Critical Care Fellows Research Articles

Understanding the "Social" in "Social Media". An Analysis of Twitter Engagement of Pulmonary and Critical Care Fellowship Programs.

Background: Social media is ubiquitous as a tool for collaboration, networking, and dissemination. However, little is known about use of social media platforms by pulmonary and critical care medicine fellowship programs.Objective: We identify and characterize pulmonary and critical care fellowship programs using Twitter and Instagram, as well as the posting behaviors of their social media accounts.Methods: We identified all adult and pediatric pulmonary, critical care medicine (CCM), and combined pulmonary and critical care medicine (PCCM) programs in the United States using the Electronic Residency Application Service. We searched for Twitter profiles for each program between January 1, 2018, and September 30, 2018. Tweets and Twitter interactions were classified into the following three types: social, clinical, or medical education (MedEd) related. We collected data about content enhancements of tweets, including the use of pictures, graphics interchange format or videos, hashtags, links, and tagging other accounts. The types of tweets, content enhancement characteristics, and measures of engagement were analyzed for association with number of followers.Results: We assessed 341 programs, including 163 PCCM, 36 adult CCM, 20 adult pulmonary, 67 pediatric CCM, and 55 pediatric pulmonary programs. Thirty-three (10%) programs had Twitter accounts. Of 1,903 tweets by 33 of the 341 programs with Twitter accounts, 476 (25%) were MedEd related, 733 (39%) were clinical, and 694 (36%) were social. The median rate of tweets per month was 1.65 (interquartile range [IQR], 0.4–6.65), with 55% programs tweeting more than monthly. Accounts tweeting more often had significantly more followers than those tweeting less frequently (median, 240 followers; 25–75% IQR, 164–388 vs. median, 107 followers; 25–75% IQR, 13–188; P = 0.006). Higher engagement with clinical and social Twitter interactions (tweets, retweets, likes, and comments) was associated with more followers but not for the MedEd-related Twitter interactions. All types of content enhancements (pictures, graphics interchange format/videos, links, and tagging) were associated with a higher number of followers, except for hashtags.Conclusion: Despite the steadily increasing use of social media in medicine, only 10% of the pulmonary and critical care fellowship programs in the United States have Twitter accounts. Social and clinical content appears to gain traction online; however, additional evaluation is needed on how to effectively engage audiences with MedEd content.

Gender Distribution of Current Surgical Critical Care Fellows, Faculty, and Program Directors.

As women surgeons continue to represent a minority within the surgical field while also holding lower ranked positions, gaining a sub-specialized set of clinical skills through surgical fellowships, like surgical critical care (SCC), is one approach to advance within the surgical field. A cross-sectional analysis was performed investigating the websites of all 106 US-based SCC fellowships. A total of 116 SCC fellows were included in this analysis, comprising 67 (59.3%) men and 46 (40.7%) women. There were 977 SCC fellowship faculty were evaluated, comprising 619 (67.9%) men and 292 (32.1%) women. Additionally, 103 SCC fellowship program directors were analyzed, consisting of 77 (74.8%) men and 26 (25.2%) women. There is a significantly lower proportion of women fellows and faculty members (P < .001) compared to men. SCC programs with female program directors on average have higher proportions of female fellows and faculty compared to programs with male program directors (52% and 36% vs 31% and 29%, respectively). There is a stable yet unbalanced gender distribution throughout all positions in SCC fellowship programs. Actively supporting women surgeons pursuing SCC fellowship and removing barriers to their advancement through effective interventions can disrupt the persistently low prevalence of women SCC fellows, faculty, and program directors.

Bedside Ultrasound-Guided Peripherally Inserted Central Catheter Placement by Critical Care Fellows in Critically Ill Patients: A Feasibility and Safety Study

Bedside Ultrasound-Guided Peripherally Inserted Central Catheter Placement by Critical Care Fellows in Critically Ill Patients: A Feasibility and Safety Study

Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration.

Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration.

Opinions among pediatric critical care physicians regarding the ethics of withdrawal of ventricular assist devices and extracorporeal membrane oxygenation

Background Pediatric critical care physician attitudes about withdrawal of ventricular assist devices (VAD) and extracorporeal membrane oxygenation (ECMO) in cases of medical futility are poorly defined. Our aim was to define current attitudes regarding the withdrawal of these devices. Methods IRB-approved, cross-sectional observational survey conducted among pediatric critical care attending physicians and fellow physicians in the United States between 2016 and 2017. Data was collected anonymously and statistically analyzed. Results A total of 158 physicians responded with 67% being attending physicians. Compared to a VAD, a higher percentage had taken care of a patient on ECMO where the device was turned off because care was believed to be futile (99% vs. 84%), including currently (95% vs. 57%). Nearly all reported that it can be ethically permissible to withdraw support from a patient with a VAD and on ECMO (97% vs. 99%), but varied opinions existed as to who should ultimately make this decision if the patient/their family disagrees. More respondents agreed that a patient/their family should agree to withdrawal of VAD or ECMO support prior to initiation if futility is later determined (60% vs. 58%) and that protocols should be created for VAD and ECMO withdrawal (77% vs. 76%). Conclusion Most pediatric critical care physicians felt that it can be ethically permissible to withdraw VAD and ECMO support. Our study indicates that pediatric VAD and ECMO withdrawal protocols are desired, but further investigation is needed to determine how to best design protocols that would incorporate multiple stakeholders.

The Journal of Clinical Pharmacology Adds 2 Associate Editors

Drs. Bertino (Editor-in-Chief) and Reed (Associate Editor), Ms. Marshall (Managing Editor), and The Journal of Clinical Pharmacology (JCP) are pleased to announce the addition of 2 associate editors: Joan Korth-Bradley, PharmD, PhD, received her BSc at the University of Toronto and completed a residency in hospital pharmacy at Ottawa General Hospital. She then received her PharmD from the University of Minnesota, completed a clinical pharmacy fellowship at the University of Texas at Austin, and then completed a PhD under Dr. Tom Ludden in the Division of Pharmaceutics at the University of Texas at Austin. After a brief career in academia and hospital pharmacy, Dr. Korth-Bradley joined Wyeth-Ayerst in 1991 and then Pfizer Inc. (which acquired Wyeth-Ayerst) in 2009. She is currently a Senior Director in Clinical Pharmacology at Pfizer Inc. Dr. Korth-Bradley is a Fellow of the American College of Clinical Pharmacology, the American College of Clinical Pharmacy, and the American Association of Pharmaceutical Scientists. She has served on numerous ACCP committees and is currently an ACCP Regent. She has also been a member of the Editorial Board of JCP. She has an extensive track record of publications and presentations in clinical pharmacology. Janice E. Sullivan, MD, started her career in nursing (as a nurse practitioner) and then received her MD from the University of Minnesota. She completed a pediatric residency at the University of Arkansas and a Fellowship in Pediatric Pharmacology and Critical Care from Case Western Reserve University. Dr. Sullivan is currently a Professor at the University of Louisville, the Vice Chair of Research in the Department of Pediatrics at the University of Louisville, and a consultant at the Kentucky Regional Poison Center of Norton Children's Hospital. She has recently stopped her many years of pediatric critical care work to focus on her research activities. Dr. Sullivan is board-certified in Pediatrics, Pediatric Critical Care, and Clinical Pharmacology. She holds fellowships in the American Academy of Pediatrics and the Society of Critical Care Medicine. She has an extensive record of extramural research funding as well as a long record of publications and presentations. We welcome Drs. Korth-Bradley and Sullivan as Associate Editors for The Journal of Clinical Pharmacology.

Critical Care Fellows’ Perceptions of Parent Distress in the Pediatric Intensive Care Unit

Critical Care Fellows’ Perceptions of Parent Distress in the Pediatric Intensive Care Unit

Editorial introductions

Editorial introductions

Identification and Prioritization of Clinical Decision Support Functionalities Built Within A Computerized Provider Order Entry System

Background: Clinical decision support (CDS) functionalities in Computerized Provider Order Entry system (CPOE) need to be identified by the institutional healthcare providers in developing countries. In this regard, CDS functionalities should be a priority for the execution in CPOE. Objectives: Thus, our study was done to identify and prioritize the CDS functionalities in CPOE. Methods: A Two-round Modified Delphi process was used. Firstly, a systematic search was conducted in electronic databases from the date of database inception to February 2019 for identifying CDS functionalities integrated into CPOE. Studies were retrieved from databases, including PubMed, Embase, ProQuest, Scopus, Web of Science, Cochrane, Science Direct, ACM digital library, and IEEE Xplore Digital Library. Secondly, the Modified Delphi method was carried out in 2019 to provide contextual priorities regarding CDS functionalities in CPOE in two iterative rounds. A total of 12 experts working in the three Intensive Care Units (ICUs) with more than three years of experience with homegrown CPOE in Shiraz Nemazee Teaching Hospital, including two clinical pharmacists, two health information management faculty member, four cases with critical care fellowship, and four critical care experts participated in the study. The ≥ 66.6% agreement was considered as the consensus level. SPSS software version 24 was used for statistical analysis. Results: Totally, 327 studies, which met eligibility criteria were found. A number of 60 potential CDS functionalities in CPOE were identified from eligible studies. Also, 13 out of 60 CDS functionalities reached high priority consensus after 2 iterative Delphi rounds, including drug-allergy checking (83.3%), basic dosing guidance (75%), single dosing checking (66.7%), duplicate therapy checking (66.7%), drug-pregnancy alerts (75%), time-based alerts (66.7%), alert for deep vein thrombosis prophylaxis (66.7%), alerts for duplicate medication order checking (66.7%), drug-drug interaction checking (75%), intelligent dosing guidance based on the patients’ characteristics (66.7%), renal-drug problems checking (83.3%), drug-disease interaction checking (66.7%), and displaying medication/test cost (75%). Conclusions: Our study identified high-priority CDS functionalities to be considered in the CPOE system from the viewpoint of multidisciplinary experts, especially in Iran. Results of this study may be beneficial to plan, design, and implement CDS functionalities in CPOE in the ICU.

Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows.

Background: Invasive procedures are a core aspect of pulmonary and critical care practice. Procedures performed in the intensive care unit can be divided into high-risk, low-volume (HRLV) procedures and low-risk, high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy, pericardiocentesis, Blakemore tube placement, and bronchial blocker placement. LRHV procedures include arterial line placement, central venous catheter placement, thoracentesis, and flexible bronchoscopy. Despite the frequency and importance of procedures in critical care medicine, little is known about the similarities and differences in procedural training between different Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) training programs. Furthermore, differences in procedural training practices for HRLV and LRHV procedures have not previously been described.Objective: To assess procedural training practices in PCCM and CCM fellowship programs in the United States, and compare differences in training between HRLV and LRHV procedures.Methods: A novel survey instrument was developed and disseminated to PCCM and CCM program directors and associate program directors at PCCM and CCM fellowship programs in the United States to assess procedural teaching practices for HRLV and LRHV procedures.Results: The survey was sent to 221 fellowship programs, 168 PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the procedural educational strategies assessed, each strategy was used significantly more frequently for LRHV versus HRLV procedures. The majority of respondents (51.1%) report having no dedicated training for HRLV procedures versus 6.9% reporting no dedicated training for any LRHV procedure (P < 0.001). For HRLV procedures, 76.9% of respondents indicated that there was no set number of procedures required to determine competency, versus 25.3% for LRHV procedures (P < 0.001). For LRHV procedures, fellows were allowed to perform procedures independently without supervision 21.7% of the time versus 3.9% for HRLV procedures (P = 0.004). Program directors’ confidence in their ability to determine fellows’ competence in performing procedures was significantly lower for HRLV versus LRHV versus HRLV procedures (P < 0.001).Conclusion: Significant differences exist in procedural training education for PCCM and CCM fellows for LRHV versus HRLV procedures, and awareness of this discrepancy presents an opportunity to address this educational gap in PCCM and CCM fellowship training.

Pulmonary Critical Care Fellows’ Use of and Self-reported Barriers to Learning Bedside Ultrasound During Training: Results of a National Survey

Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors' discretion. Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

Development of Neurological Emergency Simulations for Assessment: Content Evidence and Response Process.

To document two sources of validity evidence for simulation-based assessment in neurological emergencies. A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation. We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians. Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70). We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

Ten Year Trends in Minimally Invasive Surgery Fellowship.

Background:Minimally Invasive Surgery (MIS) is one of the more recently established surgical fellowships, with many candidates applying due to a perception of inadequate exposure to advanced MIS during residency. The desire for advanced training should be reflected in increased competitiveness for fellowship positions. The aim of this study is to determine the desirability of MIS fellowships over time through review of national application data.Methods:We reviewed the fellowship match statistics obtained from The Fellowship Council, the organizing body behind the MIS fellowship match. Data from January 1, 2008 – December 31, 2019 were included. We compared match rates to other specialties using the National Resident Matching Program, a nonprofit organization established for US residency and some fellowship programs.Results:In the period of 2008 to 2019, the number of certified MIS fellowship programs increased from 124 to 141. While this program expansion was associated with a 19% increase in available positions, the number of applications increased 36%. As a result, the number of positions filled increased from 83% to 97%, but the match rate among US applicants fell from 82% to 71% during this interval. In comparison, the match rates for pediatric surgery, surgical oncology, vascular surgery, and surgical critical care fellowships remained largely unchanged, most recently 50%, 56%, 99%, and 100% respectively.Conclusion:Over the last decade, US residents have shown an increased interest in pursuing MIS fellowship positions. As a consequence, the match process for MIS fellowships is becoming increasingly competitive.

Surgical Intensivist-Led Training in Critical Care Ultrasound Improves Performance.

Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows. This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included. Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest (P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest (P < .001). SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.

949: Demographics and Practice Patterns of Critical Care Fellowship Graduates 2000-2018

Pastores, Stephen1; Salah, Zuhair2; Kostelecky, Natalie2; Halpern, Neil3 Author Information

269: Educational Adaptation for the COVID-19 Pandemic: A Virtual Model Enables Ongoing Training

Jordan, Mary1; Evans, Susan2; Spangler, Lacey1; Miles, William3; Brintzenhoff, Rita3 Author Information

Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association

Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association

Airway Pressure Release Ventilation setting disagreements. A survey of clinicians

Background: Airway pressure release ventilation has been available to clinicians for the last four decades. Unfortunately, its clinical value continues to be debatable. One of the many reasons responsible is the lack of consistency between its settings in clinical practice and research. We hypothesized that clinicians disagree on specific methods when establishing these parameters. Materials and Methods: A questionnaire-based survey was developed and sent to clinicians (critical care attending physician, critical care fellows in training and respiratory therapists) in about one hundred different academic hospitals with critical care training program. The survey consisted of ten questions including each of the four major APRV settings: T-High, T-Low, P-High, and P-Low. The survey was anonymous. Main results: Amongst the 187 respondents, there were significant disagreements between different categories of clinicians regarding methodology for establishing initial settings of APRV. However, when the responses were analyzed after sub-grouping based on categories of clinicians (Critical care attending physician vs critical care fellows vs respiratory therapists), no significant differences could be found. Conclusions: There is no agreement between different categories of clinicians when it comes to the methodology for establishing initial APRV settings. Our study highlights the need for larger clinical trials comparing different approaches to the same which could then be used for establishing scientific guidelines based on best evidence. Keywords: APRV, survey, T-High, T-Low, P-High, P-Low

Online Learning and Echocardiography Boot Camp: Innovative Learning Platforms Promoting Blended Learning and Competency in Pediatric Echocardiography.

Mastering pediatric echocardiography (PE) requires a substantial knowledge base of echo theory and congenital heart disease (CHD), along with technical proficiency. Online self-directed learning has become increasingly utilized among medical trainees to promote competency within medical subspecialties. We sought to evaluate the impact of online learning combined with lecture-based and hands-on teaching on the acquisition of PE knowledge and confidence in pediatric cardiology and pediatric critical care fellows. We prospectively enrolled 124 learners from 2016 to 2019. These included 40 incoming cardiology and critical care fellows at Texas Children's Hospital (TCH) as well as 84 national and international participants recruited from our online echo education website. All participants completed online learning modules through our website ( www.pedecho.org ), which covers pediatric echo physics, Doppler, technique, normal anatomy, atrial septal defects, and ventricular septal defects. TCH cardiology and critical care fellows subsequently participated in an Echo Boot Camp (BC), a 3-day training program with hands-on workshops and didactic lectures. Knowledge was assessed using an 80-question pre and post-test multiple choice exams. The online learning group demonstrated improvement in exam scores following online learning (PRE 49.1 ± 15.3 vs. POST 67.8 ± 17%; p ≤ 0.01). Echo Boot Camp fellows were noted to have further incremental improvement in test scores following BC (PRE 48% ± 13% vs. POST MODULE 68.6% ± 15% vs. POST BC 75.7% ± 13%; p ≤ 0.01). Self-assessment regarding confidence in context areas showed a substantial gain in self perceived interpretive confidence across all groups as well as procedural confidence in BC participants. Online learning significantly promotes the acquisition of echocardiography knowledge. Additional lecture-based and hands-on teaching in the form of an Echo Boot Camp can further enhance knowledge and interpretative skills. Both of these learning platforms appear to work in concert as powerful and effective tools in fellow education.

Diversity and Inclusion Among US Trauma and Surgical Critical Care Fellowship Programs

Diversity and Inclusion Among US Trauma and Surgical Critical Care Fellowship Programs