OBJECTIVES:Pediatric emergency medicine (PEM) physicians deliver serious news (DSN) in stressful situations that impact both families and physicians. Our objective was to assess the impact of a PEM-focused workshop on DSN in improving the self-perceived preparedness, skill level, and stress management of PEM physicians. METHODS:We designed a simulation-based communication workshop, "PEMTalk," utilizing simulated parents to teach PEM attendings and fellows to effectively DSN. The workshop was conducted in a virtual and in-person format from 2018 to 2023. We developed 3 scenarios unique to PEM. Pre- and postintervention surveys were administered to assess the workshop's impact. RESULTS:A total of 74 participants completed surveys. Among the 34 first-time participants, there were improvements in provider's self-perceived ability to DSN (41% vs. 97%; P <0.001), respond to emotions (50% vs. 97%; P <0.001), and decrease in stress (47% vs. 21%; P =0.003) due to DSN. Among the 23 participants who participated in the study more than once, there were sustained improvements in their self-perceived ability to DSN (39% vs. 69%; P =0.02). Fellows (53% of participants) were more likely than attendings to report improvement in DSN [OR 6; 95% CI (1.05-41.67); P =0.04]. There was no difference in outcomes between in-person and virtual formats. CONCLUSION:PEMTalk enhanced participants' self-reported comfort while reducing stress associated with DSN in a simulated setting. Next steps include incorporating objective assessments, evaluating the impact on patient care, and disseminating the workshop to the broader PEM community.

Objectives:In the United States, training for physicians who manage critically ill adult patients (intensivists) evolved through parallel subspecialty critical care medicine (CCM) pathways with significant commonality. The Society of Critical Care Medicine Adult Critical Care Physician Core Knowledge and Skills Task Force aimed to delineate the common core knowledge and skills required of all intensivists.Design:A master list of content areas and procedural skills was compiled from all CCM subspecialty program requirements and blueprints of the certification examinations. Using a modified Delphi approach, participants were asked to categorize the knowledge items as "advanced knowledge is essential," "general, but not advanced, knowledge is essential," or "knowledge is not essential." Procedures were categorized as "intensivist performs routinely," "intensivist only performs in an emergency," or "intensivist knows" about the procedure.Setting:Representatives from CCM stakeholder organizations, including accreditation and certification organizations, critical care societies, and program directors' societies, were invited to participate.SUBJECTS:Members of the Adult Critical Care Physician Core Knowledge and Skills Task Force of the Society of Critical Care Medicine.Interventions:For the first two rounds of the modified Delphi process, Research Electronic Data Capture was used. For the third and fourth rounds, the process was completed through online meetings with Zoom (Zoom Video Corporations, San Jose, CA) utilizing Zoom's polling feature.Measurements and Main Results:A total of 541 items were determined to be essential, with 145 requiring advanced knowledge and 323 requiring general knowledge. For 73 items, consensus regarding advanced vs. general could not be achieved, but they remained essential. Only eight items were felt to be nonessential. Of the 16 procedures, most were categorized as "intensivist performs."Conclusions:The large number of items included in the list of essential knowledge and skills demonstrates the complexity of modern CCM. Utilization of a common framework across the subspecialties of CCM could lead to greater harmonization among the fellowship program requirements and certification examinations.

INTRODUCTION:Rigorous rater training is necessary to ensure consistent feedback. Yet, there is a lack of published recommendations for how to train raters to provide reliable, consistent assessments for communication skills, thus making competency-based training in this area challenging. We describe a method for conducting rater training for serious illness communication skills and assess interrater reliability. METHODS:We selected a previously published and validated tool for assessing serious illness communication skills. We created a rater training program adapted from a previously described program focused on team performance, making notable adjustments to tailor the program to the assessment of serious illness communication with patients given the unique challenges these conversations pose. We assessed interrater reliability at the end of the program using kappa coefficients for dichotomous checklist items and intraclass correlation coefficients for scaled items. RESULTS:Five raters who are physicians with expertise in communication skills training completed the program. After training, raters assessed eight test videos. All raters achieved substantial agreement when compared to the gold standard rater for both the checklist (average overall kappa = 0.83) and scaled items (average overall intraclass correlation coefficient = 0.83). DISCUSSION:We demonstrate an effective method for conducting rater training to assess serious illness communication skills that builds off a previously published program for team performance. Key adjustments included conducting facilitated discussions of videos and iteratively updating the rater training guide. This approach ensures reliable assessment within communication skills training.

PURPOSE:Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). METHODS:First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. RESULTS:Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. CONCLUSIONS:A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Background EM Talk is a communication skills training program designed to improve emergency providers’ serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness. Methods EM Talk consisted of one 4-h training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients’ goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses. Results A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63 to 100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of Serious Illness (SI) communication skills, improved attitude toward engaging qualifying patients in SI conversations, and commitment to using these learned skills in clinical practice. Conclusion Our study showed the extensive reach and the effectiveness of the EM Talk training in improving SI conversation. EM Talk, therefore, can potentially improve emergency providers’ knowledge, attitude, and practice of SI communication skills. Trial registration Clinicaltrials.gov: NCT03424109; Registered on January 30, 2018.

IntroductionAirway hemorrhage requires rapid treatment to prevent adverse patient outcomes. Simulation education programs are challenged to recreate learning environments with adequate fidelity for team management of airway hemorrhage.MethodsWe developed Airway Hemorrhage Simulation Scenarios consisting of low-cost partial-task simulators to mimic airway hemorrhage (nasopharyngeal, oropharyngeal, expanding neck hematoma) and multiple methods to assess team leader performance in emergent airway management [Airway Team Leader Assessment Tool (ATLAT), Airway Checklist Performance, and Global Performance Rating]. We assigned trainees in Emergency Medicine (EM) and Critical Care (CC) sequentially to 1 of the 3 possible hemorrhage scenarios, and each trainee participated in a single 1-hour session composed of 3 repeated opportunities of deliberate practice of the assigned scenario. We assessed the trainees after session 1 and session 3 with independent expert evaluators of trainee performance using the ATLAT, Airway Checklist Performance, and Global Performance Rating.ResultsWe collected data on 26 trainees: 19 EM residents [postgraduate year (PGY) 1-3] and 7 CC fellows (PGY 4-7). Trainees had significant improvement for all ATLAT domain measures, Airway Checklist Total Score, and Global Performance Rating between session 1 and session 3.ConclusionsOur pilot evaluation suggests that deliberate practice of Airway Hemorrhage Simulation Scenarios improves airway team leader performance from multiple disciplines in managing high-acuity, low-occurrence airway hemorrhage.

clinicians (69 teams), consisting of nurses (52%), social workers (35%), and chaplains (13%), attended the courses.The pre-course survey revealed spiritual and cultural aspects of care as participants' least effective areas of communication across the NCP domains.Postcourse evaluations, on a scale of 1 to 5 (1=lowest), revealed the course met participants' expectations (4.8), and the spiritual (4.8) and cultural (4.8) modules were most useful to their practice.Cohort 1 and 2's 6and 12-month follow-up revealed 1,802 clinicians (1,083 nurses, 220 social workers, 87 chaplains, 176 physicians, and 236 others) have been trained.Conclusion.ICC is an effective train-the-trainer program, and the NCP guidelines serve as an effective framework for teaching communication.A 12-month follow-up on course 2 is scheduled and the third ICC course is scheduled for August

Background Simulation is used in critical care for skill development, formative assessment, and interprofessional team performance. Healthcare educators need to balance the relatively high cost to deliver simulation education with the potential impact on healthcare quality. It is unclear how to prioritize simulation in critical care education, especially considering interprofessional needs across adult and pediatric populations. The objective of this study was to prioritize topics for critical care educators developing simulation-based educational interventions. Methodology A modified Delphi process was used to identify and prioritize critical care topics taught using simulation. We disseminated a multi-institutional survey to understand critical care simulation topics using a three-round modified Delphi technique. An expert panel was recruited based on their expertise with simulation-based education through the Society for Simulation in Healthcare and the Society of Critical Care Medicine lists. Critical care topics originated using content derived from multiple critical care board examination contents. Additional content for a critical care simulation-based curriculum was generated. Results Consensus and prioritization were achieved in three rounds, with 52 simulation experts participating. The first Delphi round surveyed priority topics in critical care content and generated additional topics for inclusion in round two. The second Delphi round added the content with the highest-ranked items from round one to generate a set of simulation-based topic priorities. The third Delphi round asked participants to determine the importance of each priority item taught via simulation compared to other modalities for clinical education. This round yielded 106 topics over four domains categorized into (1) Diagnosis and Management of Clinical Problems, (2) Procedural Skills, (3) Teamwork and Communication Skills, and (4) General Knowledge and Knowledge of Technical Adjuncts. Conclusions The modified Delphi survey revealed a prioritized, consensus-based list of topics and domains for critical care educators to focus on when creating a simulation-based critical care curriculum. Future work will focus on developing specific simulation-based critical care curricula.

1Lahey Hospital and Medical Center, Burlington, MA 2University of Pittsburgh Medical Center, Pittsburgh, PA 3Los Angeles, CA

Objectives: Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes. Data Sources and Study Selection: Review article. Data Extraction and Data Synthesis: Emergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units. Conclusions: Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

PURPOSE: Critical Care (CC) fellowship training after Emergency Medicine (EM) residency has evolved over the last decade, with multiple routes to certification and a variety of career options.In 2009, a Virtual Mentorship program was created by dualtrained EM-CC physicians in order to support the growing need for mentorship and guidance of EM physicians pursuing careers in CC.The purpose of this study was to assess the 10 year efficacy of the program, determine themes of mentoring success across a diverse practice of critical care, and find areas to improve. METHODS:We developed a survey that was sent to current and prior mentors.The questions were designed to assess the mentor's background, practice location, motivators for partaking in the program, and seek feedback for further improvement.Over the course of 10 years, there were a total of 92 mentees, 11 of these mentees went on to become mentors themselves.In total, the program had 36 mentors, 30 of those participants were given the opportunity to take the survey.IRB approval was obtained and the survey was distributed via REDCap with reminder emails sent to non-responders.This was followed by voluntary participation in a 30 minute telephone interview. RESULTS:Of the 30 individuals whom the survey was distributed to, 19 responded.The training completed by mentors were 53% Internal Medicine CC, 31% Surgical CC, and 16% Anesthesia CC, with 90% of mentors currently practicing in academic medicine.Most mentors were on average 6 years post fellowship.32% actively sought out the program with the intent of being a mentor.The mean number of mentees per mentor was 2, the mean shortest mentor-mentee relationship was 4 months, the mean longest relationship was 9 months.All mentors felt neutral to positive about how well matched they were with their mentees.69% felt that the program was overall useful and effective.The primary feedback we received on areas of improvement were creating a formal guideline of expectations as well as improved outreach and recruitment of mentees. CONCLUSIONS:The EM-CC Virtual Mentorship program has a diverse group of mentors who are eager to take on mentees.Creating a more structured format and enhancing advertisement may make the program more efficacious.Future directions include obtaining similar data for mentees to see if their needs were met, and areas where they feel the program is lacking.CLINICAL IMPLICATIONS: Assessment of the Virtual Mentor program (https://www.emra.org/be-involved/committees/critical-care-committee/critical-care-mentee-registration/) demonstrated areas to improve the program in order to help enhance the readiness of emergency medicine physicians applying into CC fellowships.

Endotracheal intubation is a commonly performed procedure in the intensive care unit (ICU). Active upper gastrointestinal bleeding, emesis in the airway, and the presence of a cervical collar are just a few examples of conditions encountered in critically ill patients that can make endotracheal intubation difficult. Furthermore, critically ill patients usually require intubation because they have exhausted their physiologic reserve and can deteriorate rapidly due to vasodilation from induction medications, reduction in preload from positive pressure ventilation, hypercapnia and acidosis during periods of apnea, hypoxia from failed attempts at intubation, and an increase in intracranial pressure during laryngoscopy attempts. Up to one third of patients undergoing emergency airway management will develop serious complications, including hypoxemia, hypotension, aspiration, or cardiac arrest. Careful planning, provision of the appropriate equipment and personnel, and an understanding of an individual patient’s physiologic derangements can help to prevent complications during intubation. This review 13 figures, 4 tables, and 27 references. Keywords: airway, intubation, endotracheal, rapid sequence, pre-oxygenation, bag-mask ventilation, laryngoscopy, cricothyrotomy, supraglottic airway

Learning Objectives: To investigate the variation in intubation learning curves in critical care fellows in a clinical training environment, to compare the performance of novice vs. experienced airway learners, and to determine the number of intubations needed to reach competency. Methods:Prospective, observational cohort study. We enrolled 21 first-year CCM fellows with base training in Internal Medicine, Surgery, Neurosurgery, Neurology, Emergency Medicine (EM), and Anesthesia. All fellows underwent airway management didactic and cadaver lab hands-on training for 1 week in July 2017. From Jul-Dec 2017 we asked each participant to provide the following information: Technique, number of attempts, complications, and which operator ultimately secured the airway. We compared the performance of experienced vs. novice airway operators by assigning Anesthesia or EM trained fellows as controls (C), and fellows from all other specialties as the intervention (I) group. Using the previously described CUSUM method we report the rate of overall and first pass competency for several acceptable failure rates (AFR) and the number of intubations to reach competency (IRC) for the cohort and per group. Results: Twenty-one fellows (C=9, I=12) performed 342 (30%) out of 1132 total intubation attempts for the institution (57/ month, 16.2 ± 8.0/fellow, 2.71 ± 1.3/fellow/month). With a 20% AFR, competency for overall success was reached by 86% of the entire cohort of fellows, and 89% of control vs. 83% of intervention fellows (IRC:9.5 vs. 13.6, respectively). Competency with first pass success was achieved by 43% of all fellows, and 56% of controls vs. 33% of intervention fellows (IRC:9 vs. 15.2, respectively). Average first pass success was 86% for control vs. 82% for intervention fellows, and average overall success was 95% for control vs. 92% for intervention fellows. Conclusions: Accounting for 30% of intubations within the system and averaging less than 3 intubations per month, 89% and 43% of fellows reached overall and first pass competency, respectively, and required 9.5 and 13.6 intubation attempts only when tolerating an acceptable failure rate of 20%. Prior intubation experience improved performance, however, at still low overall and first pass competency. These data suggest that these training conditions may not be sufficient to obtain competency during fellowship.

Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

Patients frequently require airway management during rapid response team (RRT) activations. Airway management during RRT activations frequently occurs in locations that are not well equipped or prepared to perform airway procedures. Therefore, it is important that RRTs arrive with the proper equipment and medications to safely secure the airway whenever necessary. An “airway bag” that is stocked by a hospital’s central supply department and carried by RRTs ensures the availability of functioning equipment and helps to standardize the process of airway management during RRT activation. In this chapter, we will review recommendations for equipment required in emergency airway management, including portable routine and difficult airway equipment and medications.

Deterioration in respiratory status is the most common reason for activation of rapid response teams (RRT). Severe respiratory failure may necessitate advanced airway management interventions including endotracheal intubation (ETI) in hospital environments that may be especially challenging in clinical context, space, equipment, and personnel. Furthermore, patients undergoing ETI during the course of an RRT event are critically ill, identifying them as patients who are at increased risk for adverse events during the procedure. Many of the challenges of airway management during RRT events can be overcome with appropriate staffing, proper equipment, and careful planning prior to attempts at ETI. In this chapter, we discuss the evaluation and management of patients requiring ETI during the RRT event including recommendations on pharmacology and intubation techniques.

The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.