to be identified and addressed. Challenges include cost, resources, training, and evaluation, and the lack of connection between the simulation and improvement fields, both in practice and in scholarship. The business case for simulation as an improvement technique remains to be established. This Element concludes by offering a way forward for simulation in practice and for future scholarly dir...
Background The Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Deb... more Background The Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool is a cognitive aid designed to deploy debriefing in a structured way. The tool has the potential to increase the facilitator’s ability to acquire debriefing skills, by breaking down the complexity of debriefing and thereby improving the quality of a novice facilitator’s debrief. In this pilot study, we aimed to evaluate the impact of the tool on facilitators’ cognitive load, workload, and debriefing quality. Methods Fourteen fellows from the New York City Health + Hospitals Simulation Fellowship, novice to the PEARLS Healthcare Debriefing Tool, were randomized to two groups of 7. The intervention group was equipped with the cognitive aid while the control group did not use the tool. Both groups had undergone an 8-h debriefing course. The two groups performed debriefings of 3 videoed simulated events and rated the cognitive load and workload of their experience using the Paas...
This Viewpoint discusses the structure of the National Academy of Medicine’s Scholars in Diagnost... more This Viewpoint discusses the structure of the National Academy of Medicine’s Scholars in Diagnostic Excellence program and the lessons learned from this national leadership incubator.
Background Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcom... more Background Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location. Methods Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medicatio...
BMJ Simulation and Technology Enhanced Learning, 2021
New York City became one of the epicentres of the COVID-19 pandemic in 2020. Simulation was used ... more New York City became one of the epicentres of the COVID-19 pandemic in 2020. Simulation was used to establish the COVID-19 trained observer programme to mitigate healthcare workers’ infection risk during patient care. The members of the trained observer group consisted of 32 staff members. At the start of the training programme, they were provided donning and doffing guides with a step-by-step description of personal protective equipment (PPE) usage, followed by in-situ PPE simulation training. Later on, as PPE protocols evolved, additional educational modalities were used and included training videos, picture demonstrations of common PPE mistakes and repeated in-situ simulations. The early lessons which emerged from using simulation to train observers during the COVID-19 pandemic were the following: address PPE shortages during presimulation planning, prepare to perform updates for trained observers and use multiple educational modalities to train observers. Adequate amounts of PPE...
Safety science in healthcare has historically focused primarily on reducing risk and minimizing h... more Safety science in healthcare has historically focused primarily on reducing risk and minimizing harm by learning everything possible from when things go wrong (Safety-I). Safety-II encourages the study of all events, including the routine and mundane, not only bad outcomes. While debriefing and learning from positive events is not uncommon or new to simulation, many common debriefing strategies are more focused on Safety-I. The lack of inclusion of Safety-II misses out on the powerful analysis of everyday work.A debriefing tool highlighting Safety-II concepts was developed through expert consensus and piloting and is offered as a guide to encourage and facilitate inclusion of Safety-II analysis into debriefings. It allows for debriefing expansion from the focus on error analysis and “what went wrong” or “could have gone better” to now also capture valuable discussion of high yield Safety-II concepts such as capacities, adjustments, variation, and adaptation for successful operations...
Although in 2020, there are more than 120 healthcare simulation fellowships established globally,... more Although in 2020, there are more than 120 healthcare simulation fellowships established globally, there is a paucity of literature on how to design fellowship programs most effectively, to equip graduates with the knowledge, skills, and attitudes of a competent simulation educator. Offering a systematic structure to approach simulation fellowship programmatic design may aid in better achieving program goals. In this manuscript, we present the application of the 4-component instructional design model as a blueprint to the development of Simulation Education Fellowships. We offer examples used at the NYC Health + Hospitals simulation fellowship to illustrate how the 4-component model informs fellowship program design which promotes the development of a simulation educator. This manuscript will provide a roadmap to designing curricula and assessment practices including self-reflective logbooks to focus the path toward achieving desired skills and shape future conversations around progr...
Introduction Benefits of post-simulation debriefings as an educational and feedback tool have bee... more Introduction Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing, however, data on its practice is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in emergency departments, however, limited research has been performed on this subject. The objective of this study is to characterize real-time, non-critical incident debriefing practices in Emergency Medicine (EM).
Recent literature suggests that availability and accessibility of pregnancy termination services ... more Recent literature suggests that availability and accessibility of pregnancy termination services affects patient care and decision-making. Because of this, there is a need to evaluate the impact of new legislation on accessibility. This study evaluated the accessibility of pregnancy termination throughout the United States by surveying prenatal genetic counselors and abortion providers. 116 responses from currently practicing prenatal genetic counselors and 30 responses from abortion providers within the United States were used in data analysis. Accessibility of pregnancy termination was assessed using the variables of cost, time, and distance. The degree of legislative impact was estimated using Guttmacher Institute’s Policy Trends in the States 2017, which categorizes states into four regions: supportive, middle-ground, hostile, and extremely hostile, based on the number of abortion restrictions enacted. Overall, the findings show some evidence indicating that access to abortion i...
Background: Low back pain is a common emergency department (ED) complaint that does not always ne... more Background: Low back pain is a common emergency department (ED) complaint that does not always necessitate imaging. Unnecessary imaging drives medical overuse with potential to harm patients. Quality improvement (QI) interventions have shown to be an effective solution. The purpose of this QI intervention was to increase the percentage of appropriately ordered radiographs for low back pain while reducing the absolute number. Methods: A multi-component intervention led by a clinician champion including staff education, patient education, electronic medical record modification, audit and peer-feedback, and clinical decision support tools was implemented at an urban public hospital Emergency Department. In addition to the total number ordered, Choosing Wisely and American College of Radiology recommendations were used to assess appropriateness of all ED thoracic and lumbar conventional radiographs by chart review over eight months. Results: The percent of appropriately ordered radiogra...
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2020
Since January 2020 Elsevier has created a COVID-19 resource centre with free information in Engli... more Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre -including this research content -immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
Infection Control & Hospital Epidemiology, 2020
The first recorded case of coronavirus disease (COVID-19) in New York City was on March 1, 2020, ... more The first recorded case of coronavirus disease (COVID-19) in New York City was on March 1, 2020, and by May 5, there were 171,723 confirmed cases with 13,724 confirmed deaths. The Bronx had the highest rates of hospitalization and death related to COVID-19 compared to the other 4 boroughs in New York City. Jacobi Medical Center, one of 11 acute-care facilities in the NYC municipal hospital system, is a 457-bed level 1 trauma center located in the Bronx with 3,225 healthcare workers. We began testing symptomatic employees on March 16 using the nasopharyngeal polymerase chain reaction (PCR) severe acute respiratory coronavirus virus 2 (SARS-CoV-2) test. In the first 6 weeks, we tested 1,264 employees, of whom 302 tested positive (23.9%). Recent reports showed that 12.2% of NYC healthcare workers had a confirmed positive SARS-CoV-2 PCR result. Preliminary data reveal that 19.9% of NYC residents have antibodies to SARS-CoV-2 virus, and 27.6% of Bronx residents have antibodies. Given this high prevalence of antibodies in the Bronx, we predicted that our staff would have higher prevalence of antibodies, especially those staff working in areas of perceived risk, such as the emergency department and critical care areas. Once Abbott Labs (Abbott Park, IL) received the emergency use authorization for antibody testing using the SARS-CoV-2 IgG test, 4 we began a voluntarily testing all employees at our facility. This test has a reported sensitivity of 100% and specificity of 99.6% when performed 2 weeks after symptom onset. 5 Individuals were offered the IgG test as long as they were asymptomatic and had not had COVID-19 symptoms during the prior 2 weeks. A retrospective chart review was performed to answer the following questions:
The debriefing is an essential component of simulation-based training for healthcare professional... more The debriefing is an essential component of simulation-based training for healthcare professionals, but learning this complex skill can be challenging for simulation faculty. There are multiple competing priorities for a debriefer's attention that can contribute to a high mental workload, which may adversely affect debriefer performance and consequently learner outcomes. In this paper, we conceptualize the debriefer as a learner of debriefing skills and we discuss Cognitive Load Theory to categorize the many potential mental loads that can affect the faculty debriefer as learner. We then discuss mitigation strategies that can be considered by faculty development programmes to enhance professional development of debriefing staff.
Introduction: Benefits of post-simulation debriefings as an educational and feedback tool have be... more Introduction: Benefits of post-simulation debriefings as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefing is similar to post-simulation debriefing; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefing after complicated medical situations, they do not teach debriefing skills suited to this purpose. Anecdotal evidence suggests that real-time debriefings (or non-critical incident debriefings) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefing practices in emergency medicine (EM). We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel. The data elucidate various characteristics of current real-time debriefing trends in EM, including its definition, perceived benefits and barriers, as well as the variety of formats of debriefings currently being conducted. This survey regarding the practice of real-time, non-critical incident debriefings in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefing definitely occurs in academic emergency practice; 2) in general, realtime debriefing is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefing techniques. Further study is needed to clarify actual benefits of real-time/non-critical incident debriefing as well as details on potential pitfalls of this practice and recommendations for best practices for use. [West J
Introduction: Emergency medicine physicians must have the knowledge and skills to stabilize all l... more Introduction: Emergency medicine physicians must have the knowledge and skills to stabilize all life-andlimb-threatening conditions. These skills are especially important considering that the 1989 COBRA act clearly defines active labor as a condition unsuitable to transfer. Given this context, we thought it necessary to create a work that could be used to provide emergency physicians with the necessary skills to assist in deliveries both routine and complex. Methods: The total time requirement for the workshop is 4 hours. Before the session begins, learners are asked to fill out a survey. Learners complete two 40minute small-group sessions on the topics of normal vaginal delivery and shoulder dystocia with hands-on training with birthing manikins. After a short break learners complete a 65-minute small-group session for breech delivery with hands-on training. Each small-group session is preceded by a whole-group demonstration of required skills lasting 15 minutes as well a mini lecture on maternal hemorrhage and estimation of blood loss. Results: Our workshop has been shown to successfully educate emergency physicians with a range of obstetric experience and improve their knowledge base and hands-on skills. One hundred percent of our learners felt this workshop was appropriate for them and met its stated goals. Discussion: While this is not the first workshop to educate on obstetric deliveries and their possible complications, it is the first to be created with the emergency medicine provider as the intended audience and the first to create a curriculum around uncomplicated delivery, shoulder dystocia, breech delivery, and postpartum hemorrhage.
To evaluate the prefrontal space (PFS) ratio of fetuses of African descent without Down syndrome ... more To evaluate the prefrontal space (PFS) ratio of fetuses of African descent without Down syndrome and compare it to the PFS ratio previously established in a homogeneous Caucasian population to determine whether there is a difference in the ratio in these two groups. The PFS ratio was calculated retrospectively from stored 2D images of 100 African, African-American and African-Caribbean fetuses in the second and third trimester performed at the authors’ center. Other data including the maternal age, gestational age, and ethnicity were collected. An unpaired T test was used to compare the previously published Caucasian mean, 0.97 (SD 0.29) with the mean established for the black population 1.37 (SD 0.44). The difference between these two PFS ratios was found to be significant (p < 0.0001). This pilot study suggests a significant difference in the PFS in the non-Caucasian population. In order to use the PFS as a sonographic screening tool for Down syndrome, it will be important to d...
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