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William C McGaghie, Jeffrey H Barsuk, Diane B Wayne Department of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USAWe read the analytical review by Drs. Siddaiah-Subramanya, Smith, and Lonie titled, “Mastery learning: how is it helpful?” that appeared recently in Advances in Medical Education and Practice, with great interest.1 We commend the authors for bringing the mastery learning model to the attention of the journal’s readers. However, we note some missing information and wish to amplify the rationale and contributions of mastery learning in medical education by adding four additional points:1. The basic principle of mastery learning is “excellence for all.” This means that all medical learners can reach all learning goals to very high achievement standards with little or no variation in measured learning outcomes.22. The traditional apprenticeship model of clinical medical education is becoming obsolete in light of contemporary approaches to curriculum development and advancements in educational technology, especially medical simulation. As Ericsson has pointed out, “the well-known saying, see one, do one, teach one … implies virtually instantaneous mastery of new procedures among medically trained individuals; however, objective performance measures have invalidated this conventional wisdom.”33. Mastery learning programs in medicine are grounded in carefully designed and managed curricula that engage learners and teachers in active, effortful educational activities, assessments, actionable feedback, and steps toward constant improvement.4 Mastery learning is not a passive enterprise for learners or teachers. This is also the basis for the translational outcomes described below.4. Rigorous medical education mastery learning programs can not only yield shortrun learning outcomes measured as skill and knowledge acquisition in educational settings, but also “downstream” translational results expressed as better patient care practices, improved patient outcomes, and lower health care costs.5 Translational medical education outcomes derive from mastery learning and research programs that are thematic, sustained, and cumulative. View the original article

Medical education research contributes to translational science (TS) when its outcomes not only impact educational settings, but also downstream results, including better patient-care practices and improved patient outcomes. Simulation-based medical education (SBME) has demonstrated its role in achieving such distal results. Effective TS also encompasses implementation science, the science of health-care delivery. Educational, clinical, quality, and safety goals can only be achieved by thematic, sustained, and cumulative research programs, not isolated studies. Components of an SBME TS research program include motivated learners, curriculum grounded in evidence-based learning theory, educational resources, evaluation of downstream results, a productive research team, rigorous research methods, research resources, and health-care system acceptance and implementation. National research priorities are served from translational educational research. National funding priorities should endorse the contribution and value of translational education research. [ABSTRACT FROM AUTHOR]

BACKGROUND: Temporary hemodialysis catheter (THDC) insertion is a required skill for nephrology fellows. Traditional fellowship training may provide inadequate preparation to perform this procedure. Our aim was to use a central venous catheter (CVC) simulator to assess nephrology fellows' THDC insertion skills and evaluate the impact of an educational intervention on skill development to mastery standards. STUDY DESIGN: Prospective observational cohort study. SETTING & PARTICIPANTS: 18 nephrology fellows from 3 academic centers in Chicago from May to August 2008. Six graduating fellows (traditionally-trained) underwent assessment of internal jugular THDC insertion skill using a CVC simulator. Subsequently, 12 first-year fellows (simulator-trained) underwent baseline testing and received a 2-hour education session featuring deliberate practice with the CVC simulator. Simulator-trained fellows were retested after the intervention and expected to meet or exceed a minimum passing score. PREDICTOR: Completion of CVC simulation education session. OUTCOMES: THDC insertion skill performance. MEASUREMENTS: Skills examination was scored on a 27-item checklist. Minimum passing score was set by an expert panel. RESULTS: Performance of traditionally-trained graduating fellows in THDC insertion was poor (mean, 53.1%), and only 17% met the minimum passing score. Performance of simulator-trained first-year fellows improved from a mean of 29.5% to a mean of 88.6% after simulator training (P = 0.002). Simulator-trained fellows showed significantly higher THDC insertion performance than traditionally-trained graduating fellows (P = 0.001). The education program was rated highly. LIMITATIONS: Although it represents fellows from 3 programs, sample size was small. CONCLUSIONS: A curriculum featuring deliberate practice dramatically increased the skill of nephrology fellows to mastery standards in THDC insertion. This program illustrates a feasible and reliable mechanism to achieve and document procedural competency. Copyright © 2009 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Background: Effective technical and nontechnical skills are necessary for surgeons to provide optimal patient care. The aim of this study was to assess the relationship between Nontechnical Skills for Surgeons (NOTSS) and postoperative outcomes among general surgery patients., Method: This prospective observational study was conducted at a single, large, urban, academic hospital in the USA from February to September 2022. Two raters (an observer and a nurse) assessed each participating surgeon during 3 to 5 different operations. Patient outcome data were collected from the Illinois Surgical Quality Improvement Collaborative (ISQIC) database. We used the American College of Surgeons National Quality Improvement Program (ACS NSQIP) method to calculate risk-adjusted complications. Robust linear regression models were used to assess the association between surgeons' nontechnical skills and risk-adjusted postoperative complications., Results: Of the 45 surgeons who were observed in the study, 25 (55.5%) had patient outcome data captured by the ISQIC database. The adjusted analysis found that for every unit increase in the NOTSS score, there was a significant 5.1 (95% CI: -8.1; -2.0,p = 0.003), decrease in the adjusted risk of any postoperative complication, a significant 1.1 (95% CI: -1.8; -0.2, p = 0.01) decrease in the adjusted risk of mortality, and significant 1.1 (95% CI: -1.9; -0.4, p = 0.005) decrease in adjusted risks of returning to the operating room., Conclusion: Higher surgeons' nontechnical skills scores were associated with a decreased risk-adjusted rate of any postoperative complication, mortality, and return to the operating room. Strategies to improve postoperative patient outcomes should include the improvement of surgeons' nontechnical skills., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

Purpose: Practicing endoscopists frequently perform and teach screening colonoscopies and polypectomies, but there is no standardized method to train and assess physicians who perform polypectomy procedures. The authors created a polypectomy simulation-based mastery learning (SBML) curriculum and hypothesized that completion of the curriculum would lead to immediate improvement in polypectomy skills and skill retention at 6 and 12 months after training., Method: The authors performed a pretest-posttest cohort study with endoscopists who completed SBML and were randomized to follow-up at 6 or 12 months from May 2021 to August 2022. Participants underwent SBML training, including a pretest, a video lecture, deliberate practice, and a posttest. All learners were required to meet or exceed a minimum passing standard on a 17-item skills checklist before completing training and were randomized to follow-up at 6 or 12 months. The authors compared simulated polypectomy skills performance on the checklist from pretest to posttest and posttest to 6- or 12-month follow-up test., Results: Twenty-four of 30 eligible participants (80.0%) completed the SBML intervention, and 20 of 24 (83.3%) completed follow-up testing. The minimum passing standard was set at 93% of checklist items correct. The pretest passing rate was 4 of 24 participants (16.7%) compared with 24 of 24 participants (100%) at posttest ( P < .001). There were no significant differences in passing rates from posttest to combined 6- and 12-month posttest in which 18 of 20 participants (90.0%) passed., Conclusions: Before training and despite years of clinical experience, practicing endoscopists demonstrated poor performance of polypectomy skills. SBML was an effective method for practicing endoscopists to acquire and maintain polypectomy skills during a 6- to 12-month period., (Copyright © 2023 the Association of American Medical Colleges.)

Introduction: Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness., Methods: This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations., Results: PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment., Conclusions: The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

Problem: Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures., Aims: The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses., Methods: The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure., Results: A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs ( p  < 0.001)., Conclusions: The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors have no relevant financial disclosures to declare. The ultrasound machines were provided to the facility by FUJIFILM-Sonosite. The simulators were donated to the facility by Simulab Corporation.

Background: Breaking bad news (BBN) is an important clinical task for physicians. Unfortunately, there is no standard method to teach and assess these skills of anesthesiologists. Although anesthesiology has become a relatively safe medical specialty, complications still occur that require disclosure to patients and their families. Disclosure of bad news can be a significant source of stress for clinicians, especially for those who have low confidence in their BBN skills. Anesthesiologists' skills in BBN can be improved with simulation-based mastery learning (SBML), an intense form of competency-based learning., Methods: An SBML curriculum was developed using the SPIKES (Situation, Perception, Invitation, Knowledge, Emotion, Summarize) framework for BBN and the NURSE (Naming, Understanding, Respecting, Supporting, Exploring) statements for expressing empathy. A pretest-posttest study was conducted from March 2020 to June 2022 to evaluate anesthesiologists' performance in BBN. Participants completed a 2-hour curriculum consisting of a pretest, didactic session, deliberate practice with feedback, and a posttest. Anesthesiologists were assessed using a 16-item skills checklist., Results: Six anesthesiology attendings and 14 anesthesiology fellows were enrolled in the study. Three of 20 participants met the minimum passing score (MPS) at the time of their pretest. All study participants met the MPS on their first posttest ( P < .001). The median participant confidence in BBN significantly increased (3 to 4, P < .001). Overall course satisfaction in the curriculum was high, with a median score of 5., Conclusions: Our study demonstrates that a BBN SBML curriculum for anesthesiologists significantly improved communication skills and confidence in a simulated environment. Because only 3 participants met the MPS before training, our results suggest that anesthesiologists could benefit from further education to gain effective communication skills and that SBML training may be effective to achieve this result., Competing Interests: Conflicts of interest: None, (© 2023 Society for Education in Anesthesia.)

Background: Advanced practice providers (APPs) are essential members of intensive care unit (ICU) interprofessional teams and are expected to be competent in performing procedures. There are no published criteria for establishing when APPs can independently perform procedures. Simulation-based mastery learning (SBML) is an effective strategy for improving critical care skills but has not been applied to practicing ICU APPs., Objective: The purpose of this study was to evaluate if an SBML curriculum could improve the critical care skills and procedural self-confidence of ICU APPs., Methods: We performed a pretest-posttest study of central venous catheter (CVC) insertion, thoracentesis, and mechanical ventilation (MV) management skills among ICU APPs who participated in an SBML course at an academic hospital. For each skill, APPs underwent baseline skills assessments (pretests) on a simulator using previously published checklists, followed by didactic sessions and deliberate practice with individualized feedback. Within 2 weeks, participants were required to meet or exceed previously established minimum passing standards (MPS) on simulated skills assessments (posttests) using the same checklists. Further deliberate practice was provided for those unable to meet the MPS until they retested and met this standard. We compared pretest to posttest skills checklist scores and procedural confidence., Results: All 12 eligible ICU APPs participated in internal jugular CVC, subclavian CVC, and MV training. Five APPs participated in thoracentesis training. At baseline, no APPs met the MPS on all skills. At training completion, all APPs achieved the mastery standard. Internal jugular CVC pretest performance improved from a mean of 67.2% (standard deviation [SD], 28.8%) items correct to 97.1% (SD, 3.8%) at posttest ( P  = 0.005). Subclavian CVC pretest performance improved from 29.2% (SD, 32.7%) items correct to 93.1% (SD 3.9%) at posttest ( P  < 0.001). Thoracentesis pretest skill improved from 63.9% (SD, 30.6%) items correct to 99.2% (SD, 1.7%) at posttest ( P  = 0.054). Pretest MV skills improved from 54.8% (SD, 19.7%) items correct to 92.3% (SD, 5.0%) at posttest ( P  < 0.001). APP procedural confidence improved for each skill from pre to posttest., Conclusion: SBML is effective for training APPs to perform ICU skills. Relying on traditional educational methods does not reliably ensure that APPs are adequately prepared to perform skills such as CVC insertion, thoracentesis, and MV management., (Copyright © 2023 by the American Thoracic Society.)

Ventricular assist device (VAD) implantation requires patients and caregivers to attain self-care knowledge and skills before discharge from implant hospitalization. Inability to perform these skills can have devastating outcomes (i.e., death from pump malfunction, driveline site infections, and stroke). No standard-of-care guiding VAD self-care education exists. We sought to describe how select tertiary care VAD implant centers across the United States currently educate VAD patients and their caregivers. Using a multiple case studies design with a purposive sampling strategy, we conducted semistructured interviews of VAD coordinators responsible for VAD education at 18 centers. From audio recording of interviews, we used rapid qualitative analysis to organize and analyze the data. All centers spent significant time and effort educating patients and caregivers on VAD self-care. Although centers teach similar content, the rigor of assessments and follow-up education differed vastly. Only 3/18 (17%) centers performed competency-based assessments with a skills checklist and minimum passing standard assessing readiness to perform VAD self-care independently. Twelve of 18 (67%) centers provided formal follow-up education to address skills decay, yet wide variation existed in timing and content of education. Due to the diversity among centers regarding VAD self-care education, more prescriptive practice guidelines are needed., Competing Interests: Disclosure: J.E.W. reports consulting honoraria from Abbott, Amgen and serves on the Scientific Advisory Board for Cytogenetics. The remaining authors have no conflicts of interest to report., (Copyright © ASAIO 2022.)

Background: We previously showed that an ultrasound-guided i.v. catheter insertion (USGIV) simulation-based mastery learning (SBML) curriculum improves the simulated USGIV skills of paediatric anaesthesiologists. It remains unclear if improvements in simulated USGIV skills translate to improved patient care., Methods: A cohort study was conducted from August 2018 to August 2020 to evaluate paediatric anaesthesiologists' USGIV performance in the operating theatre before and after they participated in the USGIV SBML curriculum. Paediatric anaesthesiologists' use of ultrasound for successful i.v. insertion and first-attempt i.v. insertion success rate with ultrasound were compared before and after training., Results: Twenty-nine paediatric anaesthesiologists completed training. Unadjusted analysis showed a significant increase in the percentage of i.v. catheters inserted with ultrasound for successful i.v. catheter insertion (9.5-14.5%; P <0.001) and first i.v. catheter insertion attempt success with ultrasound (5.5-8.9%; P <0.001) from before to after training. Multivariable regression analysis showed higher odds of ultrasound use for a successful i.v. catheter attempt (1.79; 95% confidence interval [CI]: 1.11-2.90; P =0.018) and first-attempt success with ultrasound (4.11; 95% CI: 2.02-8.37; P <0.001) after training., Conclusions: After completing the USGIV SBML curriculum, paediatric anaesthesiologists increased their ultrasound use for successful i.v. catheter insertion and first-attempt success rate with ultrasound for patients in the operating theatre., (© 2022 The Author(s).)

Background/objectives: To develop and evaluate a post-acute care simulation-based mastery learning (SBML) continuing medical education (CME)/maintenance of certification (MOC) procedure course., Design: Pretest-posttest study of the SBML intervention., Setting: A 2-day post-acute care procedures course., Participants: Sixteen practicing clinicians (5 physicians,11 advanced practice providers). Participants engaged in a skills pretest on knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing using a checklist created for each procedure. Participants received a didactic on each procedure followed by deliberate practice with feedback. Using the same checklists, participants completed a skills posttest and were required to meet a minimum passing standard (MPS) to obtain CME/MOC credit., Measurements: The MPS for each skills checklist was determined by a multidisciplinary panel of 11 experts. Participants completed surveys on procedure self-confidence and a course evaluation., Results: There was statistically significant improvement between pre- and posttests for all four procedures ( p < .001). All participants were able to meet or exceed the MPS for each skill during the 2-day course. Participants' self-confidence regarding each procedure improved significantly ( p < .001)., Conclusion: An SBML training course granting CME/MOC credit for post-acute care providers significantly improves performance of knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing.

Background: Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance., Aims: The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access., Methods: We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors., Results: 12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p < .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p < .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value <.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p < .001) were associated with successful intravenous catheter placement., Conclusions: Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room., (© 2022 The Authors. Pediatric Anesthesia published by John Wiley & Sons Ltd.)

Background: Ventricular assist device simulation-based mastery learning (SBML) results in better patient and caregiver self-care skills compared with usual training., Objective: The aim of this study was to evaluate the effect of SBML on driveline exit site infections., Methods: We compared the probability of remaining infection free at 3 and 12 months between patients randomized to SBML or usual training., Results: The SBML-training group had no infections at 3 months and 2 infections at 12 months, yielding a Kaplan-Meier estimate of the probability of remaining infection free of 0.857 (95% confidence interval [CI], 0.692-1.00) at 12 months. The usual-training group had 6 infections at 3 months with no additional infections by 12 months. Kaplan-Meier estimates of remaining infection free at 3 and 12 months were 0.878 (95% CI, 0.758-1.00) and 0.748 (95% CI, 0.591-0.946), respectively. Time-to-infection distributions for SBML versus usual training showed a difference in 12-month infection rates of 0.109 (P = .07)., Conclusions: Ventricular assist device self-care SBML resulted in fewer 12-month infections., Competing Interests: Dr Wilcox receives consulting honoraria from Boehringer Ingelheim and Medtronic and serves on the scientific advisory board for Cytokinetics. The other authors have no relevant conflicts of interest to report., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients., Methods: We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period., Results: One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period., Conclusions: A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses., Methods: This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention., Results: Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate., Conclusions: This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Society for Simulation in Healthcare.)

Introduction: Resident physicians are expected to acquire competence at central venous catheter (CVC) insertion to a mastery standard. Valid competence decisions about resident physicians' CVC performance rely on reliable data and rigorous achievement standards. This study used data from 3 CVC simulation-based mastery learning studies involving internal medicine (IM) and emergency medicine (EM) residents to address 2 questions: What is the effectiveness of a CVC mastery learning education intervention? Are minimum passing standards (MPSs) set by faculty supported by item response theory (IRT) analyses?, Methods: Pretraining and posttraining skills checklist data were drawn from 3 simulation-based mastery learning research reports about CVC internal jugular (IJ) and subclavian (SC) insertion skill acquisition. Residents were required to meet or exceed a posttest skills MPS. Generalized linear mixed effect models compared checklist performance from pre to postintervention. Minimum passing standards were determined by Angoff and Hofstee standard setting methods. Item response theory models were used for cut-score evaluation., Results: Internal medicine and EM residents improved significantly on every IJ and SC checklist item after mastery learning. Item response theory analyses support the IJ and SC MPSs., Conclusions: Mastery learning is an effective education intervention to achieve clinical skill acquisition among IM and EM residents. Item response theory analyses reveal desirable measurement properties for the MPSs previously set by expert faculty panels. Item response theory analysis is useful for evaluating standards for mastery learning interventions. The CVC mastery learning curriculum, reliable outcome data, and high achievement standards together contribute to reaching valid decisions about the competence of resident physicians to perform the clinical procedure., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Society for Simulation in Healthcare.)

Objectives: The aims of the study were to identify perceived barriers and facilitators to central venous catheter (CVC) insertion among healthcare providers and to understand the extent to which an existing Simulation-Based Mastery Learning (SBML) program may address barriers and leverage facilitators., Methods: Providers participating in a CVC insertion SBML train-the-trainer program, in addition to intensive care unit nurse managers, were purposively sampled from Veterans Administration Medical Centers located in geographically diverse areas. We conducted semistructured interviews to assess perceptions of barriers and facilitators to CVC insertion. Deidentified transcripts were analyzed using a grounded theory approach and the constant comparative method. We subsequently mapped identified barriers and facilitators to our SBML curriculum to determine whether or not the curriculum addresses these factors., Results: We interviewed 28 providers at six Veterans Administration Medical Centers, identifying the following five overarching factors of perceived barriers to CVC insertion: (1) equipment, (2) personnel/staff, (3) setting or organizational context, (4) patient or provider, and (5) time-related barriers. Three overarching factors of facilitators emerged: (1) equipment, (2) personnel, and (3) setting or organizational context facilitators. The SBML curriculum seems to address most identified barriers, while leveraging many facilitators; building on the commonly identified facilitator of nursing staff contribution by expanding the curriculum to explicitly include nurse involvement could improve team efficiency and organizational culture of safety., Conclusions: Many identified facilitators (e.g., ability to use ultrasound, personnel confidence/competence) were also identified as barriers. Evidence-based SBML programs have the potential to amplify these facilitators while addressing the barriers by providing an opportunity to practice and master CVC insertion skills., Competing Interests: J.H.B. and D.B.W. received consulting fees from MERCI. J.H.B., D.B.W. and E.R.C. received royalties for the central venous catheter insertion simulation-based mastery learning curriculum from Northwestern University. The remaining authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To develop and evaluate a simulation-based mastery learning (SBML) curriculum for cricothyrotomy using wet towels to suppress aerosolisation during a pandemic., Design: Quasi-experimental, pre-post study., Setting: Tertiary care, academic medical centre in Chicago., Participants: Ear, nose and throat and general surgery residents, fellows and attendings., Intervention: Cricothyroidotomy simulation-based mastery learning curriculum., Outcomes Measure: Pretest to posttest simulated cricothyrotomy skills checklist performance., Results: 37 of 41 eligible surgeons participated in the curriculum. Median pretest score was 72.5 (IQR 55.0-80.0) and 100.0 (IQR 98.8-100.0) for the posttest p<0.001. All participants scored at or above a minimum passing standard (93% checklist items correct) at posttest., Conclusions: Using SBML is effective to quickly train clinicians to competently perform simulated cricothyrotomy during a pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and study aims  Practicing endoscopists have variable polypectomy skills during colonoscopy and limited training opportunities for improvement. Simulation-based training enhances procedural skill, but its impact on polypectomy is unclear. We developed a simulation-based polypectomy intervention to improve polypectomy competency. Methods  All faculty endoscopists at our tertiary care center who perform colonoscopy with polypectomy were recruited for a simulation-based intervention assessing sessile and stalked polypectomy. Endoscopists removed five polyps in a simulation environment at pretest followed by a training intervention including a video, practice, and one-on-one feedback. Within 1-4 weeks, endoscopists removed five new simulated polyps at post-test. We used the Direct Observation of Polypectomy Skills (DOPyS) checklist for assessment, evaluating individual polypectomy skills, and global competency (scale: 1-4). Competency was defined as an average global competency score of ≥ 3. Results  83 % (29/35) of eligible endoscopists participated and 95 % (276/290) of planned polypectomies were completed. Only 17 % (5/29) of endoscopists had average global competency scores that were competent at pretest compared with 52 % (15/29) at post-test ( P  = 0.01). Of all completed polypectomies, the competent polypectomy rate significantly improved from pretest to post-test (55 % vs. 71 %; P  < 0.01). This improvement was significant for sessile polypectomy (37 % vs. 65 %; P  < 0.01) but not for stalked polypectomy (82 % vs. 80 %; P  = 0.70). Conclusions  Simulation-based training improved polypectomy skills among practicing endoscopists. Further studies are needed to assess the translation of simulation-based education to clinical practice., Competing Interests: Competing interests Dr. Wani is a consultant for Medtronic, Boston Scientific, Interpace, and Cernostics. He is supported by the University of Colorado Department of Medicine Outstanding Early Scholars Program. The remaining authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA., Objectives: We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA., Methods: We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV., Results: A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001)., Conclusion: DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Psychological safety is valued in other high-risk industries as an essential element to ensure safety. Yet, in healthcare, psychological safety is not mandatorily measured, quantified, or reported as an independent measure of safety. All members of the healthcare team's voice and safety are important. Calls for personal, physical or patient safety should never be disregarded or met with retaliation ., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We developed a simulation-based mastery learning (SBML) curriculum that boosted self-care skills for patients with a ventricular assist device (VAD). In this study, we evaluated short-term skills retention., Methods: We assessed skill retention among patients and caregivers who participated in VAD self-care SBML at a tertiary care center. We compared discharge skills tests (immediately after completing SBML) to 1- and 3-month follow-up tests to assess skill retention., Results: Fifteen patients and 15 caregivers completed discharge and follow-up testing. Skills were largely retained at 1- and 3-months., Conclusions: SBML results in short-term retention of VAD self-care skills., Competing Interests: Conflict of Interest Disclosures: The authors have no relevant financial disclosures to report.

Background: The American Board of Psychiatry and Neurology and the Accreditation Council for Graduate Medical Education (ACGME) developed Milestones that provide a framework for residents' assessment. However, Milestones do not provide a description for how programs should perform assessments., Objectives: We evaluated graduating residents' status epilepticus (SE) identification and management skills and how they correlate with ACGME Milestones reported for epilepsy and management/treatment by their program's clinical competency committee (CCC)., Methods: We performed a cohort study of graduating neurology residents from 3 academic medical centers in Chicago in 2018. We evaluated residents' skills identifying and managing SE using a simulation-based assessment (26-item checklist). Simulation-based assessment scores were compared to experience (number of SE cases each resident reported identifying and managing during residency), self-confidence in identifying and managing these cases, and their end of residency Milestones assigned by a CCC based on end-of-rotation evaluations., Results: Sixteen of 21 (76%) eligible residents participated in the study. Average SE checklist score was 15.6 of 26 checklist items correct (60%, SD 12.2%). There were no significant correlations between resident checklist performance and experience or self-confidence. The average participant's level of Milestone for epilepsy and management/treatment was high at 4.3 of 5 (SD 0.4) and 4.4 of 5 (SD 0.4), respectively. There were no significant associations between checklist skills performance and level of Milestone assigned., Conclusions: Simulated SE skills performance of graduating neurology residents was poor. Our study suggests that end-of-rotation evaluations alone are inadequate for assigning Milestones for high-stakes clinical skills such as identification and management of SE., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Medical procedures are traditionally taught informally at patients' bedside through observation and practice using the adage "see one, do one, teach one." This lack of formalized training can cause trainees to be unprepared to perform procedures independently. Simulation based education (SBE) increases competence, reduces complications, and decreases costs. We developed, implemented, and evaluated the efficacy of a right heart catheterization (RHC) SBE curriculum., Methods: The RHC curriculum consisted of a pretest, video didactics, deliberate practice, and a posttest. Pre-and posttest skills examinations consisted of a dichotomous 43-item checklist on RHC skills and a 14-item hemodynamic waveform quiz. We enrolled two groups of fellows: 6 first-year, novice cardiology fellows at Northwestern University in their first month of training, and 11 second- and third-year fellows who had completed traditional required, level I training in RHC. We trained the first-year fellows at the beginning of the 2018-2019 year using the SBE curriculum and compared them to the traditionally-trained cardiology fellows who did not complete SBE., Results: The SBE-trained fellows significantly improved RHC skills, hemodynamic knowledge, and confidence from pre- to posttesting. SBE-trained fellows performed similarly to traditionally-trained fellows on simulated RHC skills checklists (88.4% correct vs. 89.2%, p = .84), hemodynamic quizzes (94.0% correct vs. 86.4%, p = .12), and confidence (79.4 vs. 85.9 out of 100, p = .15) despite less clinical experience., Conclusions: A SBE curriculum for RHC allowed novice cardiology fellows to achieve level I skills and knowledge at the beginning of fellowship and can train cardiology fellows before patient contact., (© 2020 Wiley Periodicals LLC.)

Background: COVID-19 is associated with hypercoagulability and increased incidence of thrombosis. We compared the clinical outcomes of adults hospitalized with COVID-19 who were on therapeutic anticoagulants to those on prophylactic anticoagulation., Materials and Methods: We performed an observational study of adult inpatients' with COVID-19 from March 9 to June 26, 2020. We compared patients who were continued on their outpatient prescribed therapeutic anticoagulation and those who were newly started on therapeutic anticoagulation for COVID-19 (without other indication) to those who were on prophylactic doses. The primary outcome was overall death while secondary outcomes were critical illness (World Health Organization Ordinal Scale for Clinical Improvement score ≥5), mechanical ventilation, and death among patients who first had critical illness. We adjusted for age, sex, race, body mass index (BMI), Charlson score, glucose on admission, and use of antiplatelet agents., Results: Of 1716 inpatients with COVID-19, 171 patients were continued on their therapeutic anticoagulation and 78 were started on new therapeutic anticoagulation for COVID-19. In patients continued on home therapeutic anticoagulation, there were no differences in overall death, critical illness, mechanical ventilation, or death among patients with critical illness compared to patients on prophylactic anticoagulation. In patients receiving new therapeutic anticoagulation for COVID-19, there was increased death (OR 5.93; 95% CI 3.71-9.47), critical illness (OR 14.51; 95% CI 7.43-28.31), need mechanical ventilation (OR 11.22; 95% CI 6.67-18.86), and death after first having critical illness (OR 5.51; 95% CI 2.80-10.87)., Conclusions: Therapeutic anticoagulation for inpatients with COVID-19 was not associated with improved outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Author(s).)

Background: Caring for patients requiring mechanical ventilation is complex, and residents may lack adequate skill for managing these patients. Simulation-based mastery learning (SBML) is an educational model that trains clinicians to a high standard and can reduce complications. The mastery learning model has not been applied to ventilator management. Objective: The purpose of this study was to determine whether SBML, as compared with traditional training, is an effective strategy for teaching residents the skills necessary to manage patients requiring mechanical ventilation. Methods: We developed an SBML curriculum and a 47-item skills checklist to test ventilator management for patients with normal, restricted, and obstructed lung physiology. A minimum passing standard (MPS) on the checklist was set using the Mastery Angoff method. Residents rotating through the medical intensive care unit in Academic Year 2017-2018 were assigned to SBML or traditional training based on their medical intensive care unit team. The SBML group was pretested on a ventilator simulator using the skills checklist. They then received a 1.5-hour session (45 min didactic and 45 min deliberate practice on the simulator with feedback). At rotation completion, they were posttested on the simulator using the checklist until the MPS was met. Both SBML-trained and traditionally trained groups received teaching during daily bedside rounds and twice weekly didactic lectures. At rotation completion, traditionally trained residents were tested using the same skills checklist on the simulator. We compared pretest and posttest performance among SBML-trained residents and end of the rotation test performances between the SBML-trained and traditionally trained residents. Results: The MPS was set at 87% on the checklist. Fifty-seven residents were assigned to the SBML-trained group and 49 were assigned to the traditionally trained group. Mean checklist scores for SBML-trained residents improved from 51.4% (standard deviation [SD] = 17.5%) at pretest to 86.1% (SD = 7.6%) at initial posttest and 92.5% (SD = 3.7%) at final (mastery) posttest (both P  < 0.001). Forty-two percent of residents required more than one attempt at the posttest to meet or exceed the MPS. At rotation completion, the traditionally trained residents had a mean test score of 60.9% (SD = 13.3%). Conclusion: SBML is an effective strategy to train residents on mechanical ventilator management. An SBML curriculum may augment traditional training methods to further equip residents to safely manage ventilated patients., (Copyright © 2021 by the American Thoracic Society.)

Background: Pediatric vascular access is inherently challenging due to the small caliber of children's vessels. Ultrasound-guided intravenous catheter insertion has been shown to increase success rates and decrease time to cannulation in patients with difficult intravenous access. Although proficiency in ultrasound-guided intravenous catheter insertion is a critical skill in pediatric anesthesia, there are no published competency-based training curricula., Aims: The objective of this study was to evaluate the performance of pediatric anesthesiologists who participated in a novel ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum., Methods: Pediatric anesthesia attendings, fellows, and rotating residents participated in the ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum from August 2019 to February 2020. The 2-hour curriculum consisted of participants first undergoing a simulated skills pretest followed by watching a video on ultrasound-guided intravenous catheter insertion and deliberate practice on a simulator. Subsequently, all participants took a post-test and were required to meet or exceed a minimum passing standard. Those who were unable to meet the minimum passing standard participated in further practice until they could be retested and met this standard. We compared pre to post-test ultrasound-guided intravenous catheter insertion skills and self-confidence before and after participation in the curriculum., Results: Twenty-six pediatric anesthesia attendings, 12 fellows, and 38 residents participated in the curriculum. At pretest, 16/76 (21%) participants were able to meet or exceed the minimum passing standard. The median score on the pretest was 21/25 skills checklist items correct and improved to 24/25 at post-test (95% CI 3.0-4.0, P < .01). Self-confidence significantly improved after the course from an average of 3.2 before the course to a postcourse score of 3.9 (95% CI 0.5-0.9, P < .01; 1 = Not all confident, 5 = Very confident)., Conclusions: Simulation-based mastery learning significantly improved anesthesiologists' ultrasound-guided intravenous catheter insertion performance in a simulated setting., (© 2020 John Wiley & Sons Ltd.)

Background: Appropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians., Objective: The objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE., Methods: We used pretest-posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance., Results: The MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62-55.77) at pretest to 94.23% (IQR: 92.13-100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31-100 vs. 92.31%; IQR: 88.46-96.15; p = .13)., Conclusions: Our SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Cricothyrotomy is associated with significant aerosolization that increases the potential risk of infection among healthcare providers. It is important to identify simple yet effective methods to suppress aerosolization and improve the safety of healthcare providers., Methods: 5 ear, nose and throat and general surgeons used a locally developed hybrid cricothyrotomy simulator with a porcine trachea to test three draping methods to suppress aerosolization during the procedure: an X-ray cassette drape, dry operating room (OR) towels and wet OR towels. The three methods were judged based on three categories: effectiveness of suppression, availability in all healthcare systems and ease of handling., Results: All five surgeons performed the procedure independently using each of the three suppression methods. The wet OR towel drape was found to be an effective method to suppress aerosolization, and it did not hinder the surgeons from performing the procedure accurately. This finding was confirmed by using an atomized fluorescein dye injection into the porcine trachea, representing aerosolized material while performing the procedure., Conclusions: We present a novel intervention using wet towels to suppress aerosolization during cricothyrotomy. Wet towels are cheap and readily available within any healthcare setting regardless of the financial resources available., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Simulation-based mastery learning (SBML) programs have been shown to be beneficial to improve procedural skill acquisition. However, simulated procedure performance can be affected by a host of factors, including stress. This investigation examined the preliminary efficacy of bolstering an established SBML program for medical residents with a brief mindfulness intervention (called a PITSTOP) to reduce procedural stress and improve simulator performance. Design: The study employed a partially blinded, parallel-group, randomized, repeated-measures intention-to-treat design. Participants were blinded to the primary outcome (simulator performance) and instead were informed of the study's secondary outcome (stress prevention). The SBML faculty instructors and study investigators were blinded to participants' group assignment. Settings/location: Northwestern Memorial Hospitals of Chicago. Subjects: Twenty-six postgraduate year (PGY) 1 internal medicine residents enrolled in a required SBML central venous catheter (CVC) insertion training from June 2015 to January 2018 participated in the study. Interventions: SBML consists of a simulated skills pretest, deliberate practice, and a simulated skills post-test (within 1 week of pretest). PGY 1 participants were randomly assigned to the PITSTOP intervention (12-min PITSTOP mindfulness training video) or control group (12-min control video on ways to increase physical activity) before the SBML pretest. Outcome measures: The primary outcome was a comparison of each group's simulator performance during pre- and post-tests. Secondary outcomes were changes in groups' procedural stress during these tests (assessed using self-reported, instructor-rated, and physiologic indicators), and self-reported self-regulation outcomes. Results: Residents who watched the PITSTOP video before their SBML training made fewer procedural errors relative to controls during their pretest for intrajugular CVC insertion ( p  = 0.03). PITSTOP participants also had lower heart rate ( p  = 0.03) and less visible trembling ( p  = 0.003) relative to controls at the post-test. Conclusions: This study provides preliminary evidence that a brief, mindfulness intervention may reduce stress during SBML training.

Background: Patients who undergo ventricular assist device (VAD) implantation and their caregivers must rapidly learn a significant amount of self-care skills and knowledge., Objective: The aim of this study was to explore patient, caregiver, VAD coordinator, and physician perspectives and perceptions of existing VAD self-care training to inform development of a simulation-based mastery learning (SBML) curriculum to teach patients and caregivers VAD self-care skills and knowledge., Methods: We conducted semistructured, in-person interviews with patients with a VAD, their caregivers, VAD coordinators, and physicians (cardiac surgeons, an infectious disease physician, and advanced heart failure cardiologists). We used a 2-cycle team-based iterative inductive approach to coding and analysis., Results: We interviewed 16 patients, 12 caregivers, 7 VAD coordinators, and 11 physicians. Seven major themes were derived from the interviews including (1) identification of critical curricular content, (2) need for standardization and assessment, (3) training modalities, (4) benefits of repetition, (5) piercing it all together, (6) need for refresher training, and (7) provision of training before implant., Conclusions: Findings from this study suggest that SBML is a natural fit for the high-risk tasks needed to save VAD self-care. The 7 unique training-related themes derived from the qualitative data informed the design and development of a VAD SBML self-care curriculum.

Background: No recognized standards exist for teaching patients and their caregivers ventricular assist device (VAD) self-care skills. We compared the effectiveness of a VAD simulation-based mastery learning (SBML) self-care training curriculum with usual VAD self-care training., Methods and Results: VAD patients and their caregivers were randomized to SBML or usual training during their implant hospitalization. The SBML group completed a pretest on 3 VAD self-care skills (controller, power source, and dressing change), then viewed videos and participated in deliberate practice on a simulator. SBML participants took a posttest and were required to meet or exceed a minimum passing standard for each of the skills. The usual training group completed the existing institutional VAD self-care teaching protocol. Before hospital discharge, the SBML and usual training groups took the same 3 VAD self-care skills tests. We compared demographic and clinical information, self-confidence, total participant training time, and skills performance between groups. Forty participants completed the study in each group. There were no differences in demographic and clinical information, self-confidence, or training time between groups. More participants in the SBML group met the minimum passing standard compared with the usual training group for controller (37/40 [93%] versus 25/40 [63%]; P =0.001), power source (36/40 [90%] versus 9/40 [23%]; P <0.001), and dressing change skills (19/20 [95%] versus 0/20; P <0.001)., Conclusions: SBML provided superior VAD self-care skills learning outcomes compared with usual training. This study has important implications for patients due to the morbidity and mortality associated with improper VAD self-care., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03073005.

Introduction: Physician communication impacts patient outcomes. However, communication skills, especially around difficult conversations, remain suboptimal, and there is no clear way to determine the validity of entrustment decisions. The aims of this study were to 1) describe the development of a simulation-based mastery learning (SBML) curriculum for breaking bad news (BBN) conversation skills and 2) set a defensible minimum passing standard (MPS) to ensure uniform skill acquisition among learners., Innovation: An SBML BBN curriculum was developed for fourth-year medical students. An assessment tool was created to evaluate the acquisition of skills involved in a BBN conversation. Pilot testing was completed to confirm improvement in skill acquisition and set the MPS., Outcomes: A BBN assessment tool containing a 15-item checklist and six scaled items was developed. Students' checklist performance improved significantly at post-test compared to baseline (mean 65.33%, SD = 12.09% vs mean 88.67%, SD = 9.45%, P < 0.001). Students were also significantly more likely to have at least a score of 4 (on a five-point scale) for the six scaled questions at post-test. The MPS was set at 80%, requiring a score of 12 items on the checklist and at least 4 of 5 for each scaled item. Using the MPS, 30% of students would require additional training after post-testing., Comments: We developed a SBML curriculum with a comprehensive assessment of BBN skills and a defensible competency standard. Future efforts will expand the mastery model to larger cohorts and assess the impact of rigorous education on patient care outcomes., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Patients and caregivers need to perform ventricular assist device (VAD) self-care safely to help prevent complications (e.g., infection). We developed a VAD self-care simulation-based mastery learning (SBML) curriculum. We determined optimal minimum passing scores (MPSs) and evaluated effects of judge selection., Methods: A multidisciplinary team created a VAD self-care SBML curriculum including simulated skills and knowledge examinations. Patients, caregivers, VAD coordinators, and physicians were expert judges who determined MPSs using the Mastery Angoff method., Results: MPSs for the skills and knowledge examinations were high (range = 94-99% and 97% correct), respectively. Judges closely agreed on MPSs., Conclusions: Stakeholders set stringent MPSs for high-stakes VAD self-care., Competing Interests: Conflict of Interest Disclosures: The authors have no relevant financial disclosures to report.

Purpose: Defensible minimum passing standards (MPSs) must be used to evaluate learner performance outcomes in health professions education. In this study, the authors compared the results of traditional Angoff and Hofstee standard-setting exercises with the Mastery Angoff and Patient-Safety approaches for central venous catheter (CVC) insertion skills examinations. The authors also evaluated how these standards affected the historical performance of residents who participated in a simulation-based mastery learning (SBML) curriculum for CVC insertion skills., Method: In April and May 2015, 12 physicians with expertise in CVC insertion set MPSs for previously published internal jugular (IJ) and subclavian (SC) CVC insertion checklists using Angoff, Hofstee, Mastery Angoff, and Patient-Safety approaches. The resulting MPSs were compared using historical performance of internal medicine and emergency medicine residents who participated in CVC insertion SBML., Results: The MPSs were set as follows: Angoff: IJ 91% checklist items correct, SC 90%. Hofstee: IJ 88%, SC 90%. Mastery Angoff: IJ 98%, SC 98%. Patient-Safety: IJ 98%, SC 98%. Based on the historical performance of 143 residents assessed on IJ and SC insertion, applying the 98% MPS would result in additional practice and retesting of 55/123 residents (45%) who had previously passed the IJ examination and 36/130 residents (28%) who had passed the SC examination using the Angoff and Hofstee MPSs., Conclusions: The Mastery Angoff and Patient-Safety standard-setting approaches resulted in higher CVC insertion SBML MPSs compared with traditional standard-setting methods. Further study should assess the impact of these more rigorous standards on patient outcomes.

Background: Mastery learning in health professions education requires learners to learn and undergo assessment until they demonstrate a high level of competence. Setting defensible standards is key to accurately assessing educational outcomes in mastery learning. The Mastery Angoff method was proposed recently to set a minimum passing standard (MPS) for mastery learning curricula. However, it is unknown whether prior knowledge of trainee performance affects judges' decisions about setting an MPS using the Mastery Angoff method., Objective: We sought to determine the effect of introducing baseline data about trainee performance on faculty judges' decisions about the Mastery Angoff MPS for a written examination., Methods: We developed a mastery learning curriculum to train internal medicine residents and cardiology fellows about the correct interpretation of inpatient telemetry monitoring. All learners were required to meet or exceed an MPS on a 35-item written examination at the end of training. The MPS was set in 2017 by judges who used the item-based Mastery Angoff method without prior examinee performance information. The judges subsequently reevaluated the test items after receiving baseline data about trainee performance collected during pilot testing. Mastery Angoff MPSs with and without baseline performance data were compared., Results: Twelve judges participated in the standard-setting exercise. The initial MPS was similar to the repeat MPS set after judges received trainee performance data (86.2% versus 86.9%, P  = .23)., Conclusions: Prior knowledge about medical trainee performance data did not affect MPS as determined by the Mastery Angoff procedure., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Purpose: Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE)., Method: The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR)., Results: During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008)., Conclusions: Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.

Background: Laparoscopic common bile duct exploration is an underutilized treatment for choledocholithiasis. We sought to evaluate the impact of a simulation-based mastery-learning curriculum for surgical residents on laparoscopic common bile duct exploration utilization and to compare outcomes for patients treated with laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography (ERCP)., Methods: The number of laparoscopic common bile duct explorations performed before and after curriculum implementation was reviewed and outcomes were compared between patients with choledocholithiasis managed with laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography. Based on cost savings from increased utilization of laparoscopic common bile duct exploration, the annual return on investment associated with the curriculum was calculated., Results: Twenty-two residents completed the curriculum. In the pre-curriculum period, an average of 1.7 laparoscopic common bile duct explorations was performed yearly, which increased to 8.4 cases per year after curriculum implementation (P < .05). Identified were 155 patients with choledocholithiasis: 31 underwent laparoscopic common bile duct exploration plus laparoscopic cholecystectomy and 124 underwent endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. The laparoscopic common bile duct exploration and laparoscopic cholecystectomy group had a reduced duration of stay (2.5 ± 1.8 days versus 4.3 ± 2.2 days, P < .0001) and costs ($12,987 ± $3,286 versus $15,022 ± $4,613, P = .01) compared with endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Rates of readmission and reoperation were equivalent between groups. Cost savings were more than $38,000, resulting in a 3.8 to 1 return on investment from curriculum implementation., Conclusion: A simulation-based mastery-learning curriculum increased institutional utilization of laparoscopic common bile duct exploration and adoption of the curriculum resulted in positive return on investment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This article was migrated. The article was marked as recommended. Background Studies show that medical residents do not feel comfortable and lack the skills and confidence to perform common bedside procedures. Regulatory bodies often require a set number of procedures to determine resident competence, yet medical providers' knowledge of competency guidelines are less well known. This study aimed to qualitatively assess existing practices relevant to documentation of competency in central venous catheter (CVC) insertion and explore healthcare providers' awareness and perceptions of those practices at their institutions. Methods The authors performed a qualitative study at Veterans Affairs Medical Centers (VAMCs) from February to December 2014 as part of a larger project related to the dissemination of a simulation-based CVC insertion curriculum. Two authors conducted interviews with hospital staff (including attending physicians, nurses, and residents) at selected VAMCs. Recordings of interviews were transcribed, coded, and analyzed using a grounded theory approach and constant comparative techniques. Results Twenty-six participants were interviewed at six VAMCs. Participants reported varying perspectives regarding their institutions' policies about CVC insertion. Four major themes emerged: (1) knowledge of institutional policy; (2) competency by numbers; (3) documentation of competency; and (4) perceptions of competency measures. Participants reported concern about the reliability of these policies and measures of competence. Conclusions This study demonstrates that healthcare providers' knowledge and perceptions about institutional requirements for procedural competency vary widely. Our findings suggest the need for establishment of consistent competency policies based on evidence-based practices, and highlight the need for increased communication regarding individual institutional policies. Integration of rigorous simulation-based education, implemented consistently across institutions, can provide a reliable mechanism to train and assess procedural competence and ensure patient safety., (Copyright: © 2018 Cohen ER et al.)

Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding., (© 2017 Society of Hospital Medicine.)