Implications of Simulation and Real-Life Learning for Novice Emergency Nurses in COVID-19

Abstract &#x0D; In recent decades, technological influences have propelled the advancement of nursing education, both in practical and theoretical andragogy. Simulation technology has become an integral component of many nursing programs and clinical practice settings. The introduction of simulation challenges current mentorship and practice-based real-life learning, alluding to the question: Is the use of simulation to educate nurses within the clinical environment a sufficient replacement for real-life learning? The recent severe acute respiratory syndrome coronavirus 2 disease (SARS-CoV-2 or COVID-19) pandemic has caused emergency departments (EDs) to re-examine educational practices, potentially replacing real-life learning with simulation technology to support novice nurses as they care for acutely ill COVID-19 patients. Many experienced ED nurses have left the profession during the COVID-19 pandemic, and novice ED nurses with minimal ED experience have been hired in their places. While their enthusiasm, skill, and knowledge are highly valued, novice ED nurses face many challenges in the complex ED environment, particularly in the rapidly changing COVID-19 pandemic. This article provides an overview of simulation learning and real-life learning and how both of these models, along with their educational strategies, may be implemented by ED nurse educators in assisting novice ED nurses transitioning to independent practice.&#x0D; Keywords: simulation, real-life learning, novice nurse education, emergency department, COVID-19</jats:p

The role of mentors in addressing issues of work–life integration in an academic research environment

AbstractIntroduction:There is growing evidence for both the need to manage work–life conflict and the opportunity for mentors to advise their mentees on how to do this in an academic research environment.Methods:A multiphase approach was used to develop and implement an evidence-informed training module to help mentors guide their mentees in issues of work–life conflict. Analysis of existing data from a randomized controlled trial (RCT) of a mentor training curriculum (n = 283 mentor/mentee dyads) informed the development of a work–life mentoring module which was incorporated into an established research mentor training curriculum and evaluated by faculty at a single academic medical center.Results:Only 39% of mentors and 36% of mentees in the RCT indicated high satisfaction with the balance between their personal and professional lives. The majority (75%) of mentors and mentees were sharing personal information as part of the mentoring relationship which was significantly associated with mentees’ ratings of the balance between their personal and professional lives. The effectiveness of the work–life module was assessed by 60 faculty mentors participating in a mentor training program at an academic medical center from 2013 to 2017. Among the respondents to the post-training survey, 82.5% indicated they were very/somewhat comfortable addressing work–life issues with their mentees as a result of the training, with significant improvements (p = 0.001) in self-assessments of mentoring skill in this domain.Conclusions:Our findings indicate that a structured training approach can significantly improve mentors’ self-reported skills in addressing work–life issues with their mentees.</jats:sec

Double-Unit Cord Blood (CB) Transplantation Combined With Haplo-Identical CD34+ Cell-Selected PBSC Results In 100% CB Engraftment With Enhanced Myeloid Recovery

Abstract Background Double-unit CB transplantation (DCBT) has provided high rates of sustained donor engraftment in patients with hematologic malignancies. However, delayed engraftment is frequent with a median neutrophil &amp; platelet recovery of 25 &amp; 48 days, respectively, in adult DCBT recipients at our center. This delay is associated with increased transplant-related mortality (TRM). It is also associated with prolonged hospitalization with a median discharge time of +42 days (range 25-76) in recent adult myeloablative DCBT recipients. Methods We investigated the combined transplantation of a 4-6/6 HLA-A,-B antigen, -DRB1 allele matched double-unit CB allograft (infused on day 0) with peripheral blood stem cell derived Miltenyi column selected haplo-identical CD34+ cells (haplo-CD34+, infused on day 0 or +1) to speed myeloid recovery. We used DCB grafts to facilitate comparison with historic/concurrent DCB controls transplanted without haplo-CD34+. Results Of 23 protocol eligible patients, 6/23 (26%) underwent DCBT only due to the lack of any suitable haplo-identical donor. Thus, 17 patients [median 39 years (range 16-69), median 78 kg (range 63-133)] were transplanted 9/2012-6/2013 with DCB plus haplo-CD34+ cells for high-risk hematologic malignancies. Diagnoses included 12 acute leukemias &amp; 5 lymphomas. Conditioning was myeloablative with CSA/MMF immune suppression &amp; no ATG. Median infused CB TNC x 107/kg was 2.29 (larger unit, range 1.73-2.95) &amp; 1.82 (smaller unit, range 1.26-2.48). Haplo-identical donors (median 37 years, range 19-71) had a median donor-recipient HLA-match of 5/10 (range 5-7). 15 patients received the targeted infused haplo-CD34+ cell dose of 3 x 106/kg whereas 2 each received haplo-CD34+ cell doses of 1 x 106/kg. The median infused haplo-CD3+ dose was 0.6 x 103/kg (range 0.3-1.6). One patient died on day 14. Of 16 remaining evaluable patients, all (100%) engrafted with a median neutrophil recovery of 13.5 days (range 11-31) in 14 patients who received 3 x 106/kg haplo-CD34+ cells, and 26 and 18 days in the 2 patients who received 1 x 106/kg haplo-CD34+ cells. Platelet recovery ≥ 20 × 109/l has occurred in 12/15 patients (median 27 days, range 18-46) to date. Serial chimerism results demonstrating the contribution of haplo-CD34+ cells &amp; each CB unit to date is shown (Table). While myeloid recovery on day 14 was predominantly haplo-CD34+ cell mediated, one CB unit dominated by day 28 in both neutrophil &amp; T-cell subsets. The median total donor chimerism was 100% the dominant CB unit by day 100. With a median follow-up of survivors of 5 months (range 1-10), to date 9 of 15 evaluable patients have developed grade II-IV aGVHD by day 100 (7 grade II, 1 grade III, 1 grade IV). One patient with refractory leukemia transplanted with disease has relapsed, &amp; 4 have died of TRM (2 organ failure, 1 grade IV aGVHD, 1 CMV infection). Excluding early deaths, of patients who were discharged in the first 100 days (n = 13), the median day of discharge was day +33 (range 21-60). Conclusions Double-unit CBT supplemented by haplo-CD34+ cells is safe. The incidence of neutrophil engraftment is high &amp; the speed of neutrophil recovery is enhanced compared with recent DCBT controls. A shorter time of initial hospitalization (9 days) has offset the cost of the addition of haplo-CD34+ cells. It is intriguing that the dominant CB unit can rapidly reject the haplo-identical donor. This may be facilitated by omission of ATG, and the determinants of the speed of haplo-donor rejection are under investigation. Whether the same results could be achieved with a single CB unit plus haplo-CD34+ cells requires investigation. Addition of haplo-CD34+ cells is also an alternative to expansion, although expansion remains an important strategy to augmenting myeloid recovery given some patients do not have any suitable haplo-identical donors. Disclosures: No relevant conflicts of interest to declare. </jats:sec

Disease-Free Survival in Adult Patients with Acute Leukemia and Advanced CML Supports Use of Double-Unit Cord Blood Grafts As an Immediate Alternative to 8/8 HLA-Matched Unrelated Donors (URD)

Abstract Background: Double-unit cord blood transplantation (DCB-T) is a rapidly available alternative to unrelated donor transplantation (URD-T) for patients with high-risk acute leukemia or advanced CML. Retrospective analyses in adult DCB-T suggest that double-unit CB grafts may be associated with improved disease-free survival (DFS). However, the prioritization of URD-T vs DCB-T is controversial. Methods: We evaluated 175 consecutive adult allograft recipients (120 URD-T and 55 DCB-T) aged 16-60 years transplanted 10/2005-11/2012 for acute leukemia in morphologic remission or aplasia (113 AML/ biphenotypic, 50 ALL), or advanced CML (n = 12). URD grafts were 7-8/8 HLA-matched (74 8/8, 46 7/8). CB grafts were 4-6/6 donor-recipient HLA-matched (4 6/6, 51 5/6, 55 4/6). All patients received either high dose or reduced intensity myeloablative conditioning. The majority of URD-T recipients (n = 111, 93%) received T-cell depleted (TCD) grafts with rabbit ATG, whereas GVHD prophylaxis for DCB-T was calcineurin-inhibitor/mycophenolate mofetil. Results: The median ages of URD-T (43 years) and DCB-T (42 years) recipients were similar (p = 0.713). Distributions of gender, recipient CMV positivity, HCT-CI scores, time from diagnosis or relapse to transplant, diagnoses, disease risk, and percentage of patients with minimal residual disease pre-transplant were also similar. Neutrophil engraftment was slower in DCB-T (95%, median 24 days) than URD-T (100%, median 11 days) (p &lt;0.001). While the incidence of grade II-IV acute GVHD at day 100 was lower in TCD URD-T recipients (15%) than in unmodified URD-T (56%) and DCB-T (55%), p = 0.002, the incidence of day 100 grade III-IV acute GVHD was similar in TCD URD-T, unmodified URD-T, and DCB-T recipients (p = 0.794). With a comparable survivor follow-up [URD-T median 51 months (range 15-99) vs DCB-T median 46 months (range 15-92)], transplant-related mortality was similar (3-year estimates: URD-T 25% vs DCB-T 24%, p = 0.838) whereas the relapse risk was decreased after DCB-T (3-year estimates: URD-T 23% vs DCB-T 9%, p = 0.008). Overall, the 3-year DFS after URD-T was 52% and 68% after DCB-T (p = 0.056). When split into 3 groups, the 3-year DFS was 59% in 8/8 URD-T, 40% in 7/8 URD-T, and 68% in DCB-T, p = 0.043 (Figure). Multivariate analysis was performed to determine risk factors for disease relapse or death in the 175 patients (Table). Female gender (HR 1.65, p = 0.029), diagnosis of ALL (HR 2.11, p = 0.002), and mismatched URD-T (HR 1.97, p = 0.027) were each significantly associated with treatment failure. Conclusions: DCB-T can achieve favorable DFS in adults with acute leukemia and CML with low relapse rates. In this series, multivariate analysis demonstrated that mismatched URD-T was independently associated with lower DFS. Our findings support use of DCB-T as an immediate alternative for high-risk acute leukemia and advanced CML in adult patients without a readily available 8/8 allele HLA-matched unrelated volunteer donor. This could have the additional benefit of speeding time to transplant in high-risk patients. Table Variable MultivariateHR (95% CI) P-value Male Female Reference 1.65 (1.05-2.59) 0.029 Recipient CMV Negative Recipient CMV Positive Reference 1.34 (0.85-2.12) 0.201 HCT-CI score 0-2 HCT-CI score &gt; 3 Reference 1.56 (0.98-2.47) 0.059 AML/CML ALL Reference 2.11 (1.30-3.41) 0.002 DCB-T 8/8 URD-T 7/8 URD-T Reference 1.32 (0.72-2.41) 1.97 (1.08-3.60) - 0.365 0.027 Figure Figure. Disclosures No relevant conflicts of interest to declare. </jats:sec