Comparing Attending and Patient Evaluation of Medical Student Communication Skills on an Emergency Medicine Clerkship

Learning Objective: To determine how attending and patient assessment of medical student communication skills correlate.Background: Accurately assessing medical student (MS) patient communication skills is an essential component of undergraduate medical education. There are different methods used to evaluate MSs, including supervising attending physician ratings as well as patient assessment. However, it is unclear how these distinct types of evaluators compare with each other.Objectives: To determine how attending and patient assessment of MS communication skills correlate. We hypothesized the two would closely correlate.Methods: This was a retrospective study of rotating fourth-year MSs on an elective EM clerkship. From 7/16–10/17, ED attending physicians and patients assessed MS communication skills during the students’ ED shifts. Attendings rated MS communication skills with patients using a 1-5 Likert scale. Patients evaluated MSs using the modified Communication Assessment Tool (CAT), a 14-item questionnaire based on a 1-5 Likert scale. Mean attending ratings and patient CAT scores were calculated for each MS. Due to nonparametric distribution, means were divided into tertiles and scores weighted to assign adjacent tertiles partial agreement. Agreement between attending and CAT scores was measured using a Cohen’s kappa.Results: 25 MSs were included. A total of 217 supervising attending evaluations with a median of 9 evaluations per MS (interquartile range (IQR) 8-10, min 6) and 102 CAT questionnaires with a median of 4 evaluations per MS (IQR 3-5, min 3) were completed. Attending and CAT scores showed slight agreement (k 0.196).Conclusions: Attending and patient ratings of MS communication skills show only slight agreement. It is possible that utilizing only one type of evaluator during a clerkship may miss important communication issues that could be addressed with the MS. Utilizing a multimodal approach that includes both attending and patient evaluations may be beneficial in fully assessing and subsequently educating MSs on their patient communication skills

Analysis of Time-to-Disposition Intervals During Early and Late Parts of a Shift

Objectives: To assess whether time-to-disposition is significantly different when a patient is seen by a provider during the early half or late half of a shift.Background: Time-to-disposition is an important metric for emergency department throughput. We hypothesized that providers view the shift end as a key timepoint and attempt to leave as few dispositions as possible to the oncoming team, thereby making quicker decisions later in the shift. This study evaluates disposition distribution relative to when patients are assigned a provider during the course of a shift.Methods: 50,802 cases were analyzed over the one-year study interval. 31,869 patients were seen in the early half of a shift (hours 1-4) and 18,933 were seen in the later half (hours 5+). We ran a linear mixed model that adjusted for age, gender, emergency severity index score, time of day, weekend arrivals, quarter of arrival and shift type.Results: Median time-to-disposition for the early group was 3.25 hours (IQR 1.90-5.04), and 2.62 hours (IQR 1.51-4.31) for the late group. From our mixed model, we conclude that in the later parts of the shift, providers take on average 15.1% less time to make a disposition decision than in the earlier parts of the shift.Conclusion: Patients seen during the latter half of a shift were more likely to have a shorter time-to-disposition than similar patients seen in the first half of a shift. This may be influenced by many factors, such as providers spending the early hours of a shift seeing new patients which generate new tasks and delay dispositions, and viewing the end of shift as a landmark with a goal to maximize dispositions prior to sign-out

Trends in Endotracheal Intubation During In-Hospital Cardiac Arrests

OBJECTIVE: Airway management during in-hospital cardiac arrest (IHCA) represents a fundamental component of resuscitative efforts, yet little is known about temporal trends in intubation during IHCA. Our objective was to investigate changes in IHCA airway management over time and in response to national guideline updates. DESIGN: Observational cohort study of a prospectively collected database. SETTING: Multicenter study of hospitals participating in the Get With The Guidelines®— Resuscitation registry from January 1, 2001 through December 31, 2018. SUBJECTS: Adult patients who experienced an IHCA and did not have an invasive airway in place prior to the arrest. INTERVENTIONS: The primary outcome was the rate of intra-arrest intubation from 2001-2018. We constructed multivariable regression models with generalized estimating equations to determine the annual adjusted odds of intubation. We also assessed the timing of intubation relative to the onset of pulselessness and other arrest measures. We used an interrupted time series analysis to assess the association between the 2010 Advanced Cardiac Life Support guideline update and intubation rates. MEASUREMENTS AND MAIN RESULTS: 166,849 patients from 797 hospitals were included. From 2001 to 2018, the percentage of patients intubated during an arrest decreased from 69% to 55% for all rhythms, 73% to 60% for nonshockable rhythms, and 58% to 36% for shockable rhythms (p<0.001 for trend for all 3 groups). The median time from onset of pulselessness to intubation increased from 5 minutes in 2001 (IQR 2-8 minutes) to 6 minutes in 2018 (IQR 4-10 minutes) (p<0.001 for trend). Following the 2010 guideline update, there was a downward step change and a steeper decrease over time in the rate of intubation as compared to the pre-intervention period (p <0.001). CONCLUSIONS: Endotracheal intubation rates during IHCA have decreased significantly over time, with a more substantial decline following the updated 2010 guideline that prioritized chest compressions over airway management

Trends in Endotracheal Intubation During In-Hospital Cardiac Arrests: 2001-2018.

ObjectivesAirway management during in-hospital cardiac arrest represents a fundamental component of resuscitative efforts, yet little is known about temporal trends in intubation during in-hospital cardiac arrest. Our objective was to investigate changes in in-hospital cardiac arrest airway management over time and in response to national guideline updates.DesignObservational cohort study of a prospectively collected database.SettingMulticenter study of hospitals participating in the "Get With The Guidelines-Resuscitation" registry from January 1, 2001, to December 31, 2018.SubjectsAdult patients who experienced an in-hospital cardiac arrest and did not have an invasive airway in place prior to the arrest.InterventionsThe primary outcome was the rate of intra-arrest intubation from 2001 to 2018. We constructed multivariable regression models with generalized estimating equations to determine the annual adjusted odds of intubation. We also assessed the timing of intubation relative to the onset of pulselessness and other arrest measures. We used an interrupted time-series analysis to assess the association between the 2010 Advanced Cardiac Life Support guideline update and intubation rates.Measurements and main resultsOne thousand sixty-six eight hundred patients from 797 hospitals were included. From 2001 to 2018, the percentage of patients intubated during an arrest decreased from 69% to 55% for all rhythms, 73% to 60% for nonshockable rhythms, and 58% to 36% for shockable rhythms (p &lt; 0.001 for trend for all 3 groups). The median time from onset of pulselessness to intubation increased from 5 minutes in 2001 (interquartile range, 2-8 min) to 6 minutes in 2018 (interquartile range, 4-10 min) (p &lt; 0.001 for trend). Following the 2010 guideline update, there was a downward step change and a steeper decrease over time in the rate of intubation as compared to the preintervention period (p &lt; 0.001).ConclusionsEndotracheal intubation rates during in-hospital cardiac arrest have decreased significantly over time, with a more substantial decline following the updated 2010 guideline that prioritized chest compressions over airway management

Thiamine as adjunctive therapy for diabetic ketoacidosis (DKAT) trial protocol and statistical analysis plan: a prospective, single-centre, double-blind, randomised, placebo-controlled clinical trial in the USA

Introduction Diabetic ketoacidosis (DKA) is a potentially life-threatening diabetic complication. Despite the high prevalence of DKA and the substantial associated healthcare burden, limited research on strategies to improve outcomes currently exists.Thiamine (vitamin B1) is a cofactor of pyruvate dehydrogenase, which plays a key role in aerobic glucose metabolism. Thiamine deficiency is common in patients with DKA, resulting in a shift to anaerobic metabolism and hyperlactatemia, which can prolong and complicate recovery. Therefore, we hypothesise that thiamine administration will improve aerobic metabolism and lead to faster resolution of acidemia in patients with DKA.Methods and analysis In this single centre, double-blind, randomised, placebo-controlled, parallel group interventional trial, 100 patients admitted to the hospital with DKA will be randomised to receive either intravenous thiamine (200 mg in 50 mL 0.9% saline) or placebo (0.9% saline identical in appearance and volume) two times per day for 2 days. The primary outcome will be the change in bicarbonate level over 24 hours as compared between the two treatment groups. Additional secondary outcomes include the change over time in anion gap, lactate levels, oxygen consumption by circulating mononuclear cells, intensive care unit and hospital length-of-stay and hospital resource usage when comparing the two study arms.Ethics and dissemination This trial was approved by the Committee on Clinical Investigations, the institutional review board of Beth Israel Deaconess Medical Center (protocol number 2018P000475). Findings will be disseminated through peer-reviewed publications and professional conference presentations.Trial registration number NCT03717896; clinicaltrials.gov

Psychophysiologic Symptom Relief Therapy for Post-Acute Sequelae of Coronavirus Disease 2019

Objective: To determine if psychophysiologic symptom relief therapy (PSRT) will reduce symptom burden in patients suffering from post-acute sequelae of coronavirus disease 2019 (COVID-19) (PASC) who had mild/moderate acute COVID-19 disease without objective evidence of organ injury. Patients and Methods: Twenty-three adults under the age of 60 years with PASC for at least 12 weeks after COVID-19 infection were enrolled in an interventional cohort study conducted via a virtual platform between May 18, 2021 and August 7, 2022. Participants received PSRT during a 13-week (approximately 44-hour) course. Participants were administered validated questionnaires at baseline and at 4, 8, and 13 weeks. The primary outcome was a change in somatic symptoms from baseline, measured using the Somatic Symptom Scale-8, at 13 weeks. Results: The median duration of symptoms before joining the study was 267 days (interquartile range: 144, 460). The mean Somatic Symptom Scale-8 score of the cohort decreased from baseline by 8.5 (95% CI: 5.7-11.4), 9.4 (95% CI: 6.9-11.9), and 10.9 (95% CI: 8.3-13.5) at 4, 8, and 13 weeks, respectively (all P<.001). Participants also experienced statistically significant improvements across other secondary outcomes including changes in dyspnea, fatigue, and pain (all P<.001). Conclusion: PSRT may effectively decrease symptom burden in patients suffering from PASC without evidence of organ injury. The study was registered on clinicaltrials.gov (NCT 04854772)