Objectives: Early in the coronavirus 2019 (COVID-19) pandemic, a high frequency of pulmonary embolism was identified. This audit aims to assess the frequency and severity of pulmonary embolism in 2020 compared to 2019. Methods: In this retrospective audit, we compared computed tomography pulmonary angiography (CTPA) frequency and pulmonary embolism severity in April and May 2020, compared to 2019. Pulmonary embolism severity was assessed with the Modified Miller score and the presence of right heart strain was assessed. Demographic information and 30-day mortality was identified from electronic health records. Results: In April 2020, there was a 17% reduction in the number of CTPA performed and an increase in the proportion identifying pulmonary embolism (26%, n = 68/265 vs 15%, n = 47/320, p < 0.001), compared to April 2019. Patients with pulmonary embolism in 2020 had more comorbidities (p = 0.026), but similar age and sex compared to 2019. There was no difference in pulmonary embolism severity in 2020 compared to 2019, but there was an increased frequency of right heart strain in May 2020 (29 vs 12%, p = 0.029). Amongst 18 patients with COVID-19 and pulmonary embolism, there was a larger proportion of males and an increased 30 day mortality (28% vs 6%, p = 0.008). Conclusion: During the COVID-19 pandemic, there was a reduction in the number of CTPA scans performed and an increase in the frequency of CTPA scans positive for pulmonary embolism. Patients with both COVID-19 and pulmonary embolism had an increased risk of 30-day mortality compared to those without COVID-19. Advances in knowledge: During the COVID-19 pandemic, the number of CTPA performed decreased and the proportion of positive CTPA increased. Patients with both pulmonary embolism and COVID-19 had worse outcomes compared to those with pulmonary embolism alone.
Background Simulation-based mastery learning (SBML) is an effective, evidence-based methodology for procedural skill acquisition, but its application may be limited by its resource intensive nature. To address this issue, an enhanced SBML programme has been developed by the addition of both pre-learning and peer learning components. These components allowed the enhanced programme to be scaled up and delivered to 106 postgraduate doctors participating in a national educational teaching programme. Methods The pre-learning component consisted of an online reading pack and videos. The peer learning component consisted of peer-assisted deliberate practice and peer observation of assessment and feedback within the SBML session. Anonymised pre- and post-course questionnaires were completed by learners who participated in the enhanced programme. A mixture of quantitative and qualitative data was obtained. Results Questionnaires were distributed to and completed by 50 learners. Both sections of the pre-learning component were highly rated on the basis of a seven-point Likert scale. The peer learning component was also favourably received following a Likert scale rating. Peer observation of the performance and assessment process was rated similarly by first and second learners. The thematic analysis of the reasons for which peer-assisted deliberate practice was considered useful showed that familiarisation with equipment, the rehearsal of the procedure itself, the exchange of experiences and sharing of useful tips were important. The thematic analysis of the reasons why peer observation during ‘performance, assessment and feedback’ was useful highlighted that an ability to compare a peer’s performance to their own and learning from observing a peer’s mistakes were particularly helpful. Conclusion The SBML programme described has been enhanced by the addition of pre-learning and peer learning components which are educationally valued and allow its application on a national scale.
This study demonstrates a significant change of clinical practice due to IGRA use. Our findings support the NICE 2011 recommendations.
Background Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience. Methods Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student’s unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance. Results Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P = < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience. Conclusions SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.
Background Postgraduate medical curricula contain mandatory procedural skills, including lumbar puncture, thoracocentesis and central venous cannulation. Simulated skills training can improve technical ability in laboratories but does this ensure safe clinical performance? We propose that the environment significantly affects procedural skill performance, and that using simulation in the ‘real-life’ clinical environment will bring us closer to ensuring safe and successful practice. Methodology The NHS Lothian Clinical Skills Mastery Programme was introduced in Edinburgh in 2013. For each procedural skill, trainees receive knowledge packs (written and video resources) and a 2-phase supervised simulated training programme. Phase 1: Skills lab (non-clinical) Phase 2: In situ (clinical environment) We are currently studying the development of a complex clinical procedural skill (lumbar puncture) by our trainees via our Mastery methodology, with particular focus on the impact of the environment on performance. This study takes the form of a randomised control trial, using 2 groups of candidates: Lab Simulation ‘vs. In Situ Simulation. Both groups undergo a series of formative, standard-set, checklist-based assessments, culminating in an assessment of simulated performance in situ. Results A combination of quantitative and qualitative data from our study will be presented. Conclusions and recommendations ‘Mastery Learning’ has an evidence base to support its methodology in the development of clinical skills in the USA. This study aims to expand the established literature, demonstrating measurable improvement in the simulated performance of a complex clinical procedural skill by UK trainees. The environment can negatively impact on skill performance and we believe that simulation within the clinical environment is the key to improving skill levels in a meaningful way. This dramatically improves fidelity and provides the additional challenge of progressing from motor skill to psychomotor, whereby trainees must employ their newly-acquired non-technical skills to ensure technical success and patient safety. References McGaghie W, Issenberg SB, Barsuk JH, et al. A critical review of simulation-based mastery learning with translational outcomes. Med Educ 2014;48:375–385 Barsuk JH, Cohen ER, Caprio T, et al. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology 2012;79:132–7 Wayne DB, Barsuk JH, O’Leary K, et al. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54
MethodsOne-hundred and two Scottish medical trainees attended a 3-day boot camp starting in August 2019. The novel enhanced SBML pathway entailed online pre-learning resources, deliberate practice, and simulation assessment and feedback. Data were gathered via pre-and post-boot camp questionnaires and assessment checklists. ResultsThe vast majority of learners achieved the required standard of performance. Learners reported increased skill confidence levels, including skills not performed at the boot camp. ConclusionAn enhanced SBML methodology in a boot camp model enabled streamlined, standardised procedural skill teaching to a national cohort of junior doctors. Training curricular competencies were achieved alongside increased skill confidence.
Conclusion Overall there was a high concordance between the two IGRAs. Four of the 12 with positive IGRA results had a past history of TB making interpretation uncertain. The low rate of indeterminate results likely reflects the high CD4 counts among this patient group.
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