CRITICAL CARE CLINICS www.criticalcare.theclinics.com Consulting Editor JOHN A. KELLUM April 2018 • Volume 34 • Number 2

a critical care specialist in a rural emergency room, was evaluating Mrs

of several new materials in clean rooms, the monitoring of trace metallic contamination is a real and present need. It is well known [1][2][3] that these impurities are detrimental to the efficiency of the microelectronics devices: they could cause crystal defects, act as electron traps, degrade minority carrier lifetime or increase the leakage current. Concerning the noble metallic contaminants (Au, Pt, Ir, Ru, Ag and Pd), now used in microelectronics to improve devices performances, their surface contamination control at low level (< 1010 at.cm-2) remains a great challenge.

AlGaAs/GaAs tunnel junctions for use in high concentration multijunction solar cells were designed and grown by chemical beam epitaxy (CBE) using trimethyl aluminium (TMA) as the p-dopant source for the AlGaAs active layer. Controlled hole concentration up to 4⋅1020 cm−3 was achieved through variation in growth parameters. Fabricated tunnel junctions have a peak tunneling current up to 6140 A/cm2. These are suitable for high concentration use and outperform GaAs/GaAs tunnel junctions.

Objective: To examine an electronic platform that engages medical crisis resource management (CRM) trainees in the performance critiquing process, and to assess the acceptability and credibility of the “individualized” feedback generated by the platform. The training is focused on organizational aspects of crisis management, and reinforces teamwork. Design: An electronic critiquing and feedback platform was developed to (a) engage trainees in the critiquing process and (b) individualize feedback to trainees. This study –the second of two– focused on examining the credibility of the approach for generating individualized trainee feedback. All trainees used the system after every simulated crisis throughout the course, and their critiques were compared to that of an expert rater. Subjects: Thirty-two physicians, nurses, and respiratory therapists participated in the study as part of their hospital mandated CRM training. Procedure: CRM trainees experienced rounds of simulated crises on computerized mannequins followed by debriefing sessions that involved performance critiquing and feedback. Before starting the debriefing session, trainees critiqued their own performance and that of their co-trainees. All trainees instantly received individualized feedback based on their peers’ critiques. A survey was administered to trainees to determine the acceptability of the approach. Results: Electronic critiquing was always completed in less than 3 minutes, and did not interfere with regular training procedures. The system was unanimously perceived as intuitive and easy to use. All but one subject agreed that the critiques were accurate, motivational, improved their self-awareness, and enhanced their focus. Trainees extensively over-estimated their own and their peers’ performance in the first simulated crisis, as well as that of their peers. During the second simulated crisis, trainees under-estimated their own performance. After the second crisis, trainees’ perceptions became closer to the expert rater’s assessments. Conclusion: The electronic critiquing approach was acceptable and useful to trainees. The approach was credible for individualizing the feedback to trainees only after trainees became conscious about their own incompetence. Full scale simulation focused on organizational aspects of team performance during crisis is correlated with an improved ability to self assess performance. Discordance between perceived performance and actual performance decreases with training. Conflict of Interest: Authors indicated they have nothing to disclose.

Managing care requires the ability to audit care delivered, evaluate its effectiveness, and provide real-time feedback to clinicians. Care managers and physicians design relatively standardized care delivery protocols to reduce variation and improve outcome. Such care management strategies are relatively easy for some disease processes that are homogeneous but are considerably more difficult to design for patient populations that have significant heterogeneity in terms of disease types and severity of illness. Therefore, many critically ill patients have been excluded from managed care practices. Studies have now made it possible to validly compare populations of critically ill patients and accurately assess the resources consumed by those patients. As a result, benchmarks for quality, resource use, and cost are being developed. This article reviews recent studies that have contributed to clinicians' ability to quantify outcome and resource utilization. Several studies assessing the effect of variations in provider class, patient payor, and cost are discussed.

Objective: To study the incidence of phrenic neuropathy following coronary artery bypass grafting and determine long-term outcome.Design: Prospective observational.Setting: Surgical ICU in a university hospital, out-patient follow-up.Patients: Ninety-two consecutive patients undergoing open heart surgery.Interventions: None.Measurements: Chest radiographs (CXR) 48 to 72 h post-operatively, ultrasonography of diaphragm, phrenic nerve conduction studies, diaphragmatic electromyogram, each repeated every 1 to 3 months until normal.Main results: Seventy-eight of 92 (78 percent) patients had abnormal radiographs, 42 of 78 (54 percent) with abnormal CXRs had abnormal diaphragm motion, 24 of 42 (57 percent) with abnormal motion had phrenic neuropathy. Patients with normal diaphragm motion improved faster than those without; patients with normal nerve conduction (and abnormal motion) improved faster than those with abnormal nerve conduction.Conclusions: Phrenic neuropathy is relatively common if sensitive tests are utilized for diagnosis. Nerve conduction studies can predict duration of morbidity. Most patients have low morbidity and recover fully. Abnormal diaphragm motion alone is not diagnostic of phrenic nerve injury.