자연주의적 탐구조사(Naturalistic Inquiry)

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

Pedagosko i psiholosko testiranje i procjenjivanje spadaju među najvažnije doprinose znanosti o ponasanju nasem drustvu i pružaju temeljna i znacajna poboljsanja u odnosu na ranije postupke. Iako se ne može ustvrditi da su svi testovi dovoljno usavrseni niti da su sva testiranja razborita i korisna, postoji velika kolicina informacija koje ukazuju na ucinkovitost kvalitetnih instrumenata u onim situacijama u kojima je njihovo koristenje potkrijepljeno validacijskim podacima. Pravilna upotreba testova može dovesti do boljih odluka o pojedincima i programima nego sto bi to bio slucaj bez njihovog koristenja, a također i ukazati na put za siri i pravedniji pristup obrazovanju i zaposljavanju. Međutim, losa upotreba testova može dovesti do zamjetne stete nanesene ispitanicima i drugim sudionicima u procesu donosenja odluka na temelju testovnih podataka. Cilj Standarda je promoviranje kvalitetne i eticne upotrebe testova te uspostavljanje osnovice za ocjenu kvalitete postupaka testiranja. Svrha objavljivanja Standarda je uspostavljanje kriterija za evaluaciju testova, provedbe testiranja i posljedica upotrebe testova. Iako bi evaluacija prikladnosti testa ili njegove primjene trebala ovisiti prvenstveno o strucnim misljenjima, Standardi pružaju okvir koji osigurava obuhvacanje svih relevantnih pitanja. Bilo bi poželjno da svi autori, sponzori, nakladnici i korisnici profesionalnih testova usvoje Standarde te da poticu druge da ih također prihvate.

Standards for educational and psychological testing

https://globalhealth.duke.edu/sites/default/files/event-attachments/2.18_meara.pdf

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

Methods  This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969–2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003–2009.

Results  The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

Conclusions  Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

Medical Education 2010: 44: 50–63

A critical review of simulation-based medical education research: 2003-2009

Purpose This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP). Method This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.

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Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence

Objective:To determine the effect of a simulation-based mastery learning model on central venous catheter insertion skill and the prevalence of procedure-related complications in a medical intensive care unit over a 1-yr period.Design:Observational cohort study of an educational intervention.Setting

Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit.

Background Simulation-based education improves procedural competence in central venous catheter (CVC) insertion. The effect of simulation-based education in CVC insertion on the incidence of catheter-related bloodstream infection (CRBSI) is unknown. The aim of this study was to determine if simulation-based training in CVC insertion reduces CRBSI. Methods This was an observational education cohort study set in an adult intensive care unit (ICU) in an urban teaching hospital. Ninety-two internal medicine and emergency medicine residents completed a simulation-based mastery learning program in CVC insertion skills. Rates of CRBSI from CVCs inserted by residents in the ICU before and after the simulation-based educational intervention were compared over a 32-month period. Results There were fewer CRBSIs after the simulator-trained residents entered the intervention ICU (0.50 infections per 1000 catheter-days) compared with both the same unit prior to the intervention (3.20 per 1000 catheter-days) ( P  = .001) and with another ICU in the same hospital throughout the study period (5.03 per 1000 catheter-days) ( P  = .001). Conclusions An educational intervention in CVC insertion significantly improved patient outcomes. Simulation-based education is a valuable adjunct in residency education.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1108514/ioi90050_1420_1423.pdf

Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections

BACKGROUND:

Central venous catheter (CVC) insertions are performed frequently by internal medicine residents. Complications, including arterial puncture and pneumothorax, decrease when operators use fewer needle passes to insert the CVC. In this study, we evaluated the effect of simulation-based mastery learning on CVC insertion skill.



DESIGN:

This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertions by 41 internal medicine residents rotating through the medical intensive care unit (MICU) over a five-month period. Thirteen traditionally-trained residents were surveyed about the number of needle passes, complications, and procedural self-confidence on CVCs inserted in the MICU. Concurrently, 28 residents completed simulation-based training in IJ and SC CVC insertions. Simulator-trained residents were expected to perform CVC insertions to mastery standards on a central line simulator. Simulator-trained residents then rotated through the MICU and were surveyed regarding CVC placement. The impact of simulation training was assessed by comparing group survey results.



RESULTS:

No resident met the minimum passing score (MPS) (79.1%) for CVC insertion at baseline: mean (M) (IJ) = 48.4%, standard deviation (SD) = 23.1, M(SC) = 45.2%, SD = 26.3. All residents met or exceeded the MPS at testing after simulation training: M(IJ) = 94.8%, SD = 10.0, M(SC) = 91.1%, SD = 17.8 (p < 0.001). In the MICU, simulator-trained residents required fewer needle passes to insert a CVC than traditionally-trained residents: M = 1.79, SD = 1.0 versus M = 2.78, SD = 1.77 (p = 0.04). Simulator-trained residents displayed more self-confidence about their procedural skills: (M = 81, SD = 11 versus M = 68, SD = 20, p = 0.02).



CONCLUSIONS:

Simulation-based mastery learning increased residents' skills in simulated CVC insertion, decreased the number of needle passes when performing actual procedures, and increased resident self-confidence. Journal of Hospital Medicine 2009;4:397–403. © 2009 Society of Hospital Medicine.

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Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit.

Interventions to reduce preventable complications such as catheter-related bloodstream infections (CRBSI) can also decrease hospital costs. However, little is known about the cost-effectiveness of simulation-based education. The aim of this study was to estimate hospital cost savings related to a reduction in CRBSI after simulation training for residents.
This was an intervention evaluation study estimating cost savings related to a simulation-based intervention in central venous catheter (CVC) insertion in the Medical Intensive Care Unit (MICU) at an urban teaching hospital. After residents completed a simulation-based mastery learning program in CVC insertion, CRBSI rates declined sharply. Case-control and regression analysis methods were used to estimate savings by comparing CRBSI rates in the year before and after the intervention. Annual savings from reduced CRBSIs were compared with the annual cost of simulation training.
Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs in the year after the intervention. Incremental costs attributed to each CRBSI were approximately $82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). The annual cost of the simulation-based education was approximately $112,000. Net annual savings were thus greater than $700,000, a 7 to 1 rate of return on the simulation training intervention.
A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.

Elaine R. Cohen

Papers

Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence

Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit.

Use of Simulation-Based Education to Reduce Catheter-Related Bloodstream Infections

Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit.

Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit.