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Introduction: Parental leave policies have the potential to adversely impact faculty well-being and retention if not designed and deployed in a beneficial manner. This exploratory study aims to determine the perceptions of and experiences with parental leave for faculty at pharmacy institutions., Methods: An exploratory, cross-sectional survey was sent to pharmacy school deans to distribute to faculty. The survey obtained demographic information and asked questions pertaining to parental leave experiences and expectations, including workload coverage and the perceived impact on performance evaluations. Comments regarding ideal parental leave were qualitatively summarized., Results: Fifty-five respondents who had taken parental leave completed the survey, and 51 free text responses were received. A large effect size for the association between academic rank and planned timing of leave and a larger than medium effect size for the association with gender identity was identified., Conclusion: The availability, duration, and requirements of parental leave at pharmacy institutions have the potential to negatively impact faculty well-being and retention. This exploratory study provides initial insight into pharmacy faculty's experiences with and expectations of parental leave. Further research is needed to examine this issue on a broader scale and corroborate these findings., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Understanding factors that motivate and deter student pharmacists from joining professional pharmacy organizations may assist schools and organizations in determining ways to recruit, engage, and support the next generation of pharmacy professionals. The objective is to identify motivating and hindering factors related to student pharmacist membership in professional pharmacy organizations., Methods: A cross-sectional survey was sent to the American Association of Colleges of Pharmacy Student Services Personnel community members for distribution to student pharmacists at their respective schools. The survey collected demographic data, determined the extent of student membership and leadership involvement within professional organizations, and assessed factors that motivate and deter student pharmacist membership in organizations., Results: 467 students completed the survey. Seventy percent indicated they are currently involved in one or more pharmacy organizations. Final-year students were less likely to join organizations than other professional years (p < 0.001). Women (p = 0.001) were more likely to join and hold leadership positions, as were younger-aged students (p = 0.001) and those living on or near campus (p = 0.049). Opportunities for professional development was the highest-ranked factor motivating students to join a professional organization, and the time required for participation was the highest-ranked hindering factor., Conclusion: Numerous factors affect student pharmacists' decisions to join professional pharmacy organizations. This information may assist in determining ways to recruit and engage students starting early in their pharmacy education. It may be prudent to redefine student engagement within professional organizations, especially in the context of new generations of students., Competing Interests: Conflicts of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit., Methods: This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist., Results: Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation., Conclusion: The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events., Competing Interests: Declaration of competing interest The author(s) have no relevant disclosures. There was no grant funding or financial support for this manuscript., (Copyright © 2024 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Context: Faculty productivity is of interest for hospital and university administrators as pressure is placed on them by government and private payors. Further, the effect of trainees on clinical productivity is of personal interest to physicians because their performance evaluations and earning potential are often tied to their productivity. Several groups have utilized creative methodology to study the effect of learners on emergency department (ED) productivity, but they were faced with multiple confounding variables for which it was difficult to adjust. In this study, we utilize relative value unit (RVU)/h to study the effect of resident physicians and medical students on the productivity of academic emergency physicians (EPs) during the implementation of a new residency program. Each physician's productivity on shifts with distinct types of learners present is compared to their shifts worked without any learners during the same time frame. Each attending physician serves as their own control while the confounding variables introduced by comparing over multiple years are minimized., Objectives: The objective of this study is to measure the influence of emergency medicine (EM) residents on the clinical productivity of attending EPs., Methods: We conducted an observational study of a single ED during implementation of a new residency program. The productivity of each EP was measured by RVU/h billed. Trainees' schedules and end-of-shift evaluations were utilized to determine what learners (if any) were working with the EP on each shift. RVU/h calculations were performed for each EP (overall, when working without learners, and when working with each of the four learner categories). The primary outcome (determined a priori ) was the difference in RVU/h for the attending EPs when they worked without learners compared to when they worked a majority of their shift with at least one learner. The secondary outcome (also determined a priori ) was determining the influence of the learners of each type on EP RVU/h for the subgrouped shifts in which a learner was present for the majority of the shift., Results: There was no significant difference in mean EP RVU/h when attendings worked with a medical student or non-EM R1 in comparison to working without learners in the 1761 ED encounters analyzed (12.95 RVU/h vs. 12.52 RVU/h; p=0.125). Although there was variability among individual physicians, EP RVU/h increased significantly for the overall group when one or more EM R1s were present (15.19 RVU/h with one EM R1 present, 15.25 RVU/h with two, 24.75 RVU/h with three; p<0.001). Similarly, mean EP productivity increased significantly with the addition of an EM R2 (17.96 RVU/h vs. 16.84 RVU/h; p=0.001)., Conclusions: The presence of EM residents was positively associated with the clinical productivity of EM faculty as measured by RVU/h. There was also a positive association between productivity and the number of EM residents present as well as their training level. Non-EM residents and medical students had no effect on EP productivity., (© 2024 the author(s), published by De Gruyter, Berlin/Boston.)

Background: The use of progesterone as a component of feminizing gender-affirming hormone therapy (GAHT) is controversial; however, use in transgender women continues owing to anecdotal reports of benefit., Objectives: This study aimed to provide quantifiable outcomes data regarding the use of progesterone in transgender women by comparing groups from this population who use feminizing GAHT with and without progesterone., Methods: This retrospective cohort study captured data from transgender female patients seen at the Summa PRIDE Clinic between September 2019 and December 2021. Data were extracted from chart documentation for patients who were prescribed feminizing GAHT, with and without progesterone, for at least 6 months during the study window. Outcomes included satisfaction with breast development, satisfaction with libido, mental health trends, and weight change at 0, 6, and 9 months from initiation of GAHT., Results: A total of 88 charts were reviewed (59 in the standard group, 29 in the progesterone group). The progesterone group had statistically significant improvements in satisfaction with breast development at 6 months (53.8% vs. 19.6%; P = 0.004) and 9 months (71.4% vs. 20.8%; P = 0.003). The progesterone group had more patients at goal testosterone levels < 55 ng/dL at 6 months (47.6% vs. 33%) and 9 months (50% vs. 24.4%), but these were not statistically different. The progesterone group was also more likely to show improved provider-documented mental health at 6 months (70.6% vs. 28.2%; P = 0.009); however, the difference was not statistically significant at 9 months. There were no differences between groups for weight change and patient satisfaction with libido., Conclusion: The addition of progesterone to standard feminizing GAHT was associated with greater satisfaction with breast development and improved patient mental health within 6 months compared with standard GAHT regimens alone in this patient population. Progesterone's impact on libido, testosterone suppression, and weight were nonsignificant., (Copyright © 2023 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Introduction: Alumni are essential but often overlooked stakeholders for pharmacy programs, and engaging alumni in philanthropy, volunteerism, events, and communication may have important implications for the growth and success of pharmacy programs. This research aims to preliminarily characterize pharmacy alumni engagement across four metrics and provide a call to action for standardized tracking and reporting of alumni engagement efforts across the Academy., Methods: A cross-sectional survey was sent to alumni relations and advancement personnel at United States schools and colleges of pharmacy. The survey gathered information on the accuracy of pharmacy alumni records, alumni engagement within four categories (philanthropy, communication, events, and volunteering), alumni relations personnel, and barriers to alumni engagement efforts., Results: Respondents reported using various database systems to track and measure alumni engagement, and 41% noted having accurate pharmacy alumni records. Opportunities for alumni engagement within the four categories varied across institutions. Fifty percent of respondents indicated that one full-time equivalent position is allocated to pharmacy alumni engagement efforts at their institution. Barriers to alumni engagement efforts included limited budgets, and staff, engaging alumni via in-person events, and maintaining accurate alumni records., Conclusions: The Academy may benefit from expanding the annual alumni survey and developing a consistent tracking mechanism to capture and report alumni engagement activities. Additionally, education on alumni engagement metrics and potential collaborative efforts with institutional alumni relations personnel would be of value. This is vital in developing and optimizing alumni relations efforts and engaging pharmacy alumni bases., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Inc.)

Background: Before the COVID-19 pandemic, most states limited administration of vaccines to trained pharmacists and pharmacy interns. In October 2020 due to the public health emergency, the Federal Public Readiness and Emergency Preparedness Act (PREP Act) authorized qualified pharmacy technicians to administer vaccines nationally. Currently available research on the perception of pharmacy technician-administered vaccines is limited. Objectives: The primary objective was to evaluate the perceptions of licensed pharmacists and pharmacy technicians regarding pharmacy technician-administered vaccines. The secondary objective was to analyze correlations between demographic data and the perceptions of respondents. Methods: An anonymous, 24-question survey including 5-point Likert-scale and ranking type questions was distributed using Qualtrics® survey software to licensed pharmacists and pharmacy technicians in the state of Ohio. Results: Total of 52,240 pharmacists and pharmacy technicians were invited to participate in the survey, 26,226 viewed the e-mail and 2179 responses were collected, yielding a response rate of 8.3%. Results showed 65.9% (n = 365) of pharmacists and 76.2% (n = 675) of pharmacy technicians agreed that trained pharmacy technicians should be able to administer vaccines post-COVID-19 pandemic. Conclusion: Licensed pharmacists and pharmacy technicians in the state of Ohio support the continued administration of vaccines by trained pharmacy technicians fostering the need for legislative change., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The purpose of this study was to validate the Stanford Professional Fulfillment Index (PFI) for assessment of burnout and professional fulfillment in a study population of pharmacy residents and residency preceptors., Summary: The historical gold standard for assessing professional burnout is the Maslach Burnout Inventory (MBI); there is no established standard for professional fulfillment. The PFI is a 16-question assessment that has previously been validated in medical residents and practicing physicians. In this study, surveys including both PFI and MBI items were sent to active pharmacy residents and residency preceptors. To determine concurrent validity, domains of the PFI were compared to the closest related MBI domain as well as composite burnout rates measured in each portion of the survey. A total of 142 preceptors and 68 residents completed both the PFI and a version of the MBI previously validated in physicians. In assessing indicators of pharmacist burnout and fulfillment, data captured by domains of the PFI closely correlated with data captured by corresponding domains of the MBI (Pearson correlations of 0.683-0.822), with high internal consistency (Cronbach α of 0.866-0.903)., Conclusion: The PFI is a valid method of assessing burnout in both pharmacy residents and residency preceptors. Additionally, the PFI contributes a reliable system of assessing professional fulfillment while also being highly accessible for both research and residency program monitoring applications., (© American Society of Health-System Pharmacists 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Therapeutic drug monitoring in pediatric inflammatory bowel disease (IBD) has been used to achieve and maintain remission. Few guidelines exist to aid clinicians in the adjustment of anti-tumor necrosis factor therapies. The objective was to assess the agreement between real-world postinduction and posteriori analysis of retrospective data, using 2 novel pharmacokinetic (PK) models for adalimumab., Methods: A retrospective chart review was conducted in pediatric IBD patients treated with adalimumab. A Bayesian clinical decision support tool (InsightRX) was used. Postinduction serum concentration measurements of adalimumab were performed by drug-tolerant, homogenous shift mobility assay. Predicted serum adalimumab concentrations from both models were compared to the actual serum concentrations through a Bland-Altman analysis. Paired sample t test was used for equivalence., Results: A total of 47 patients were included. Forty-one patients (87%) had Crohn disease, and 30 (64%) were male. Most were induced with 160 mg of adalimumab and maintained on 40 mg biweekly. No significant difference resulted between the de Klaver average prediction and mean population concentration (p = 0.294). Significant difference was observed between Ternant and mean population serum adalimumab concentration (p < 0.001). The Bland-Altman plot for the de Klaver method showed no proportional bias. Additionally, 49% of patients required a dose adjustment during maintenance therapy., Conclusions: The de Klaver model was able to provide less bias than the Ternant model and may aid in predicting serum adalimumab concentrations. Approximately half of the patients required dose adjustment during maintenance therapy to obtain a therapeutic drug concentration or achieve clinical remission., (Copyright. Pediatric Pharmacy Association. All rights reserved. For permissions, email: membership@pediatricpharmacy.org.)

Purpose: Chronic disease state management utilizing pharmacists improves quality metrics, allows providers to focus on acute issues, and decreases physician burnout risk. Minimal data exist on pharmacist panel size and its impact. This study aimed to determine appropriate pharmacist panel size based on workload, quality metrics, and patient access., Methods: This study was a retrospective, multiclinic cohort analysis of patients with diabetes managed by pharmacists at 7 outpatient clinics. The primary objective calculated panel size per full-time equivalent (FTE) utilizing the National Health Interview Survey. Secondary objectives calculated the ideal FTE based on provider to pharmacist ratio and determined the impact of pharmacist panel size on patient access and quality metrics., Results: A total of 4,399 patients were analyzed from 2017 through 2019, with age (range, 57.4 to 62.6 years), sex (52.5% to 63.5% female), race (41.2% to 93.7% African American), insurance type (13.3% to 41% Medicaid), and mean number of medications (13.1 to 20.3) significantly different between sites. Primary outcome results showed that actual panel sizes were less than calculated. However, secondary outcomes indicated that each site was understaffed (actual 0.2 to 0.5 FTE vs calculated 2.52 to 7.34 FTEs) and overbooked (95% to 122% capacity, 17 to 54.2 days for time to third next available appointment). Patients met the composite quality metric 35.1% to 56.3% of the time across sites., Conclusion: This study supports the use of patient access data to determine appropriate pharmacist panel size. Utilizing provider panel size to pharmacist ratio and time to third next available appointment is preferable for determining appropriate pharmacist panel size. Further research is needed to evaluate return times to help determine an ideal pharmacist panel size., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Studies involving the glucagon-like peptide-1 receptor agonist (GLP-1 RA) liraglutide have shown reductions in hemoglobin A1c (HbA1c), weight, and insulin requirements in patients with type 2 diabetes mellitus (DM2) requiring high-dose insulin therapy. The effect of the class of GLP-1 RAs on these parameters is unknown., Data Sources: A retrospective cohort analysis was conducted in patients with DM2 where a GLP-1 RA was added to high-dose insulin therapy. The primary composite outcome was the change from baseline to 9 months in HbA1c, weight, and insulin dose., Results: GLP-1 RA therapy was associated with a significant reduction in HbA1c from baseline (-0.9%; P = 0.022). Weight and insulin dose were not significantly reduced from baseline. There was a moderate effect of individual agents on these outcomes, but no significant reductions were seen due to the small sample size., Limitations: Generalizability of these findings may be limited by the characteristics and size of the study population., Therapeutic Opinion: The effect of GLP-1 RA therapy on HbA1c may be attributed to the medication class. The effect of individual agents on weight and insulin requirements needs further investigation., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Nonsterile compounding is essential to meeting the individualized drug therapy needs of patients. While compounding education is a required component of Doctor of Pharmacy (PharmD) curricula, student training varies notably in scope, duration, and assessment across programs. Variations in training, coupled with a potential lack of emphasis on the importance of nonsterile compounding, may impact pharmacy students' interest in nonsterile compounding, their perceptions of its importance in pharmacy practice, and their pursuit of compounding careers. The objective of this study was to assess pharmacy student exposure to nonsterile compounding and determine its impact on their perceptions of nonsterile compounding and its applicability to their future careers. Faculty members at colleges and schools of pharmacy within the U.S. were asked to distribute cross-sectional surveys to pharmacy students in the Class of 2022. Surveys collected demographic information and addressed the following: nonsterile compounding experience; exposure to nonsterile compounding within PharmD curricula; and perceptions and expectations of nonsterile compounding. Tests of associations between nominally measured and ordinally measured survey questions were performed via Pearson chi-square tests. Associations between two ordinally measured questions were performed via Kendall's tau tests. In total, 252 students completed the survey. Numerous factors were associated with student perceptions and expectations of nonsterile compounding, including paid work experience in a compounding pharmacy, the number of semesters inclusive of nonsterile compounding education, and the perceived quality of didactic and experiential training in nonsterile compounding. It is imperative that pharmacy students receive nonsterile compounding education that not only ensures appropriate skill development but instills confidence and emphasizes the vital role of compounding pharmacists in patient care. Additional research is needed to determine how best to optimize compounding education to ensure students have sufficient exposure and opportunity for skill development and assessment., (Copyright© by International Journal of Pharmaceutical Compounding, Inc.)

Introduction: Does rural status influence glycemic outcomes among participants in the type 1 diabetes T1D Exchange clinic registry?, Research Design and Methods: Data from the T1D Exchange clinic registry between January 2016 and March 2018 were identified by rural-urban status and stratified by age and hemoglobin A1c (HbA1c). Multivariable regression modeling was performed to isolate HbA1c differences. A full model including all significant (p<0.05 via two-sided testing) differential factors was determined with an additional indicator for rural status, and adjusted for duration of diabetes, use of continuous glucose monitoring device, age, race/ethnicity, and private insurance status. The model was reduced using backwards elimination stepwise procedures until only significant factors remained., Results: Mean HbA1c levels for all rural participants were significantly higher (8.71%; 72 mmol/mol) compared with the urban group (8.48%; 69 mmol/mol), p<0.001. For youth under 13 years of age, rural participants had a higher mean HbA1c (8.65%; 71 mmol/mol) compared with urban (8.45% 69 mmol/mol), p=0.022. Rural youth (13-<18 years) had a higher mean HbA1c (9.39%; 79 mmol/mol) than urban youth (9.14%; 76 mmol/mol), p<0.001. Rural young adults (18-<26 years) had a higher mean HbA1c (9.07%; 76 mmol/mol) than urban young adults (8.88%; 74 mmol/mol), p=0.042. Rural adults (≥26 years; n=589) were the only group that did not have a higher mean HbA1c (7.76%, 61.3 mmol) than urban adults (n=4770; 7.72%, 60.9 mmol/mol), p=0.503. Rural locale was highly significant (beta=0.175, p<0.001) despite controlling for potentially confounding differences between rural and urban groups., Conclusions: Among this T1D Exchange cohort, there is a pattern of higher mean HbA1c being associated with rural status, even after adjustment for characteristic differences, most strikingly among those under 26 years of age. This disparity and contributing factors need to be more thoroughly studied to provide effective solutions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare the acceptance rate of pharmacist recommendations in an interdisciplinary team for patients interviewed by the pharmacist versus those assessed by chart review., Design: Retrospective chart review., Setting: Interdisciplinary consultative team in an outpatient setting as part of a large academic health system provided care for "high utilizer" patients., Participants: Sixty-five patients at moderate to high risk of hospitalization who completed their first appointment with the team between March 1, 2019, and December 30, 2019. Most patients were 65 years of age or older and all had Medicare insurance., Interventions: A pharmacist completed a chart review for all patients. A cohort of patients were also interviewed. Recommendations were recorded in the electronic medical record, discussed with the team, and forwarded to the patient's primary care provider., Results: A total of 253 recommendations were made by pharmacists, with a significantly higher acceptance rate for patients who completed an interview with the pharmacist (40.7% vs. 28.4%; P = 0.046). Patientspecific factors resulting in higher acceptance rates in the interview group included age younger than 65 years ( P = 0.013), 10 to 19 medications ( P = 0.004), and mental health diagnosis ( P = 0.02)., Conclusion: The addition of an interview to chart review allowed pharmacists to make recommendations that were more likely to be accepted and therefore more clinically impactful.

Background: The events of the coronavirus disease 2019 (COVID-19) pandemic forced the world to adopt telemedicine frameworks to comply with isolation and stay-at-home regulations. Telemedicine, in various forms, has been used by patients and medical professionals for quite some time, especially telepsychiatry. To examine the efficacy and role of telesimulation as a method to educate health sciences students via telepresence robots. The study recruited students from the above health science disciplines. All participants were trained to administer a contextual interview to a standardized patient (SP) for mental health concerns. Methods: The completion of the contextual interview observation form adult (CIOF-A), National Aeronautics and Space Administration Task Load Index, self-efficacy in patient centeredness questionnaire (SEPCQ), and communication skills attitude scale with or without a telepresence robot. All participants completed baseline metrics and were trained to conduct a contextual interview to an SP. Researchers block-randomized the participants to either the telepresence robot group (TP) or in-person (IP) group. Results: The study recruited n  = 43 participants to the IP group ( n  = 21) or TP group ( n  = 22). Mean participant demographics of age were 25.3 (±1.9) years in the IP group and 24.3 (±2.1) years for the TP group. Mean and standard deviation scores with effect sizes in CIOF-A scores IP: 0.05 (±1.91) and TP: -0.45 (±1.71), Cohen's d  = 0.28; SEPCQ-Patient Domain scores IP: 0.42 (±4.69) and TP: 0.50 (±7.18), Cohen's d  = 0.01; change in SEPCQ-Sharing Domain scores IP: 0.53 (±5.10) and TP: 0.91 (±9.98), Cohen's d  = 0.05. These effect sizes will inform future studies and appropriate sample sizes. Conclusion: These data indicate that health sciences students utilizing a telepresence robot in an SP scenario to perform a behavioral health screening felt as comfortable and competent as those health sciences students performing the same behavioral health screening in person. ClinicalTrials.gov Identifier: NCT03661372.

Background: Rates of mass casualty incidents (MCIs) have been on the rise in the United States, highlighting the need for health care systems to have an emergency response plan. Trauma centers are fundamental during MCIs and serve a crucial leadership role in preparedness for them., Objective: The purpose of this study was to describe the design and implementation of simulated MCI drills at an American College of Surgeons verified Level I trauma center in the Midwest., Methods: A quasi-experimental time-series design was utilized to determine MCI simulation effects on staff performance using an emergency department checklist to measure emergency department throughput time. A multidisciplinary MCI design team developed a checklist for the emergency department, which identified tasks required to complete it. The 16-item checklist, Critical Pathway Management methodology, was used to identify the critical pathway for patient throughput during a surge. Two in situ MCI simulation drills were conducted in the emergency department (October and December 2019), and Critical Pathway Management identified the primary patient throughput rate limiters as notification and inpatient nursing staff presentation., Results: Emergency department throughput decreased from a mean of 15 to 11 min (reduction of 26.7%) between the two time periods after focusing on rate-limiting tasks., Conclusion: This quality improvement project demonstrated that the use of institution-specific checklists and Critical Pathway Management to identify critical pathways and potential rate limiters led to patient throughput improvements., Competing Interests: The authors have no known conflict of interest to disclose related to this article., (Copyright © 2021 Society of Trauma Nurses.)

Background: Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients., Objective: In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program., Methods: The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities., Results: A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019., Conclusion: This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Society of Trauma Nurses.)

Background: United States student loan debt has surpassed $1.7 trillion and continues to rise. Generally described as a "crisis," the state of student loan debt in the United States is a subject of increasing consideration, research, and analysis by federal government agencies, nonprofit organizations, economists, and students who carry the balance. Excessive student loan debt has been hypothesized to affect students' career choice, diminish quality of life, negatively affect their ability to give back to society at large, and delay progress on achieving other financial goals such as saving for retirement. Current available research evaluating the impact of this debt on student pharmacists and new practitioners is limited., Objective: To assess the impact of student loan debt on financial stability, career choice, professional development, and overall well-being among pharmacists who received first licensure in Ohio within a 5-year period; hereafter referred to as "new practitioners.", Methods: An anonymous survey, consisting of 39 items, was administered using Verint survey software to new practitioners holding an active pharmacist license in Ohio with date of first licensure between May 1, 2012 and March 1, 2017., Results: Total of 4026 pharmacists were invited to participate in the survey, and there were 471 responses, yielding a response rate of 11.7%. Higher student loan debt was associated with perceived limitations regarding amount of available disposable income, career mobility, work satisfaction, charitable contributions, participation in professional organizations, retirement savings, purchasing a home, delay in starting a family, diminished quality of life, and worries about paying off student loans. However, this study did not find a statistically significant relationship between student loan debt and the decision to pursue a residency., Conclusion: On the basis of the results of this study, higher student loan debt has statistically significant effect on new practitioner's perception of their financial stability, ability to pursue professional development opportunities, and overall well-being., (Copyright © 2021 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Introduction: One critical aspect of successful simulation facilitation is development of written scenarios. However, there are no validated assessment tools dedicated to the evaluation of written simulation scenarios available. Our aim was to develop a tool to evaluate the quality of written simulation demonstrating content validity., Methods: A comprehensive literature search did not yield a validated assessment tool dedicated for the evaluation of written simulation scenarios. A subsequent search yielded six templates published for written simulation scenario design. From these templates, critical scenario elements were identified to create an evaluation instrument with six components of scenario quality with corresponding anchors and rating scale. Subsequently, a national group of simulation experts were engaged via survey methodology to rate the content of the proposed instrument. Ultimately, a modified two-round Delphi approach was implemented to demonstrate consensus of the final assessment tool., Results: 38 responses were obtained in round 1, while 22 complete responses were obtained in round 2. Round 1 kappa values ranged from 0.44 to 1.0, indicating moderate to almost perfect rater agreement for inclusion of the six proposed components. Kappa values specifically regarding scale and anchors ranged from 0 to 0.49. After revisions, there was a significant level of agreement (p<0.05) of all items of the proposed assessment tool in the second-round survey except for item 10. Of note, all initial respondents indicated that they had never evaluated written scenarios with an assessment tool., Conclusions: The Simulation Scenario Evaluation Tool, developed using a national consensus of content experts, is an instrument demonstrating content validity that assesses the quality of written simulation scenarios. This tool provides a basis to guide structured feedback regarding the quality of written simulation scenarios., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Antimicrobial stewardship of anti-infectives prescribed upon hospital discharge was implemented to improve the rate of appropriate prescribing at discharge. Appropriate prescribing significantly improved from 47.5% to 85.2% (P < .001), antimicrobial days of therapy decreased, and 30-day readmission rates decreased. Discharge antimicrobial stewardship was effective in improving anti-infective prescribing practices.

Objective. To examine the relationship between class attendance by Doctor of Pharmacy students and their performance on pharmacotherapy examinations within an active-learning classroom model. Methods. Second-year pharmacy students enrolled in a pharmacotherapy course series were included in the study (N=160). Class attendance was taken manually by members of the study team over a one-year study period (fall 2017 and spring 2018 semesters). Course attendance was not required and had no direct impact on student grades. Scores from the six competency-based examinations and overall course grades for each semester course, respectively, were then linked to class attendance records. Two additional examination attempts (retake and extended learning experience) were administered to students who did not receive a score of at least 80% on the initial exam or retake exam, respectively. Results. Class attendance was documented during 48 class sessions. Of the six examinations given each semester, students required an average of 1 retake of the examination during the fall semester and 1.5 retakes in the spring semester. A significant negative correlation was found in both courses between students missing more classes and receiving a lower final course grade. For each missed class session, there was a reduction in overall course grade of 0.18% and 0.14% in the fall and spring courses, respectively. Conclusion. Regular class attendance by pharmacy students enrolled in an active-learning pharmacotherapy curriculum was associated with higher scores on examinations. The results of this study illustrate the importance of attending active-learning sessions to attain higher examination scores. Further research is needed to determine whether class attendance is associated with students' improved ability to apply pharmacotherapy concepts., (© 2020 American Association of Colleges of Pharmacy.)

Background: With the regionalization of specialty care, there is an increasing need for interfacility transport from local to regional hospitals. There are very limited data on rates of cardiopulmonary resuscitation (CPR) during medical transport and relationship between transport-specific factors, such as transport program type and need of CPR during transport of critically ill patients. We present the first, multicenter, international report of CPR during medical transport using the large Ground and Air Medical qUality Transport (GAMUT) database., Methods: We retrospectively reviewed the GAMUT database from January 2014 to March 2017 for CPR during transport. We determined the overall CPR rate and CPR rates for adult, pediatric, and neonatal transport programs. The rate of CPR per total transports was expressed as percentage, and then, Spearman's rho nonparametric associations were determined between CPR and other quality metrics tracked in the GAMUT database. Examples include advanced airway presence, waveform capnography usage, average mobilization time from the start of referral until en route, 1 st attempt intubation success rate, and DASH1A intubation success (definitive airway sans hypoxia/hypotension on 1 st attempt). Data were analyzed using chi-square tests, and in the presence of overall significance, post hoc Bonferroni adjusted z tests were performed., Results: There were 72 programs that had at least one CPR event during the study period. The overall CPR rate was 0.42% (777 CPR episodes/184,272 patient contacts) from 115 programs reporting transport volume and CPR events from the GAMUT database during the study period. Adult, pediatric, and neonatal transport programs ( n  = 57, 40 and 16, respectively) had significantly different CPR rates ( P < 0.001) i.e., 0.68% (555/82,094), 0.18% (138/76,430), and 0.33% (73/21,823), respectively. Presence of an advanced airway and mobilization time was significantly associated with CPR episodes ( P < 0.001) (Rs = +0.41 and Rs  = -0.60, respectively). Other transport quality metrics such as waveform capnography, first attempt intubation, and DASH1A success rate were not significantly associated with CPR episodes., Conclusion: The overall CPR rate during medical transport is 0.42%. Adult, pediatric, and neonatal program types have significantly different overall rates of CPR. Presence of advanced airway and mobilization time had an association with the rate of CPR during transport., Competing Interests: All authors declare no conflicts of interest., (Copyright © 2020 Utpal S. Bhalala et al.)

Purpose: Recently, the American College of Graduate Medical Education included medical decision-making as a core competency in several specialties. To date, the ability to demonstrate and measure a pedagogical evolution of medical judgment in a medical education program has been limited. In this study, we aim to examine differences in medical decision-making of physician groups in distinctly different stages of their postgraduate career., Methods: The study recruited physicians with a wide spectrum of disciplines and levels of experience to take part in 4 medical simulations divided into 2 categories, abdominal pain (biliary colic [BC] and renal colic [RC]) or chest pain (cardiac ischemia with ST-segment elevation myocardial infarction [STEMI] and pneumothorax [PTX]). Evaluation of medical decision-making used the Medical Judgment Metric (MJM). The targeted selection criteria for the physician groups are administrative physicians (APs), representing those with the most experience but whose current duties are largely administrative; resident physicians (RPs), those enrolled in postgraduate medical or surgical training; and mastery level physicians (MPs), those deemed to have mastery level experience. The study measured participant demographics, physiological responses, medical judgment scores, and simulation time to case resolution. Outcome differences were analyzed using Fisher exact tests with post hoc Bonferroni-adjusted z tests and single-factor analysis of variance F tests with post hoc Tukey honestly significant difference, as appropriate. The significance threshold was set at P  < .05. Effect sizes were determined and reported to inform future studies., Results: A total of n = 30 physicians were recruited for the study with n = 10 participants in each physician group. No significant differences were found in baseline demographics between groups. Analysis of simulations showed a significant ( P  = .002) interaction for total simulation time between groups RP: 6.2 minutes (±1.58); MP: 8.7 minutes (±2.46); and AP: 10.3 minutes (±2.78). The AP MJM scores, 12.3 (±2.66), for the RC simulation were significantly ( P  = .010) lower than the RP 14.7 (±1.15) and MP 14.7 (±1.15) MJM scores. Analysis of simulated patient outcomes showed that the AP group was significantly less likely to stabilize the participant in the RC simulation than MP and RP groups ( P  = .040). While not significant, all MJM scores for the AP group were lower in the BC, STEMI, and PTX simulations compared with the RP and MP groups., Conclusions: Physicians in distinctly different stages of their respective postgraduate career differed in several domains when assessed through a consistent high-fidelity medical simulation program. Further studies are warranted to accurately assess pedagogical differences over the medical judgment lifespan of a physician., Competing Interests: Declaration of Conflicting Interests:The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: For M.L.M.C., R.L.G., and R.A.A., a percentage of time was paid by the subcontract grant with Zin Technologies, Inc. M.D.G. and A.S. served as a consultant paid by the subcontract grant with Zin Technologies, Inc. The other authors declared no potential conflict of interest to disclose., (© The Author(s) 2020.)

Background: To investigate differences in the tibial tubercle-trochlear groove (TT-TG) and patellar tendon-posterior cruciate ligament (PT-PCL) distances in symptomatic patients with non-contact internal knee derangements (IKD) and symptomatic patients with internally intact knees (control)., Methods: A retrospective review of MRI studies was completed by comparing 78 patients with meniscal and ligamentous derangements of the knee to 63 internally intact knees (age range, 13 to 50 years). MRI findings were reviewed independently by two board-certified radiologists to assess for agreement. TT-TG and PT-PCL distances were measured on proton density-weighted axial images by two independent observers blinded to the MRI and arthroscopic findings. Independent t tests were used to determine differences in TT-TG distance between the internal derangement and control groups. Chi-square tests were used to compare categorical variables for distributional equality between study groups., Results: The mean TT-TG distance averaged across the two raters in the IKD group was 11.5 mm (95% confidence interval [CI], 10.6-12.4), compared to 8.3 mm (95% CI, 7.6-9.0) in the control group (p < 0.001). The mean PT-PCL distance similarly averaged across both raters was 20.6 mm (95% CI, 19.7-21.5) for the IKD group compared to 18.2 mm (95% CI, 17.2-19.2) for the control group (p < 0.001). Among the IKD group, there were 51 meniscal tears, 12 cruciate ligament tears, and 15 tears with a combination of meniscal and cruciate findings. IKD was significantly correlated with greater TT-TG distance (p < 0.001) and greater PT-PCL distance (p < 0.003) when compared with control., Conclusions: Increased TT-TG distances and PT-PCL distances are associated with both cartilaginous and ligamentous internal knee injuries in the present study, with TT-TG distances greater than the 12 mm representing a new threshold for concern.

Current surgical options for treating genu varum in achondroplasia include tibial and fibular osteotomy and growth modulation using plates and screws. However, a single surgeon consistently treated genu varum using a planned fibular nonunion (PFN). The purpose of this study is to describe his surgical technique and report radiographic and clinical outcomes for the cohort studied.This is an observational retrospective review. The cohort studied included patients with achondroplasia who had PFN surgery for the treatment of genu varum at a young age (<13 years) and was followed through to skeletal maturity. The surgery included meticulous closure of the periosteum over the remaining fibula. The surgery was considered a success if the patient did not require subsequent surgery and had acceptable or improved clinical alignment. Radiographic measures used to determine change in genu varum included the anatomic tibio-femoral angle (aTFA), tibia varus, and tibia-fibula ratio. Clinically, changes in lower limb alignment were defined using a plumb line and 6 categories of alignment ranging from extreme varus to valgus. Statistics were used to validate the plumb line categorization to available radiographic measures. Other appropriate statistical methods were used with P < .05 considered significant.Of the 53 PFN cases (27 patients) included in the study, 34 (64%) did not require subsequent surgery and had acceptable or improved alignment. The average age at surgery and follow-up was 6.1 and 17.0 years, respectively. For the 37 limbs (19 patients) with available radiographs, pre- and post-surgery radiographic measures significantly improved including aTFA (3° varus to 2° valgus, P = .003), tibia varus (2° varus to 3° valgus, P = .004), and the tibia-fibula ratio (0.977 to 1.013, P < .001). Clinically, 32 cases (60%) demonstrated significant improvement by translating into an improved alignment and 9 (17%) remained the same (P < .01). Complications were minimal and insignificant. Failures were readily managed by tibia-fibular osteotomies in adolescence and at maturity.PFN for the treatment of genu varum in young achondroplasia patients significantly improved radiographic and clinical measures of lower limb alignment through skeletal maturity with relatively few complications.

Background: Postpartum hemorrhage prophylaxis guidelines lack consensus and do not address the major factor of delivery mode. This creates quality and safety concerns. The objective of this study was to evaluate the effect of implementing a standardized prophylaxis protocol on postpartum hemorrhage treatment by delivery mode., Methods: A secondary analysis was conducted of all women ≥ 24 weeks' gestational age who delivered from January 2010 to June 2015 at one perinatal center. Women were grouped according to delivery pre-protocol (nonstandardized postpartum oxytocin) or post-protocol (standardized postpartum oxytocin). This retrospective cohort study compared outcomes by delivery mode. The primary outcome was treatment for postpartum hemorrhage or uterine atony., Results: A total of 16,811 women were studied, stratified by three delivery modes: spontaneous vaginal (n = 10,542), operative vaginal (n = 963), and cesarean (n = 5,306). Delivery post-protocol introduction was associated with a lower treatment rate of postpartum hemorrhage for spontaneous vaginal (5.7% vs. 3.1%; p < 0.001) and cesarean (9.4% vs. 7.8%; p = 0.036) modes. Delivery post-protocol introduction was associated with a decreased risk of the primary composite outcome across all modes: spontaneous vaginal (adjusted odds ratio [AOR] = 0.537; 95% confidence interval [CI]: 0.442-0.653), operative vaginal (AOR = 0.490; 95% CI: 0.285-0.842), and cesarean (AOR = 0.812; 95% CI: 0.666-0.988)., Conclusion: A standardized oxytocin protocol was associated with a lower postpartum hemorrhage treatment rate for cesarean and vaginal deliveries, but not for operative vaginal deliveries. The prophylactic effect of our higher dose protocol had the strongest benefit with women delivering vaginally., (Copyright © 2019. Published by Elsevier Inc.)

Background: While academic detailing seems to be the most promising intervention to improve prescribing patterns, implementation could be challenging for small community practices. Objective: A pharmacy-led, interactive, and tailored small-group academic detailing in a federally qualified health center is described. The primary objective of the study was to determine if the small-group academic detailing improved the prescribing patterns of the medical providers for select disease states: type 2 diabetes mellitus (T2DM), hyperlipidemia (HLD), and essential hypertension (HTN). Methods: Prescribing patterns in a federally qualified health center were examined in relation to small-group academic detailing sessions from April 2010 to March 2015. The markers for improvement were the increase in utilizing metformin and statins in patients diagnosed with T2DM and HLD, respectively, and the reduction of β-blocker use in patients diagnosed with essential HTN. Changes in prescribing patterns were evaluated using Pearson's χ 2 and Fisher's exact tests. Results: The average number of active, adult patients with T2DM, HLD, and essential HTN was 839, 1768, and 2547, respectively. Utilization of metformin in T2DM increased from 5.5% at baseline to 37.7%, statin utilization in HLD increased from 77.1% to 86.9%, and β-blocker use in HTN decreased from 17.9% to 13.8% ( P < .005). Conclusions: A pharmacy-led, small-group academic detailing program improved and maintained appropriate prescribing patterns in an underserved community practice. This study serves as a successful pilot emphasizing the pharmacist's role as an educator and a resource to medical providers regarding appropriate medication use., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2018.)

Background: Spin-reporting that distorts the interpretation of results-is not unusual within scientific literature., Objective: To appraise strategies of spin among placebo-controlled double-blind clinical trials of topical treatments for photoaged skin., Methods: A systematic review of the literature was performed to identify placebo-controlled double-blind clinical trials of topical treatments for photoaged skin. A survey of spin strategies was developed and applied to the cohort of identified studies., Results: The systematic review led to the identification of 20 studies in which various types of spin strategies, broadly classified as either inappropriate statistical analyses or inappropriate interpretation of results, were used. The most commonly used strategies included use of multiple primary outcomes (95%), inappropriate extrapolation of results from specific outcomes to global improvements (95%), focus on within-group comparisons (75%), and focus on interim analyses to give more weight to nonsignificant findings (65%)., Limitations: Classification of spin strategies was subjective and might not encompass all the methods used in the published literature., Conclusion: Findings in this study inform efforts to reduce spin in the dermatologic literature., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal death, and its rate and severity have been increasing. Oxytocin is widely recommended for PPH prophylaxis, but consensus is lacking on the dose or duration, leading to disparate and subjective practices. In this study, clinical outcomes were compared before and after introduction of a quality measure: a standardized oxytocin protocol for PPH prophylaxis., Methods: A retrospective cohort study was conducted of postpartum women ≥24 weeks' gestation delivered from 2010 to 2015. Women were grouped according to delivery pre-protocol (PREP) or post-protocol (POSTP) then subgrouped by specified criteria indicating low risk for PPH. The protocol was standardized for all POSTP women: 60 units of oxytocin over 5.25 hours postdelivery. The primary outcome was a composite: defined treatment for hemorrhage or uterine atony., Results: Of 16,811 women included, 46.3% were PREP (n = 7,791), and 53.7% were POSTP (n = 9,020). A total of 2,315 subjects (13.8%) met low risk for PPH criteria. The primary outcome rate was lower after protocol introduction for all subjects (7.0% vs. 4.6%; p <0.001) and low-risk subset women (3.8% vs. 1.4%; p <0.001). Delivery after protocol introduction was associated with a decreased risk of the primary outcome among all subjects women (adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI] = 0.55-0.72) and low-risk subset women (AOR, 0.33; 95% CI = 0.19-0.57)., Conclusion: Standardized, higher-dose postpartum oxytocin may be associated with less PPH treatment in this cohort. These findings support standardization and set the stage for a randomized controlled trial., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is an important gender-affirming procedure sought by many transmasculine and nonbinary individuals. Current literature is focused primarily on details of surgical technique and complication rates, with limited data available on how top surgery affects subjective quality-of-life measures., Methods: An anonymous online survey was distributed to 81 of the senior author's former top-surgery patients. The survey response rate was 72 percent (58 respondents). Responses were analyzed to investigate quality of life, sexual confidence, mental health, satisfaction with top surgery, and patient attitudes toward top surgery's role in gender affirmation., Results: Following top surgery, measures of quality of life and sexual confidence improved significantly (p < 0.001). In addition, 86 percent reported improvement in gender dysphoria-related mental health conditions. All but one respondent reported that top surgery had an overall positive impact on their life., Conclusions: Top surgery had major positive effects on all mental health and quality-of-life metrics. The authors' findings contribute to a much-needed body of evidence that top surgery markedly improves the daily lives and functioning of transgender and nonbinary individuals who choose to undergo it.

Background: Mechanical ventilation is a complex topic that requires an in-depth understanding of the cardiopulmonary system, its associated pathophysiology and comprehensive knowledge of equipment capabilities., Introduction: The use of telepresent faculty to train providers in the use of mechanical ventilation using medical simulation as a teaching methodology is not well established. The aim of this study was to compare the efficacy of telepresent faculty versus traditional in-person instruction to teach mechanical ventilation to medical students., Materials and Methods: Medical students for this small cohort pilot study were instructed using either in-person instruction or telementoring. Initiation and management of mechanical ventilation were reviewed. Effectiveness was evaluated by pre- and post-multiple choice tests, confidence surveys and summative simulation scenarios. Students evaluated faculty debriefing using the Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV)., Results: A 3-day pilot curriculum demonstrated significant improvement in the confidence (in person P<0.001; telementoring P=0.001), knowledge (in person P<0.001; telementoring P=0.022) and performance (in person P<0.001; telementoring P<0.002) of medical students in their ability to manage a critically ill patient on mechanical ventilation. Participants favoured the in-person curriculum over telepresent education, however, resultant mean DASH-SV scores rated both approaches as consistently to extremely effective., Discussion: While in-person learners demonstrated larger confidence and knowledge gains than telementored learners, improvement was seen in both cases. Learners rated both methods to be effective. Technological issues may have contributed to students providing a more favourable rating of the in-person curriculum., Conclusions: Telementoring is a viable option to provide medical education to medical students on the fundamentals of ventilator management at institutions that may not have content experts readily available., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Children admitted to the general care floor sometimes require acute escalation of care and rapid transfer (RT) to the PICU shortly after admission. In this study, we aim to investigate the characteristics of RTs and the impact RTs have on patient outcomes, including PICU length of stay (LOS), mortality, and emergency transfer defined as critical care interventions occurring within 1 hour on either side of transfer to the PICU., Methods: We conducted a 2-year, single-center, retrospective analysis including all patients admitted to the general care floor of a tertiary children's hospital that were subsequently transferred to the PICU, with attention to those transferred within 4 hours of admission, meeting criteria as RTs. Patient-level data and outcomes were tracked. Statistical summaries were stratified by RT or non-RT strata and between-strata comparisons were performed. Significant univariate factors were entered into a multivariate logistic regression model and reduced with statistical significance required for final model inclusion., Results: Of 450 patients with an unplanned PICU transfer, 105 (23.3%) experienced RTs. Significant factors in the reduced multivariate logistic regression model associated with decreased risk for RT were increased baseline Pediatric Overall Performance Category ( P = .046) and PICU origin of admission ( P = .012). RT patients had shorter PICU LOSs (2.8 vs 5.5 days, P < .001) compared with non-RT patients despite a higher rate of emergency transfer (15.2% vs 7.5%, P = .018) and no difference in mortality ( P = .741)., Conclusions: In this study, we demonstrate RTs have an increase in emergency transfer rate but no apparent risk of increased PICU LOS or mortality., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Introduction: Tracheal intubation (TI) is a lifesaving critical care skill. Failed TI attempts, however, can harm patients. Critical care transport (CCT) teams function as the first point of critical care contact for patients being transported to tertiary medical centers for specialized surgical, medical, and trauma care. The Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement Collaborative uses a quality metric database to track CCT quality metric performance, including TI. We sought to describe TI among GAMUT participants with the hypothesis that CCT would perform better than other prehospital TI reports and similarly to hospital TI success., Methods: The GAMUT Database is a global, voluntary database for tracking consensus quality metric performance among CCT programs performing neonatal, pediatric, and adult transports. The TI-specific quality metrics are "first attempt TI success" and "definitive airway sans hypoxia/hypotension on first attempt (DASH-1A)." The 2015 GAMUT Database was queried and analysis included patient age, program type, and intubation success rate. Analysis included simple statistics and Pearson chi-square with Bonferroni-adjusted post hoc z tests (significance = p < 0.05 via two-sided testing)., Results: Overall, 85,704 patient contacts (neonatal n [%] = 12,664 [14.8%], pediatric n [%] = 28,992 [33.8%], adult n [%] = 44,048 [51.4%]) were included, with 4,036 (4.7%) TI attempts. First attempt TI success was lowest in neonates (59.3%, 617 attempts), better in pediatrics (81.7%, 519 attempts), and best in adults (87%, 2900 attempts), p < 0.001. Adult-focused CCT teams had higher overall first attempt TI success versus pediatric- and neonatal-focused teams (86.9% vs. 63.5%, p < 0.001) and also in pediatric first attempt TI success (86.5% vs. 75.3%, p < 0.001). DASH-1A rates were lower across all patient types (neonatal = 51.9%, pediatric = 74.3%, adult = 79.8%)., Conclusions: CCT TI is not uncommon, and rates of TI and DASH-1A success are higher in adult patients and adult-focused CCT teams. TI success rates are higher in CCT than other prehospital settings, but lower than in-hospital success TI rates. Identifying factors influencing TI success among high performers should influence best practice strategies for TI.

Objectives: Telepresent education is becoming an important modality in medical education, as it provides a means for instructors to lead education sessions via videoconferencing technologies. This study aimed to compare the effectiveness of telepresent ultrasound training versus traditional in-person ultrasound training., Methods: Medical student cohorts were educated by either traditional in-person instruction or telementoring on how to perform a focused assessment with sonography for trauma (FAST) examination. Effectiveness was evaluated by pre- and post-multiple-choice tests (knowledge), confidence surveys, and summative simulation scenarios (hands-on FAST simulation). Formative simulation scenario debriefings were evaluated by each student using the Debriefing Assessment for Simulation in Healthcare student version (DASH-SV)., Results: Each method of instruction had significant increases in knowledge, confidence, and hands-on FAST simulation performance (P < .05). The collective increase in knowledge was greater for the in-person group, whereas the improvement in FAST examination performance during simulations was greater for the telementored group. Confidence gains were comparable between the groups. The DASH-SV scores were significantly higher for the in-person group for each criterion; however, both methods were deemed effective via median scoring., Conclusions: Telepresent education is a viable option for teaching the FAST examination to medical students., (© 2018 by the American Institute of Ultrasound in Medicine.)

Objective: Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking., Methods: The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests)., Results: Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance., Conclusion: Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks., (Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Background: The National Aeronautics and Space Administration (NASA) developed plans for potential emergency conditions from the Exploration Medical Conditions List. In an effort to mitigate conditions on the Exploration Medical Conditions List, NASA implemented a crew medical officer (CMO) designation for eligible astronauts. This pilot study aims to add knowledge that could be used in the Integrated Medical Model., Methods: An analogue population was recruited for two categories: administrative physicians (AP) representing the physician CMOs and technical professionals (TP) representing the non-physician CMOs. Participants completed four medical simulations focused on abdominal pain: cholecystitis (CH) and renal colic (RC) and chest pain: cardiac ischaemia (STEMI; ST-segment elevation myocardial infarction) and pneumothorax (PX). The Medical Judgment Metric (MJM) was used to evaluate medical decision making., Results: There were no significant differences between the AP and TP groups in age, gender, race, ethnicity, education and baseline heart rate. Significant differences were noted in MJM average rater scores in AP versus TP in CH: 13.0 (±2.25), 4.5 (±0.48), p=<0.001; RC: 12.3 (±2.66), 4.8 (±0.94); STEMI: 12.1 (±3.33), 4.9 (±0.56); and PX: 13.5 (±2.53), 5.3 (±1.01), respectively., Discussion: There could be a positive effect on crew health risk by having a physician CMO. The MJM demonstrated the ability to quantify medical judgement between the two analogue groups of spaceflight CMOs. Future studies should incorporate the MJM in a larger analogue population study to assess the medical risk for spaceflight crewmembers., Competing Interests: Competing interests: Summa Health System received financial support for this study. The funding was provided entirely by a subcontract with Zin Technologies, Inc. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The authors report no other conflicts of interest.

Background: Structured training courses have shown to improve patient outcomes; however, guidelines are inconsistently applied in up to 50% of all neonatal resuscitations. This is partly due to the fact that psychomotor skills needed for resuscitation decay within 6 months to a year from the completion of a certification course. Currently, there are no recommendations on how often refresher training should occur to prevent skill decay., Purpose: Improve provider proficiency and confidence in the performance of neonatal resuscitation with a focus on chest compression effectiveness., Methods: The study recruited neonatal intensive care unit providers (n = 25). A simulation-based Neonatal Resuscitation Program (NRP) curriculum was developed and executed. Training sessions were delivered utilizing in situ simulations at varying time intervals. Pre- and postconfidence surveys and practicum skill scores were collected and evaluated by a content expert. Categorical data were summarized by frequency and percentage and tested for distributional equality via Pearson chi-square tests or Fisher exact tests depending on cell sample size distribution. All statistical tests were 2-sided with P < .05 considered statistically significant., Results: Provider overall confidence and rate of chest compressions improved; however, there was no statistically significant difference between groups. Rolling refresher training at varied time intervals did not demonstrate statistically significant differences in chest compression quality among NRP providers., Implications for Practice: Rolling refresher training more frequently than every 6 months may not provide added benefit to NRP providers., Implications for Research: Additional research is needed to determine optimal refresher training frequency to prevent skill decay.

Background: Medical decision making is a critical, yet understudied, aspect of medical education. Aims: To develop the Medical Judgment Metric (MJM), a numerical rubric to quantify good decisions in practice in simulated environments; and to obtain initial preliminary evidence of reliability and validity of the tool. Methods: The individual MJM items, domains, and sections of the MJM were built based on existing standardized frameworks. Content validity was determined by a convenient sample of eight experts. The MJM instrument was pilot tested in four medical simulations with a team of three medical raters assessing 40 participants with four levels of medical experience and skill. Results: Raters were highly consistent in their MJM scores in each scenario (intraclass correlation coefficient 0.965 to 0.987) as well as their evaluation of the expected patient outcome (Fleiss's Kappa 0.791 to 0.906). For each simulation scenario, average rater cut-scores significantly predicted expected loss of life or stabilization (Cohen's Kappa 0.851 to 0.880). Discussion : The MJM demonstrated preliminary evidence of reliability and validity.

Background: The preferred route for providing nutrition in the pediatric intensive care unit is enteral. Placement of postpyloric feeding tubes using an electromagnetic-tipped stylet that emits a signal detected by a device held over the patient's abdomen is effective in adult intensive care units, but has not been well studied in pediatric units., Objectives: To determine the effectiveness of the electromagnetic device in reducing the numbers of radiation exposures, intrahospital transports, tubes used, and tube placement attempts in the pediatric intensive care unit., Methods: Data from a historical control group were compared with data from a prospective intervention group of patients less than 18 years of age and weighing at least 3 kg who required a postpyloric feeding tube in a 23-bed pediatric intensive care unit. Primary outcome was number of radiation exposures. Independent-samples Student t tests were used to compare the 2 study groups for mean equality; Pearson χ 2 tests were used to compare categorical data. Statistical testing was 2-sided, and P less than .05 was considered statistically significant., Results: Of 73 children (30 in control group, 43 in intervention group), those in the intervention group had a higher success rate at tube placement ( P = .009) and fewer radiation exposures ( P = .006), intrahospital transports ( P = .004), and tubes used ( P < .001)., Conclusions: Successful placement of postpyloric feeding tubes by nurse practitioners was safely enhanced using an electromagnetic device. Establishing users' expertise with the device before studying outcomes may improve effectiveness., (©2017 American Association of Critical-Care Nurses.)

Study Objective: To assess the association between medroxyprogesterone acetate exposure and bone mineral density (BMD) loss and weight change in adolescents., Design: Forty-eight-week prospective, randomized trial conducted May 2012-April 2014., Setting: Recruitment occurred in the general community and outpatient clinics in central Ohio., Participants: Self-referred sample of 34 female adolescents aged 12-21 years initiating depot medroxyprogesterone acetate (DMPA)., Interventions: Randomization to 1 of 3 DMPA doses (150, 104, or 75 mg) given intramuscularly every 12 weeks for 48 weeks., Main Outcome Measures: Absolute and percent change in BMD from 0-48 weeks at the L1-L4 lumbar spine, total hip, and femoral neck; absolute and percent change in weight at 48 weeks., Results: DMPA dose was associated with medroxyprogesterone acetate exposure as evidenced by a direct relationship (P < .001) between dose group and area under the concentration time curve. At 48 weeks, no significant BMD decreases were seen in the 75 mg dose group. The 104 and 150 mg dose groups experienced significant (P < .01) decreases in L1-L4 lumbar spine BMD (3.1% and 4.0%, respectively). The 150 mg group also had significant (P < .05) decreases in total hip (3.0%) and femoral neck (4.0%) BMD. No group differences in weight change were observed. No pregnancies occurred in any DMPA dose group., Conclusions: Our data provide evidence of a dose-response relationship between DMPA and BMD loss. Intramuscular DMPA doses less than 150 mg can decrease risk of BMD loss in adolescents. The risk/benefit ratio of lower-dose DMPA should be further investigated in larger and more diverse adolescent populations., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to determine the rate of pain assessment in pediatric neonatal critical care transport (PNCCT). The GAMUT database was interrogated for an 18-month period and excluded programs with less than 10% pediatric or neonatal patient contacts and less than 3 months of any metric data reporting during the study period. We hypothesized pain assessment during PNCCT is superior to prehospital pain assessment rates, although inferior to in-hospital rates. Sixty-two programs representing 104,445 patient contacts were analyzed. A total of 21,693 (20.8%) patients were reported to have a documented pain assessment. Subanalysis identified 17 of the 62 programs consistently reporting pain assessments. This group accounted for 24,599 patients and included 7,273 (29.6%) neonatal, 12,655 (51.5%) pediatric, and 4,664 (19.0%) adult patients. Among these programs, the benchmark rate of pain assessment was 90.0%. Our analysis shows a rate below emergency medical services and consistent with published hospital rates of pain assessment. Poor rates of tracking of this metric among participating programs was noted, suggesting an opportunity to investigate the barriers to documentation and reporting of pain assessments in PNCCT and a potential quality improvement initiative., (Copyright © 2016 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: 58.9 ± 8.9 versus post: 72.8 ± 6.1, p = 0.01) and CS total scores (pre: 22.2 ± 6.4 versus post: 29.9 ± 3.4, p = 0.007). Significant differences were noted in airway management, p = 0.008; appropriate cycles of drug/shock-CPR, p = 0.008; left uterine displacement, p = 0.008; and identifying causes of cardiac arrest, p = 0.008. Nonsignificant differences were noted for administration of appropriate drugs/doses, p = 0.074; chest compressions, p = 0.074; bag-mask ventilation before intubation, p = 0.074; and return of spontaneous circulation identification, p = 0.074. Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.

Study Design: Retrospective case series., Objectives: To compare radiographic and clinical outcomes in posterior spine fusions with pedicle screw instrumentation of varying screw densities in the treatment of adolescent idiopathic scoliosis (AIS)., Summary of Background Data: Posterior spinal fusion with pedicle screw instrumentation is the mainstay of surgical treatment for AIS. The most commonly used construct consists of screws placed at every level on the concave side of the deformity and nearly every level on the convex side. However, some surgeons have begun using constructs with fewer pedicle screws. The literature comparing outcomes of these differing pedicle screw constructs is limited., Methods: Fifty-two consecutive cases of posterior spinal fusions for AIS performed by four surgeons were reviewed. High screw density constructs were used in 26 cases and limited screw density constructs in 26 cases. Construct characteristics and radiographic measurements were compared preoperatively and at last follow-up. Operative time and estimated costs were also evaluated. Student t tests were used to compare the groups with p < .05 considered significant., Results: There was no significant difference in magnitude of correction for the high versus limited screw density group initially (38.5° vs. 34.9°, p = .093) or at final follow-up (36.9° vs. 32.2°, p = .054). Sagittal alignment, coronal balance, and translation of the major apical vertebra were comparable and stable in both groups. The high versus limited screw density group utilized significantly more pedicle screws (16.8 vs. 11.6 screws, p < .0001), had longer operative times (309 vs. 267 minutes, p = .007), and had additional estimated direct costs of $5,800., Conclusions: Excellent curve correction, stability, and balance can be achieved using fewer screws than commonly used in posterior pedicle screw fusions for AIS. Operative time is reduced, and risk and cost are decreased with the use of limited screw density constructs., Level of Evidence: III., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Objectives. Management of mechanically ventilated patients may pose a challenge to novice residents, many of which may not have received formal dedicated critical care instruction prior to starting their residency training. There is a paucity of data regarding simulation and mechanical ventilation training in the medical education literature. The purpose of this study was to develop a curriculum to educate first-year residents on addressing and troubleshooting ventilator alarms. Methods. Prospective evaluation was conducted of seventeen residents undergoing a twelve-hour three-day curriculum. Residents were assessed using a predetermined critical action checklist for each case, as well as pre- and postcurriculum multiple-choice cognitive knowledge questionnaires and confidence surveys. Results. Significant improvements in cognitive knowledge, critical actions, and self-reported confidence were demonstrated. The mean change in test score from before to after intervention was +26.8%, and a median score increase of 25% was noted. The ARDS and the mucus plugging cases had statistically significant improvements in critical actions, p < 0.001. A mean increase in self-reported confidence was realized (1.55 to 3.64), p = 0.049. Conclusions. A three-day simulation curriculum for residents was effective in increasing competency, knowledge, and confidence with ventilator management.

Background: There are nearly 200,000 US infants/children transported annually for specialty care and there are no published best practices in transport intubation., Objective: Respiratory interventions are a priority in pediatric and neonatal critical care transport (PNCCT). A recent Delphi study identified intubation performance as an important PNCCT quality metric, though data are insufficient. The objective of the study is to determine multi-center rates of first attempt intubation success in pediatric/neonatal transport and identify practice processes associated with higher performing centers., Methods: Retrospective chart review where data was collected from the 9 participating centers over a 6-month period from January-June 2013. Data describing intubation training and practices were gathered using SurveyMonkey® (Palo Alto, CA). Data were tabulated in Microsoft Excel (Redmond, WA) and analyzed using descriptive statistics. Through the determination of 1(st) intubation success rate across multiple pediatric/neonatal critical care transport programs, we hypothesized that the features of higher and lower performing centers can be identified to inform practice., Results: 9 of 14 invited institutions participated. The median (IQR) 6-month transport volume for neonates(neo) was 289(35-646) and pediatric (ped) 510(122-831). On average, 7%(+/-3.0) of neo and 1.6%(+/-0.7) of ped transport patients required intubation. Individual centers had their initial success rate calculated and a 95% confidence interval was determined for those centers satisfying the np > 5 and n(1-p) > 5 sample size requirement for normality assumption of proportions. Since the overall success rate was 64%, it was determined that n = 14 initial intubation attempts would be the minimum number needed per center in order to fulfill the sample size requirement for normality assumption. Centers whose 95% confidence interval did not contain the initial overall success rate were identified., Conclusion: This represents the first multi-center neo/ped intubation dataset in PNCCT. First attempt intubation success lags behind reported anesthesia intubation rates but parallels pediatric emergency department intubation success rates. Training and operational processes are variable in PNCCT, though top performing teams require live-patient intubation success to achieve initial intubation competency.

Objectives: Hip fractures account for less than 1% of all pediatric fractures; however, femoral head osteonecrosis (ON) after this injury ranges from 0% to 92%. The aim of this investigation was to add our experience to the literature and identify factors that may increase or decrease the risk of ON in pediatric patients with hip fractures., Design: Institutional review board-approved retrospective review., Setting: Pediatric level II trauma center., Patients/participants: Two hundred fifty-five pediatric hip fracture cases were reviewed from 1983 to 2009. Children were excluded if they had metabolic bone disease, subtrochanteric or pathologic fractures, slipped capital femoral epiphysis, or less than 1 year follow-up. This left 43 patients with 44 fractures in the study., Intervention: Standard fixation procedures., Main Outcome Measurements: Factors that could influence ON were analyzed and included age, Delbet classification, displacement, time to reduction, reduction quality and type, and whether a decompression was performed. Fisher exact tests were used with P <0.05 considered statistically significant., Results: Of the 44 cases included in the study, 9 (20%) developed ON. Age ≥11 years was the only statistically significant independent predictor of ON (P = 0.04). The details of 3 unique cases are also presented., Conclusions: The rate of ON in this case series was 20%. No ON occurred in any child <11 years old. We were unable to demonstrate that earlier time to reduction reduced the incidence of ON., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Abstract Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.