Introduction to debriefing

time. This manuscript serves as an introduction to debriefing, covering a range of topics that include a brief review of its origin, the structure and process of debriefing-specifically in the context of simulation-based medical education, and factors that facilitate effective, successful debriefing. An approach to debriefing immediately after real clinical events will be presented, as well as an evidence-based approach to evaluating debriefing skills of healthcare simulation instructors

Development and Evolution of a Model Interprofessional Education Program in Parkinson’s disease: A Ten-year Experience

OBJECTIVE This paper describes development, evolution and learner reactions in a model interprofessional education program for medical, nursing, physician assistant, occupational therapy, physical therapy, music therapy, social work and speech-language pathology practitioners. Sponsored by the National Parkinson Foundation (NPF) (currently Parkinson’s Foundation), Allied Team Training for Parkinson (ATTP) is a U.S.-based multi-day interprofessional education program in best practices for integrated, interprofessional team-based Parkinson’s disease (PD) care. NPF sponsored 26 ATTP trainings from 2003 to 2013. METHODS This mixed methods evaluation uses case study document review and observation to outline ATTP curriculum development, evolution, and implementation challenges. Learner-perceived effectiveness ratings, knowledge change, pre-post ratings on the Team Skills Scale, confidence in working with people with PD and caregivers, and trainee-reported practice changes at 6-month follow-up were collected. RESULTS Qualitative results identified multiple factors in building an effective interprofessional education program, including interprofessional team practice opportunities through case-based learning, engaging care networks and continuous feedback loops for program improvement. Quantitative results showed that trainees across professions, geographic regions and work settings rated the overall program and curriculum effectiveness, amount of new knowledge and knowledge change very highly. ATTP resulted in significant post-training improvement in team skills, confidence in working with PD, and post-training self-reported practice changes. CONCLUSION Findings suggest that ATTP is an effective interprofessional education program that could be replicated or adapted to other settings and neurodegenerative or chronic illnesses. The model of combining interprofessional team training with disease-specific curriculum content appears to be an effective “next practice” in continuing professional development

The Influence of Adverse Childhood Experiences on Trauma Informed Care Among Primary Care Providers: A Cross-Sectional Study

Adverse childhood experiences (ACEs) are linked to lasting health and socioeconomic challenges; however, less is known about how primary care providers’ own trauma histories impact their provision of trauma-informed care (TIC). This cross-sectional survey study assessed the relationship between primary care providers’ personal trauma history (ACE scores), personal reaction to trauma (burnout, compassion fatigue, and vicarious victimization), and TIC practice. A total of 167 primary care providers were recruited between March 2024 and August 2024 and completed a 38-item online survey. Measures included the Trauma Informed Care-Provider Assessment Tool (TIC-PAT), the Professional Quality of Life Scale (ProQLS), the ACEs Study Questionnaire, and demographics. Descriptive statistics and multiple linear regression analysis was conducted. Respondents were an average of 59.73 years old, white (88.89%) and medical doctors (90.48%). Average ACE score of respondents was 1.4 (SD = 1.47). Analysis revealed that providers with higher ACEs scores were significantly more likely to implement TIC ( B  = 0.11, P  = .02). However, no significant association was found between personal reaction to trauma and TIC provision. Findings suggest that primary care providers with personal trauma histories may be more attuned to the effects of trauma, leading to greater TIC implementation. The study highlights the importance of TIC training for all providers—particularly for those with lower ACE scores—while also recognizing that providers with higher ACE scores may benefit from training to manage personal trauma and enhance their clinical practice

Choropleth Map Design for Cancer Incidence, Part 2

Choropleth maps are commonly used in cancer reports and community discussions about cancer rates. Cancer registries increasingly use geographic information system techniques. The Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control convened a Map Work Group to help guide application of geographic information system mapping techniques and to promote choropleth mapping of data from central cancer registries supported by the National Program of Cancer Registries, especially for comprehensive cancer control planning and evaluation purposes. In this 2-part series, we answer frequently asked questions about choropleth map design to display cancer incidence data. We recommend that future initiatives consider more advanced mapping, spatial analysis, and spatial statistics techniques and include usability testing with representatives of state and local programs and other cancer prevention partners

Cost of Starting Colorectal Cancer Screening Programs: Results From Five Federally Funded Demonstration Programs

IntroductionIn 2005, the Centers for Disease Control and Prevention (CDC) started a 3-year colorectal cancer screening demonstration project and funded five programs to explore the feasibility of a colorectal cancer program for the underserved U.S. population. CDC is evaluating the five programs to estimate implementation cost, identify best practices, and determine the most cost-effective approach. The objectives are to calculate start-up costs and estimate funding requirements for widespread implementation of colorectal cancer screening programs.MethodsAn instrument was developed to collect data on resource use and related costs. Costs were estimated for start-up activities, including program management, database development, creation of partnerships, public education and outreach, quality assurance and professional development, and patient support. Monetary value of in-kind contributions to start-up programs was also estimated.ResultsStart-up time ranged from 9 to 11 months for the five programs; costs ranged from $60,602 to$337,715. CDC funding and in-kind contributions were key resources for the program start-up activities. The budget category with the largest expenditure was labor, which on average accounted for 67% of start-up costs. The largest cost categories by activities were management (28%), database development (17%), administrative (17%), and quality assurance (12%). Other significant expenditures included public education and outreach (9%) and patient support (8%).ConclusionTo our knowledge, no previous reports detail the costs to begin a colorectal cancer screening program for the underserved population. Start-up costs were significant, an important consideration in planning and budgeting. In-kind contributions were also critical in overall program funding. Start-up costs varied by the infrastructure available and the unique design of programs. These findings can inform development of organized colorectal cancer programs

Novel Opioid Safety Clinic Initiative to Deliver Guideline-Concordant Chronic Opioid Therapy in Primary Care

Objective: To develop and evaluate a novel Opioid Safety Clinic (OSC) initiative to enhance adherence to guidelines on the assessment and monitoring of patients prescribed chronic opioid therapy (COT). Patients and Methods: The OSC was developed at an urban Federally Qualified Health Center to provide guideline-concordant care for COT, standardize workflows, and efficiently use clinic staff. We evaluated the OSC using a matched cohort study. Five hundred thirty-nine patients participated in the clinic between July 1, 2014, and March 31, 2016. Of these, 472 clinic participants were matched to 472 nonparticipants by sex and age on the date of the OSC visit. The OSC was evaluated by its completion rates of standardized pain assessments, urine toxicology, and naloxone dispensings. We conducted logistic regression comparing OSC participants to OSC nonparticipants. Results: A total of 539 patients attended an OSC visit, representing approximately 53% of patients in the chronic opioid registry. The OSC participants were more likely than nonparticipants to have completed a pain assessment (adjusted odds ratio [aOR], 169.8; 95% CI, 98.3-293.5), completed a urine toxicology (aOR, 46.1; 95% CI, 30.4-69.9), or had naloxone dispensed (aOR, 2.8; 95% CI, 1.9-4.3) over 12 months of follow-up. Conclusion: The OSC model improved adherence to guideline-concordant COT in primary care. Future research is needed to assess the impact of these interventions on pain, quality of life, and adverse events from opioid analgesics

Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers

Category: Diabetes Introduction/Purpose: With approximately 29.1 million diabetics in the United States and estimated total annual cost of $245 billion, diabetes and its associated complications continue to be an increasing burden on society. The management of diabetic foot ulcers accounts for a significant portion of those expenses. We propose a safe, efficacious and economically prudent model for the outpatient treatment of uncomplicated diabetic foot ulcers. Methods: Enrolled patients had initial sharp wound debridement by one of two foot and ankle fellowship trained orthopaedic surgeons. Patients were treated with total contact casting and subsequently evaluated every two weeks by nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results of healing and complications were recorded. Digital photographs of the ulcers from each clinical encounter were retrospectively reviewed in a blinded fashion by two orthopaedic foot and ankle surgeons and compared to the nursing decisions at the time of treatment. Financial calculations estimated the potential cost savings by having nurses perform CSWD. State boards of nursing were systematically surveyed to assess current policies related to CSWD. Results: Average time to clinical healing was 6.03 weeks. There were no identified complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100$774.60 per patient. When extrapolated to the estimated number of diabetic foot ulcers annually within the United States, this could approach $1.8 to$2.1 billion in potential annual healthcare savings. Conclusion: CSWD of diabetic foot ulcers and calluses by trained nurses is a safe, effective and fiscally responsible clinical practice supported by greater than 90% of state boards of nursing. Utilizing a clinical decision algorithm, nursing evaluation and appropriate referral of ulcers at risk demonstrated 100% sensitivity and 89.58% accuracy. There were no complications associated with nurses performing conservative sharp debridement. When considering the most recent CDC estimates of 29.1 million diabetics with an 8% annual incidence of DFU, implementation of this clinical model on a national scale could result in approximately $2 billion in annual healthcare savings

Causes of Death Among Patients Supported by Extracorporeal Membrane OxygenationTake-Home Points

Background: Mortality for patients who are critically ill receiving extracorporeal membrane oxygenation (ECMO) support (venovenous or venoarterial) is high, but the proximal causes of death have not been characterized fully. Research Question: We aimed to characterize the reasons for death in patients who underwent cannulation while receiving venoarterial or venovenous ECMO. Study Design and Methods: This was a retrospective multicenter observational cohort study of adult patients who underwent cannulation for ECMO and who died while receiving ECMO at 6 medical centers in the United States. Results: We categorized the causes of death for 751 patients who underwent cannulation for ECMO. We summarized and compared baseline patient characteristics among the 6 sites. Reasons for death were comorbid withdrawal of life-sustaining therapy (n = 248 [33%]), progressive hemodynamic shock (n = 200 [27%]), neurologic withdrawal of life-sustaining therapy (n = 135 [18%]), cardiogenic shock (n = 126 [17%]), respiratory failure (n = 31 [4.1%]), and equipment failure (n = 11 [1.5%]). Comorbid withdrawal of life-sustaining therapy was the most common cause of death in patients who underwent cannulation for both venoarterial (n = 141 [29%]) and venovenous (n = 107 [41%]) ECMO. The rate of palliative care consultation differed among sites. Interpretation: This study showed that most deaths result from comorbid withdrawal of life-sustaining therapy and that death or withdrawal because of refractory respiratory failure and cardiogenic shock account for a lower proportion of deaths in patients receiving ECMO. Our efforts to reduce mortality in patients receiving ECMO should account for the proportion of deaths attributable to comorbid withdrawal of life-sustaining therapy