Physician Coverage Research Articles

Telapheresis: One institution's experience.

Telemedicine in its most common form is the use of videoconferencing to consult with a patient and telapheresis is telemedicine in the form of videotelephony applied to consult with a patient for apheresis. The article discusses how a large apheresis program in a metropolitan area provided physician coverage for apheresis in a more remote hospital using telapheresis with local physician "partners" and local nurses employed by and trained by the apheresis program that perform the procedure. Consent for the procedure was obtained, and orders were placed by the local physician after consultation with the apheresis physician, or the apheresis physician him/herself, having obtained privileges at the remote hospital. This allowed patients access to apheresis procedures nearer to their place of residence and in familiar surroundings which generally made them feel more positive about their health care experience.

Abstract TP47: When Folks Stroke at a Freestand: Building Successful Stroke Workflows for Freestanding Emergency Departments

Background: Services offered at freestanding emergency departments (FSED) vary and often have inconsistent clinical education and workflow standardization. Delivery of clinical education and implementation of hospital-based emergency department (ED) workflows to FSEDs contributes to a successful system of care. All sites in a mostly rural region are held to PSC standards with 24/7 ED physician coverage from a local, contracted group. All sites have 24/7 neurology provider coverage from an internal Neurohospitalist group that responds to stroke alerts in person or via telestroke. Nursing, radiology, and pharmacy leadership across the region participate in regional stroke and quality committees. Methods: Clinical education for FSED staff aligns with hospital-based EDs but includes competencies related to lack of ancillary services at the FSEDs. NIHSS certification is required and renewed every two years. Quarterly stroke education posters team are at all sites and new hire training is standardized. Availability of thrombolytics is maintained by pharmacy even though they are not on site at FSEDs. Volume and accuracy of 2022 stroke alert activations were reviewed as were door to CT first slice times, total thrombolytic cases, and median D2N times. FSED data was compared to local hospital-based ED outcomes and national stroke standards. Results: There were 27 total FSED stroke alert activations in 2022; 13 had a final coded stroke diagnosis. This 48% accuracy rate is above the range of 35-40% across the region’s hospital-based EDs and meets national standards for alert accuracy. Median door to CT time was 20 minutes and is among the best for the region though slightly longer than national standards. There were 5 FSED thrombolytic cases with a median D2N time of 55 minutes—below the 60-minute national recommendation for treatment time. Conclusion: Providing clinical education and standardizing workflows in the FSEDs resulted in stroke metrics aligning with (or exceeding) regional and national standards. leading to a positive impact patient care when stroke patients present for emergent evaluation and treatment at a FSED.

2232. Comparison of Empiric Vancomycin Prescribing in Response to Gram Positive Cocci Alerts on Blood Cultures Between Primary and Overnight Physicians on General Medicine Services: A Retrospective Study

Abstract Background Blood culture contamination is associated with unnecessary antibiotic use, increased length of stay, and increased costs. Assessing the likelihood of true bacteremia versus contamination requires consideration of clinical context and microbiologic data. This may be more difficult for covering physicians overnight, who typically cover more patients and may not know patients’ clinical history as well. We compared rates of vancomycin (VAN) initiation in response to microbiology alerts for gram-positive cocci (GPC) in blood cultures during primary team shifts versus overnight. Methods We queried the University of Virginia Clinical Data Repository for blood culture results positive for GPC from 07/01/2021 to 12/30/2022 in inpatient general medicine patients. Cultures were stratified by time of the initial positive gram stain alert, which is called as a critical result to the team. All new positive blood cultures are run on a rapid molecular diagnostic (ePlex GenMark Diagnostics) with speciation results passively entered into the chart 2 hours after gram stain. Results were excluded if the patient was already on VAN or daptomycin at the time of gram stain or if the gram stain resulted during hours when the physician coverage (primary vs covering) was not consistent. The primary outcome was the rate of VAN initiation within 2 hours of gram stain with GPCs. Secondary outcomes were number of repeat blood cultures, length of stay (LOS), and incidence of acute kidney injury (AKI). Results 320 instances of positive blood cultures were reviewed. 141 were excluded. Of 179 included instances, there was no significant difference in VAN initiation by overnight physicians compared to primary teams (21% vs 26%; p=0.418). There was no significant difference in repeat cultures or incidence of AKI. Comparison of primary and overnight physicians Blood culture speciation Conclusion There was no difference in VAN use, repeat blood cultures, or AKI when positive gram stain alerts were received by overnight physicians versus primary teams. Stewardship interventions targeting VAN prescribing in the setting of a rapid diagnostic workflow may not need to be specifically adapted to covering physicians or teams. Disclosures Amy Mathers, MD, D(ABMM), Merck: Advisor/Consultant

Overnight staffing in Canadian neonatal and pediatric intensive care units.

Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.

Essential human and material resources for emergency care in the district hospitals of Burundi

IntroductionBurundi, like many African nations, faces challenges in providing accessible emergency care. The aim of this study was to assess the type of staff training, accessibility to imaging, and availability of essential equipment in the district hospitals of Burundi in order to inform strategic planning for healthcare delivery. MethodsIn June 2022 an online survey was sent to each district hospital of the country. Complete responses were analysed and, where appropriate, significance determined by chi-square analysis, with p<0.05 considered significant. ResultsForty of 45 district hospitals completed the survey, of which 35 were rural (matching national demographics). The majority of district hospitals (21/40) had ready access to ≥4/5 critical drugs while few (5/40) were equipped with ≥4/5 key material. One quarter had 24/7 physician coverage and X-ray available. Only 3 had continuous access to ultrasound studies despite most district hospitals having ultrasound machines. Trained emergency room staff were almost totally absent from the field, with only 6 nurses, 4 generalists, and 1 specialist reported across 9 sites. Even a single EM-trained staff member was significantly correlated with being better equipped for emergencies (p<0.01). ConclusionBurundi needs a strategic investment in emergency preparedness and care. Policy initiatives and technology purchases have demonstrated reasonable penetration down to the district hospital level, however, trained personnel are essential to develop sustainable emergency capacity.

Football Saturday: are collegiate football stadiums adequately prepared to handle spectator emergencies?

Mass gatherings are a commonly occurring event, especially on college campuses. Any mass gathering gives rise to possible small- or large-scale emergencies. Mass gathering medicine is an integral part of emergency medical services (EMS). An assessment was performed to see if collegiate stadiums possess capabilities for advanced medical care when emergencies arise among attendees. A standardized survey was sent by a single researcher to all National Collegiate Athletic Association (NCAA) Division I programs regarding medical services they currently have in place at their stadiums during Saturday football games. A follow-up inquiry was made at each local community office of emergency management (OEM) to confirm responses or obtain missing data. Only 21.5% (N.=17) of stadium facilities reported having physicians solely dedicated to the care of fans and other support staff. Most stadiums (N.=70, 88.6%) offered ALS services for their fans, with the remaining ALS services provided by paramedics (N.=46, 58.2%) or registered nurses (N.=7, 8.9%). The remaining stadiums only offered BLS services (N.=6, 7.6%) or basic first aid (N.=3, 3.8%). One stadium offered athletic trainer services to its fan in addition to the ALS care. Given the potential for a large influx of patients at sporting events, almost all stadiums have some degree of prehospital emergency care on site. More than a 10% of stadiums lacked ALS services and very few stadiums have physicians on site. Many stadiums were unaware of the resources available during these events. The ability to have ALS services on site who can provide rapid, advanced care to spectators is important due to likely delays in 911 response. At a minimum ALS services should be available within the stadium with consideration of physician coverage as well.

Did the Long-Term Care Physician Workforce Change During the Pandemic? Describing MRP Trends in Ontario, Canada.

To examine the practice patterns and trends of long-term care (LTC) physicians between 2019 and 2021 in Ontario, Canada. Population-level descriptive time trend study. Most responsible physicians (MRPs) of LTC residents of publicly funded LTC homes in Ontario, Canada, from September 2019 to December2021. We examined the number of MRPs in publicly regulated Ontario LTC homes before and during the COVID-19 pandemic using population-level administrative databases. Characteristics of MRPs and practice patterns were generated at baseline and across distinct time periods of the pandemic in descriptive tables. We created a Sankey diagram to visualize MRP practice changes over time. More than one-quarter of pre-pandemic MRPs were no longer MRPs by the end of 2021, although most continued to practice in non-LTC settings. There was a decrease from 1444 to 1266 MRPs over time. Other characteristics of MRPs remained stable over the pandemic time periods. At baseline, LTC physicians were MRP for an average of 57.3 residents. By the end of 2021, this caseload decreased to 53.3 residents per MRP. MRPs increasingly billed monthly management compensation fees over the fee-for-service model across the pandemic time periods. The number of MRPs working in an LTC home shifted to fewer MRPs per home. MRP demographic characteristics did not change over the course of the pandemic. The observed shifts in practice patterns showed a reduction in the overall LTC MRP workforce, who delivered care to fewer residents on average in LTC homes with fewer colleagues to rely on. Future work can study how changes to LTC MRPs' practice patterns impact physician coverage, access and continuity of care, and health services and quality outcomes among residents.

Physician attitudes toward sports medicine coverage of mixed martial arts.

The popularity of modern Mixed Martial Arts (MMA) has been increasing since 2000s. It has drawn the attention of the media due to higher injury rates compared to other sports, and it is possible that this may have led to a generally negative image of MMA among viewers, including but not limited to, physicians. Therefore, our study aimed to understand the attitudes of physicians toward MMA and being asked to cover MMA events. A cross-sectional study with an online survey was answered by 410 physicians from four physician organizations throughout the USA. Demographic data, sports event-related, sports coverage experience, athleticism, and familiarity with MMA answers were analyzed. Wilcoxon, Fisher Exact, and χ2 tests were used to compare the data. The main outcomes was the association between characteristics of physicians and attitude toward MMA coverage. Physician characteristics influenced positive attitudes toward MMA coverage. Those who regularly followed MMA felt more strongly that combat sport events required physician coverage, mainly for boxing (92.4% vs. 73.4%; P<0.001), kickboxing (89.9% vs. 54.7%; P<0.001), and taekwondo (50.6% vs. 38.4%; P=0.046). Doctors who considered themselves athletic or who had covered MMA events in the past were more likely to think that all sporting events should be covered by physicians (97.4% vs. 65.9%; P<0.01; 98.4% vs. 72.8%, P<0.001, respectively). Family medicine (72/139 [51.8%]) and physical medicine and rehabilitation (7/11 [63.6%]) were the specialties more inclined to agree with physician coverage for these events. Physicians familiar with MMA, either as a previous ringside physician or as a spectator, are more inclined to believe these events should have physician coverage as are those more experienced with sports medicine, such as family medicine and physical medicine and rehabilitation specialists. Therefore, specialized sports medicine training should be provided to allow for appropriate MMA physician coverage. With additional training, MMA event organizers should feel comfortable asking physicians in any specialty to provide sports medicine coverage to improve care for MMA athletes.

A Multi-Level Analysis of Individual and Neighborhood Factors Associated with Patient Portal Use among Adult Emergency Department Patients with Multimorbidity.

Patient portals tethered to electronic health records (EHR) have become vital to patient engagement and better disease management, specifically among adults with multimorbidity. We determined individual and neighborhood factors associated with patient portal use (MyChart) among adult patients with multimorbidity seen in an Emergency Department (ED). This study adopted a cross-sectional study design and used a linked database of EHR from a single ED site to patients' neighborhood characteristics (i.e., zip code level) from the American Community Survey. The study population included all adults (age &gt; 18 years), with at least one visit to an ED and multimorbidity between 1 January 2019 to 31 December 2020 (N = 40,544). Patient and neighborhood characteristics were compared among patients with and without MyChart use. Random-intercept multi-level logistic regressions were used to analyze the associations of patient and neighborhood factors with MyChart use. Only 19% (N = 7757) of adults with multimorbidity used the patient portal. In the fully adjusted multi-level model, at the patient level, having a primary care physician (AOR = 5.55, 95% CI 5.07-6.07, p &lt; 0.001) and health insurance coverage (AOR = 2.41, 95% CI 2.23-2.61, p &lt; 0.001) were associated with MyChart use. At the neighborhood level, 4.73% of the variation in MyChart use was due to differences in neighborhood factors. However, significant heterogeneity existed in patient portal use when neighborhood characteristics were included in the model. Among ED patients with multimorbidity, one in five adults used patient portals. Patient-level factors, such as having primary care physicians and insurance, may promote patient portal use.

The Explosive Growth of Telehealth Throughout the COVID-19 Pandemic and Beyond

The Explosive Growth of Telehealth Throughout the COVID-19 Pandemic and Beyond

Deploying Advanced Practice Practitioners in Response to the Healthcare Workforce Crisis in the Ambulatory Setting.

The clinical staffing shortages that the US healthcare sector is experiencing are sure to become even more profound as the general population continues to grow and age. With more people living well beyond age 65, more physicians will be needed to provide care.A solution to help fill the gaps in physician coverage is centered on the use of advanced practice practitioners, especially in the ambulatory setting. The growing shortage of primary care physicians could be significantly reduced or eliminated if the appropriate contributions of advanced practice practitioners-including physician assistants/physician associates (PAs) and nurse practitioners (NPs)-are considered when calculating financial costs.My organization uses a model in the ambulatory setting that emphasizes the use of PAs and NPs who are supported by physician oversight in their clinical practice. Throughout the critical challenges of the recent past, the model has served us well. Other organizations may also see important benefits with this strategy.

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit.

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight. What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being? A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction. Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education. As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Adaptive Radiation Therapy Physician Guidelines: Recommendations From an Expert Users’ Panel

PurposeOnline adaptive radiation therapy (ART) allows real-time plan generation and delivery to account for daily anatomic changes. Owing to the time-intensive nature of this process, physicians frequently cover adaptive treatments for patients whose original treatment plan was prescribed by another provider. There is currently no published guidance on the contents of physician sign-outs, or adaptive guidelines, to ensure the safe and consistent delivery of adaptive treatments. Methods and MaterialsA group of radiation oncologists, each with at least 3 years of experience prescribing and covering online adaptive radiation treatments, formed a working group to identify the critical components of adaptive guidelines. The members of the working group collectively were experienced with the 3 commercially available real-time ART platforms. Key components of the adaptive guidelines necessary to preserve the prescribed treatment intent were identified. ResultsEleven radiation oncologists from 9 cancer centers, with a range of 3 to 6 years ART experience, formed the adaptive guidelines working group. Three categories of information that are essential for safely delivering an online ART approach were identified: recontouring instructions (including anatomic considerations for specific cases), defining replanning rules, and establishing motion management guidelines. ConclusionsWhen physician coverage is needed for ART, clear communication is critical for treatment to be delivered according to the original intent of the prescription. The proposed ART recommendations that include physician sign-out for this highly technical treatment process can be especially beneficial in improving communication across potentially multiple transitions of care.

543 Challenges in Burn Nurse and Therapy Staffing During and After a Category 4 Hurricane

IntroductionBurn nurse/therapy staffing has been stretched for months by the pandemic. Along the Gulf Coast, Hurricane Ida recently taxed these resources further as regional burn centers saw a weeks-long surge in serious burn injuries in the setting of prolonged power and water outages. We reviewed the execution of a plan for the provision of burn nurse/therapist staffing at an ABA-verified adult burn center that experienced a direct hit by a Category 4 storm.MethodsHospital leadership planned to activate Code Gray on 8/29/21 at which time the hospital would be placed on lockdown with no one allowed in or out until Code Gray was lifted.Our burn leadership subsequently designed a plan to have ten burn nurses and one Occupational Therapist (TEAM A) in house from the inception of Code Gray at 7am on 8/29 thru 7am on 9/1. If Code Gray conditions persisted, nine dedicated burn nurses (TEAM B) were to relieve TEAM A. TEAM B was planned to remain in-house until 7am on 9/4. If Code Gray conditions continued, the plan was to be reassessed at that time. The same burn therapist was planned to remain in-house throughout. Physician coverage was to be provided by the in-house trauma team during Code Gray. No housing or bedding was provided for in-house personnel, and the hospital generator system ostensibly had a 30-day fuel supply.ResultsTEAM A day/night staffing was 6/4 with the off crew sleeping in conference rooms and clinic spaces. An unexpected event occurred when a mission-critical tower for the city’s grid toppled into a river resulting in delays for restoration of the grid, and city-wide boil-water and burn-ban policies. As generators came into widespread use, our pre-storm census of 9 increased to a mean of 12.7 + 1.4. Due to this increase, on the morning of 9/1 six TEAM A nurses elected to stay and be absorbed into Team B with day/night staffing of 6/6.The rapid influx in number and complexity of burn patients made it clear a burn surgeon presence was needed during Code Gray. One burn attending was able to make it to the hospital at 7am on 8/30 and worked until being relieved at 7am on 9/5. An informal triage strategy was enacted in which only burns of >10% TBSA would be considered for admission. OR availability went down to 2 + 1 at the inception of Code Gray and 3 + 1 on 9/6. Eleven cases were done during this time with a mean TBSA of 20.2 + 10.7%.Hospital generators were found to consume fuel at a rate almost twice predicted. Due to prioritization, the hospital went back on city power on 9/2. Code Gray was lifted at 7am on 9/4 and normal operations resumed at 7am on 9/11.ConclusionsThe successful provision of care required a willingness for nurses and one therapist to remain in the hospital for six consecutive days and for hospital administration to approve the overtime.

Patient and clinician perceptions of the trauma and acute care surgery hospitalization discharge transition of care: a qualitative study

ObjectivesTrauma and acute care surgery (TACS) patients face complex barriers associated with hospitalization discharge that hinder successful recovery. We sought to better understand the challenges in the discharge transition of...

Survey of neonatal nursing: Staffing, education, and equipment availability in Rwanda

IntroductionResearch studies have repeatedly shown that better educated nurses provide safer and higher quality care. In Rwanda, neonatal nursing is not recognized as a nursing specialty and there is no consistent approach in neonatal education or training of nurses who work with newborn infants. PurposeThe purpose of the study was to describe existing neonatal nursing practices in Rwanda, specifically 1) orientation program content and orientation process; 2) nurses' education, skill levels and comfort with performing neonatal care; and 3) availability and use of medical equipment. MethodsA descriptive cross-sectional survey design was used. Data were collected from October through November 2017. A convenience sample of nurses and midwives was used; nurses and midwifes working in Rwandan neonatal care units (NCUs) were invited to participate and complete a questionnaire specifically designed for this study. ResultsA total of 99 participants representing all 47 Neonatal Care Units (including 2 neonatal Intensive care units-NICUs) in Rwanda completed the questionnaire. Seventy-six (76) were nurses, 19 were midwives, and 4 were nurse-midwives. A lack of consistency in orientation/training to the neonatal unit was evident with approximately 70% who felt that the orientation was not sufficient. Comfort level with skills depended on the type of procedure. Basic neonatal care procedures were reported as comfortable, however this level varied across the geographic regions. Some vital equipment was unavailable. For more than half the respondents there was no 24-h physician coverage available for back up. DiscussionThe findings of this exploratory descriptive study reveal that the majority of Rwandan nurses/midwifes had limited neonatal care experience. Orientation program content and duration varied across the country. Most included basic content but was not always sufficient when there was poor staffing or a lack of physician coverage. Procedures that were rarely performed were uncomfortable because there was no opportunity for practice. Competency demonstration not expected of most of the respondents. ConclusionsThere needs to be consistent education/training for neonatal nurses. Competency based education and practice performance should be developed. Further research needs to focus on staffing patterns, education/competencies of the nursing staff, and the direct impact on neonatal outcomes.

The Emerging Role of Telestroke in the Middle East and North Africa Region in the Era of COVID-19.

Stroke is the second most common cause of death worldwide. It is a medical emergency demanding immediate recognition to provide time-sensitive acute management. The coronavirus disease 2019 (COVID-19) pandemic has challenged acute stroke care, and alternate models of treatment are needed. Telestroke is well proven as a valid tool for acute stroke assessment and has been utilized successfully to manage patients remotely in many parts of the world, though it is underutilized in the Middle East and North Africa region. Given the challenges associated with the COVID-19 pandemic, such as risk of physician exposure to infection, implementation of a telestroke system is critical to provide consultant stroke physician coverage. This article provides a proposed model for coordinated telestroke. Implementation of telestroke in the Middle East and North Africa region and other underdeveloped areas will optimize stroke management, especially during the COVID-19 era.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

Association of Simulation Training With Rates of Medical Malpractice Claims Among Obstetrician-Gynecologists.

To compare malpractice claim rates before and after participation in simulation training, which focused on team training during a high-acuity clinical case. We performed a retrospective analysis comparing the claim rates before and after simulation training among 292 obstetrician-gynecologists, all of whom were insured by the same malpractice insurer, who attended one or more simulation training sessions from 2002 to 2019. The insurer provided malpractice claims data involving study physicians, along with durations of coverage, which we used to calculate claim rates, expressed as claims per 100 physician coverage years. We used three different time periods in our presimulation and postsimulation training claim rates comparisons: the entire study period, 2 years presimulation and postsimulation training, and 1 year presimulation and postsimulation training. Secondary outcomes included indemnity payment amounts, percent of claims paid, and injury severity. Compared with presimulation training, malpractice claim rates were significantly lower postsimulation training for the full study period (11.2 vs 5.7 claims per 100 physician coverage years; P<.001) and the 2 years presimulation and postsimulation training (9.2 vs 5.4 claims per 100 physician coverage years; P=.043). For the 1 year presimulation and postsimulation training comparison, the decrease in claim rates was nonsignificant (8.8 vs 5.3 claims per 100 physician coverage years; P=.162). Attending more than one simulation session was associated with a greater reduction in claim rates. Postsimulation claim rates for physicians who attended one, two, or three or more simulation sessions were 6.3, 2.1, and 1.3 claims per 100 physician coverage years, respectively (P<.001). Compared with presimulation training, there was no significant difference in the median or mean indemnity paid, percent of claims on which an indemnity payment was made, or median severity of injury after simulation training. We observed a significant reduction in malpractice claim rates after simulation training. Wider use of simulation training within obstetrics and gynecology should be considered.

Excess COVID-19 mortality among critically ill patients in Africa

Excess COVID-19 mortality among critically ill patients in Africa