Are you curious about the recent buzz phrase, "Knowledge, Skills and Abilities" and maintenance of skills? Wonder about the requirements being developed to keep us ready to give care in a deployment environment? Would you like to be able to speak to your leadership and a possible employer regarding your skill sets? How do you defend that some of the more rarely done EM procedures are done with simulation? Find the answers to these and more discussion in this session about the current process of clinical sustainment.
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Hello and welcome to GSS virtual 2021. I'm Lieutenant Commander grace landers and today we're going to speak about perfect practice, clinical sustainment of the modern times, knowledge, skills and abilities. I would like to recognize my co author, Commander Robert old, a tireless advocate for skill sustainment in our ever changing world of operational and emergency medicine.Unknown:
Before we begin, it's important that I acknowledge the GSS 20. And now 21 planning committee members and the GSA said leadership, I have no conflicts of interest to disclose, and the views expressed in this presentation are my own, and do not reflect the official policy or position of the Department of the Navy Department of Defense nor the United States government. So where do we start? Well, in 2018, an article blasted across US News stating that, with fewer opportunities to hone their skills, military surgeons are inadvertently putting certain patients at risk for adverse outcomes. And this quickly became the born standard, that military physicians were falling below safety thresholds due to our patient population and remote practice locations. In other words, we were starting to become stale. US News then added fuel to their fire with a survey of 20 army surgeons. Now this is only 14% of the total they attempted to survey. But it brought to light such quotes as the army doesn't care about having well trained surgeons, it only cares about having bodies. Now I could stand here on my pedestal and say that I would never say something like this. But I'm well aware that since the early days, Ensign landers could have easily substituted navy and physician into this statement. And I have likely said something to this effect over the years while bemoaning some reasoning why I needed to get my hands back in the game prior to deployment opportunity. But I'm a military physician trained through and through. And so a part of me said, How could my instructors from my USU days to present have left me out there. So I set upon a personal quest to write this wrong champion this cause. And in that quest, I had my tires deflated and realized that military medicine might actually be on to something, we are actually going in the right direction. And my job isn't to criticize, but to educate, pick up that standard and move us forward. So let's speak about maintenance of skills. From the moment you graduate residency, whether civilian or military, pediatrician, surgeon or emergency physician, you are at the peak of the learning curve. And what US News uncovered is not an uncommon fear, maintenance of skills is not a new topic. The goal has always been to not fall off the mountain. So what were the actual findings? Well, US News pulled their data from a military health system bank from 2012 to 2016. The procedures highlighted were bariatric surgery, hip and knee replacements, mitral valve repairs, abdominal aortic grafting, carotid artery stenting, and cancer resections. And as my audience, you recognize that these procedures are not common unless you're at the highest level of care for military medicine. And even then we don't do as many as the civilian sector. These procedures, though, are not actually the ones we require on the battlefield. So in other words, this sensational grabbing headline of US News wasn't bringing to light procedures needed by military medicine at all. However, the important piece to pick up with this energy is we can use this momentum. The numbers of procedures were contracted with National Safety thresholds. And there is a causal relationship with a small procedural number, and worsening patient outcomes. And so military medicine leaders responded very quickly, and will lead to why in a few minutes. But they responded with updated knowledge, skills and abilities, the desire for enhanced simulations, also the use of perfused cadavers, and they included a group that US News hadn't physician extenders and nurses and corpsman so what are the current requirements well, Core clinical competence is met with board certification and maintenance certification. And as we know, the class of 2019 has had a delay in their oral boards, which has led to a delay in their overall board certification. However, we have a lot of other pieces that go into this hospital privileging and qualitative reviews, for example. And those make up the base of what we understand to be our clinical competence. The next piece is our universal skills. So your deployment requirements as an emergency medicine physician, most of us are going to need a TLS when we deploy downrange, because we're going to see trauma patients. And there's also work requirement for t Triple C. We'll speak a little bit more about this later. But this is a point of injury course that we teach from a basic corpsman all the way up. Then we also have our service and job specific skills. So these courses would be the qualifications required for your specific platform. Some of these might include training for seacat dive medicine, or flight medicine. But involved in that is any specification that you need to perform your job as a military physician. So what are the knowledge skills and abilities from a military medicine standpoint, was I alluded to previously, in 2018, military medicine responded very quickly. And that's because they already had a working group formed that had tri service representation, and five of our critical wartime specialties, surgery, anesthesia, orthopedic surgery, critical care, and emergency medicine. And this group of individuals was developing specialty specific case essays. These are based on JTS cpgs case registries and relevant literature. And they developed 2800 of these kshs across 52 domains. In emergency medicine, specifically, there were 486k essays in eight domains. Now these were defined with an expeditionary mindset involved, but the scoring system overlapped with our peacetime workload, to then develop a readiness indicator for each clinician, MTF, and market. And so the goal was that if you were going to see a septic patient, in a recess Bay here in the United States, that that transferability of skills would then say that you could then resuscitate a trauma patient downrange, the pathophysiology, while not exactly the same, was close enough. And so these scores were used as a guide for deployment readiness. And I want to absolutely emphasize the fact that they are a guide. commanders have the data now to optimize the readiness of their clinicians, and their MTF through acgme requirements. So on July the 14th of 2020, the Navy Surgeon General signed a memo that established our kshs through the Naval Medical Readiness Training criteria. Now we're going to break from a try service mentality and move more towards the Navy, and then specifically towards one of our facilities to totally hone down on how our services doing this, but also to inspire a conversation across the services to understand this better. Naval Medical Readiness Training criteria have three categories. So the first category is core practice and clinical currency. And this deals with fundamental training and skills. Now, these are usually obtained through medical education, and they should be maintained through the MTF experience and or civilian partnerships. This category of requirements, blinks to the attainment of your core practice your clinical currency, and then our KSA threshold. The KSA threshold should be met by about 768 emergency department patients per year. And this is where I want to caution you on this, because as we previously discussed where a septic patient and a trauma patient, that pathophysiology and that transferability of skills may be there. This can be obtained in a separate way. So if you think of an urgent care and the number of patients that they see in an urgent care, you could easily meet your kshs for the Through the number of patients alone, however, you would have to be very cautious in obtaining the exact same types of patients or the exact same level of difficulty with patients. Those are not going to be the same level of difficulty with patients, as you're going to see in a busy Trauma Center, for example. So the piece is, while you're looking at this equality of numbers, you have to understand the complexity must be there. So let's speak about the procedures that are still in category one. once per year, you need to be able to perform the three following pericardiocentesis thoracotomy and a lateral can thought me twice a year we'd like to be able to see you perform chest tubes ieos and transfuse blood products or their components, and also perform a crack with our anatomy. Three times in a year, you need to be able to introduce a central venous catheter and perform cardio versions or defib relations five times in a year, you need to perform procedural cetaceans and reduce fractures and dislocations. And then 10 times in a year, you need to be able to introduce an ET tube and perform IE fast. And I want to have a caveat on this, that, especially for the procedures that are not commonly performed in the emergency department, there is a simulation component allowed. Let's move to the second category. This is expeditionary skills for readiness and readiness currency. So this should be your combat specialty knowledge or the individual skills you need specific to operating in your expeditionary environment. This ensures the transference of the skills from category one to that expeditionary environment, and this includes caring for patients during combat operations. This also can include some general platform training requirements that an individual specialty requires across the continuum. And this is where we bring in a TLS and T Triple C. So every four years, we will renew our ACLs every three years renewing our tactical combat casualty course. And as I said previously with the T Triple C. While this is a point of injury course, the basics are in there to understand how to care for a patient under fire. Also, every three years, there's a renewal of two online courses that deal with CPR and E so that you understand your preparedness, but then also your protective equipment and measures. And then once in your career, they want you to go through a CBR personal protection and decontamination course, c four for which Bushmaster does take the component of for us EU students, and then not a requirement, but considered in there under they once per year is attending the naval trauma training course out in California. Moving on to category three, this is your platform training for readiness. So this is your team and unit level specific platform training. This could include requirements such as readiness proficiency or joint interoperability with your platform. And currently the two courses we have deal with the expeditionary medical facilities that are staffed outside outside of our hospitals. And so these are our team training performance, and also the operational readiness exercise. And both of these take place in California as well. So let's move over to an example of how a department within the Navy performs this tracking. I want to paraphrase from a recent panel on kshs that we don't want to require men wanting to meet these Readiness Standards. But we also want to ensure that we do not punish those who obtained their readiness through moonlighting. So the goal is to record the numbers that you get in an outpatient, er, for example, to chest tubes over the weekend, and not punish you by saying, hey, you have to come in and do two chest tubes in a simulation environment because we don't technically have those recorded through our Navy system. Now while this is a self entry pathway that we're going to discuss, the goal is eventually to access these numbers through carepoint. As we move more online with da ha Now this specific tracking example is from a trauma level three facility. And like I said, we capture this manually into this datasheet. And I can tell you from personal experience, that since we receive a vast number of traumas, we do a vast number of E fast exams. But we only capture about a quarter of those into this data entry sheet. Because this is at the end of your shift, another thing that the provider has to think of and has to do. For our specific example, we capture at 80% for a green status. And then also, in addition to the previous procedures mentioned, we added in reboa to these numbers. So you can see at the bottom of this page, the physician would see their katiyar or their KSA deployment readiness number. And for this specific provider, they have a number of 77%. So looking at their sheet very quickly for me to say yeah, you look like you feel okay to deploy or you feel proficient to deploy, we would probably get them in for some simulation training, we would do a pericardiocentesis thoracotomy, a lateral can't automate. And if we have the capability, also a reboa. With simulation, they also need to re record a few of their e fast exams. But other than that, they seem like they're going to be pretty full up. Looking at the end of tracheal intubation, they might need to get into the LR for a few of those. And so we'll discuss a little bit later how we should move through getting these kshs up and online. Now pulling from this tracking example, we have a course of 30 providers throughout the year. And briefly I'll explain what I brought blue provider and a green provider are so a blue provider is someone in the Navy who is assigned to a hospital billet. This individual their main job is to work within the hospital and they may hold other roles within the hospital such as department head, or DMS, but they are an ER provider assigned to that hospital. Greenside providers, on the other hand, their commanding officer is a marine. And so while they are not deployed, or while they're not in workups, for deployment, their main job is to be at the hospital, getting those procedures and maintaining their skill set. But they also might be pulled out for certain field exercises, etc. So you can see on the whole, that the green providers have a bit more of a difficult time maintaining their procedural competency. And that goes without saying throughout the years of things that we've understood that our readiness and our skill sets degrade as we do operational medicine. What this provides, though, is a guideline and a platform for us to advocate to our CEOs on the green side, that we need to get back into the hospital that it's very similar to being able to go to the rifle range and maintain our skill sets. So across the board, when you're taking these tracking examples, we want to use them as that launch platform and that communication platform with the people that truly are going to benefit from us having a good skill set. The second example I want to bring up is this tracking example, which shows the procedures completed throughout the year. Now the blue boxes are the total procedures completed. And then the red boxes are the total live procedures completed. And as a department, you can start to look at this, and we'll pull out into tracheal intubation into this example. But the total completed far outweighs the numbers that we have done on live patients. So as a department head and as a CEO of the MTF, you can start to look at this and say, maybe we need to get some of our emergency medicine providers into the O r, so that their simulation training is not the only place that they're getting their intubation skills maintained. So as you can see when we're pulling these data sets out, where we can really start to advocate for ourselves and for our maintenance of certification. Now I want to bring this slide in here specifically, so that we do not confuse the nomenclature kshs across the specialty are a little bit different. And this is specifically pulled from a bam. These are the K essays that they use to talk about what they certify us with at the basic level for our board certified Question. And these are much more in detail than the ones that we use on the military side. For example, they bring in a, b, and c as the levels that they need you to provide each specialty with or each procedure with. And so they want you to be able to perform the indicated procedure on all patients, including those that are uncooperative at extremes of age hemodynamically, unstable, etc, etc, etc. This is a basis from which we launch, then our understanding of the military KSA. So we want to make sure that when we're communicating this, that we don't say, we don't have any of these skills, no, we're already starting from a very high level of these skills. And these requirements that we start at this very high level is met with board certification and maintenance of certification. So if you really want to delve into this, I encourage you to go look at the milestones project, which was a joint initiative between the acgme and AVM. And then I also want you to go look at the A o b, e m, similar requirements. They have a bit of a different nomenclature and some specialty specific requirements. But I want to encourage you when you're speaking to this, for example, with potential employers, that you state that this basis, and this level that we start at on these skill sets is very high. And then in the military, I maintained them through this, this and this level as well. So what is the best answer to maintaining these kshs? Well, quick answer is, we don't really know. We know that experience with patients has no equal simulation is an alternative. But which simulation tool is really the best? Well simulation for rare and uncommon procedures. Absolutely. That is wonderful to go for. But we also must remind ourselves that even pilots don't just practice on simulators, we need some hands on time. Going through some of the research, we do have the Heart Study. Now this study was a live tissue versus synthetic tissue training for critical procedures. And this highlighted lack of data that we have on this subject. This usyd army combat medics, over 185 simulators and seven core procedures and of the seven core procedures junctional, hemorrhage control, tourniquet placement, chest seals, needle thoracostomy, nasal pharyngeal Airways, tube thoracostomy, and crakes. Only two of them truly showed that you needed to have live tissue. Otherwise, they were equal as far as simulation went. I do want to caution you on the one piece though, there is further study that is needed. And some of these had slightly underpowered studies as well. But as far as a significant difference in performance of skills, junctional, hemorrhage, tourniquet, use chest seals, NPA, and also needle thoracostomy is showed no significant difference in performance across simulation and live tissue. The key with all of this is to prevent skill decay, right? So as I stated earlier, you're starting at a very high level as emergency physicians, you're an experienced practitioner. And so maintenance of skills through tracking of procedures and tracking of a very small number 486 patients per year may be sufficient in maintaining your skill set, or even a short course, such as a trauma course. But like I already alluded to, there is a lack of data on this, especially when our skills deteriorate, and how we avoid this decay. This also is a huge question for our physician extenders, our idcs or sokos, or medics, PhDs and nurse practitioners, because they're not necessarily starting out at the exact same level that we are. And so where do their skill sets need to really be improved? And how do we maintain them so that they don't have deterioration and there's always another piece to this. What is The cost prices vary enormously. Some of the cadaver models cost 12 $150 per model. And One study showed an almost two fold increase though, in that over simulation, learner confidence. If we talked about live tissue models, those can be 40 to $60 apiece, but then you have to maintain the lab and the lab staff on top of that, simulation varies enormously. And the prices as far as patient encounters also do, the Navy and Army and Air Force have all gone so far as to send their learners to certain environments to be able to maintain procedures. So we also have to put a cost on our travel for that. But all of this pulls into a guarantee vise, what comes into our MTF 's on a regular basis. So what is the evidence? Well, we already discussed this, we need to understand more, as far as our resuscitative procedural competence and where those skills degrade. We need to continue to have collaboration, as far as this goes across the different services, for example, sending an emergency medicine physician up to anesthesia, to be able to go into the ER and be able to get some of those intubations. I do believe that all of this will lead to improved confidence, though. But we need to especially look at some of our publication bias. The limitations observed here, we don't have the longest timeline to say we have this evidence captured. And especially with COVID, and the decrease of patients into the emergency department, we have to have a lot of flexibility and understanding how to maintain these skills, we also need to move forward in defining our exact platform requirements. Lastly, we don't have a lot of live tissue training publications. Because as a military system, we have become very aware on how we present ourselves to the public with our live tissue. So what is the future? Well, we'll continue with our codification of the KSA we're going to revisit our threshold scores will further map the expeditionary scope of practice. And we'll continue to align our price services. I do believe that we need to have a JTS comparison from our implementation of this versus our prior data. We need to look at our outcome improvement in garrison in our MTS and we need to continue with a case by case analysis. We also need to consider head to head model testing across simulation and live tissue to see whether or not there is a difference in which way we should maintain our certification and our KSA is moving forward. Thank you very much for the care of your patients and the dedication that you show on a daily basis. I'm now very happy to take any of your questions and you'll see my references in the next slide.