Nikhil Seth, MD

The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.

Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.¹

Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.² Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.

TRANSITION OF CARE PROGRAM

Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.³ Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.⁴

Program Goals

The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.

This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.

At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.

When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.

Implementation

This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.

Findings

Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.

While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.

The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.

Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.⁵ A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.⁶

In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.⁷ In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.⁸

Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.

While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.

Challenges

Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.

CONCLUSIONS

The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.

The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.

Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.¹

Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.² Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.

TRANSITION OF CARE PROGRAM

Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.³ Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.⁴

Program Goals

The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.

This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.

At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.

When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.

Implementation

This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.

Findings

Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.

While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.

The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.

Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.⁵ A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.⁶

In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.⁷ In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.⁸

Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.

While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.

Challenges

Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.

CONCLUSIONS

The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.

The Olin E. Teague Veterans’ Center (OETVC) in Temple, Texas, is a teaching hospital with 189 beds that provides patients access to medical, surgical, and specialty care. In 2022, 116,359 veterans received care at OETVC and 5393 inpatient admissions were noted. The inpatient ward consists of 3 teaching teams staffed by an attending physician, a second-year internal medicine resident, and 2 to 3 interns while hospitalists staff the 3 nonteaching teams. OETVC residents receive training on both routine and complex medical problems.

Each day, teaching teams discharge patients. With the complexity of discharges, there is always a risk of patients not following up with their primary care physicians, potential issues with filling medications, confusion about new medication regiments, and even potential postdischarge questions. In 1990, Holloway and colleagues evaluated potential risk factors for readmission among veterans. This study found that discharge from a geriatrics or intermediate care bed, chronic disease diagnosis, ≥ 2 procedures performed, increasing age, and distance from a veterans affairs medical center were risk factors.¹

Several community hospital studies have evaluated readmission risk factors. One from 2000 noted that patients with more hospitalizations, lower mental health function, a diagnosis of chronic obstructive pulmonary disorder, and increased satisfaction with access to emergency care were associated with increased readmission in 90 days.² Due to the readmission risks, OETVC decided to construct a program that would help these patients successfully transition from inpatient to outpatient care while establishing means to discuss their care with a physician for reassurance and guidance.

TRANSITION OF CARE PROGRAM

Transition of care programs have been implemented and evaluated in many institutions. A 2017 systematic review of transition of care programs supported the use of tailored discharge planning and postdischarge phone calls to reduce hospital readmission, noting that 6 studies demonstrated a statistically significant reduction in 30-day readmission rate.³ Another study found that pharmacy involvement in the transition of care reduced medication-related problems following discharge.⁴

Program Goals

The foundational goal of our program was to bridge the gap between inpatient and outpatient medicine. We hoped to improve patient adherence with their discharge regimens, improve access to primary care physicians, and improve discharge follow-up. Since hospitalization can be overwhelming, we hoped to capture potential barriers to medical care postdischarge when patients return home while decreasing hospital readmissions. Our second- and third-year resident physicians spend as much time as needed going through the patient’s course of illness throughout their hospitalization and treatment plans to ensure their understanding and potential success.

This program benefits residents by providing medical education and patient communication opportunities. Residents must review the patient’s clinical trajectory before calling them. In this process, residents develop an understanding of routine and complex illness scripts, or pathways of common illnesses. They also prepare for potential questions about the hospitalization, new medications, and follow-up care. Lastly, residents can focus on communication skills. Without the time pressures of returning to a busy rotation, the residents spend as much time discussing the hospital course and ensuring patient understanding as needed.

At the beginning of each week, second- and third-year residents review the list of discharges from the 3 teaching teams. The list is generated by a medical service management analyst. The residents review patient records for inpatient services, laboratory results, medication changes, and proposed follow-up plans designed by the admission team prior to their phone call. The resident is also responsible for reviewing and reconciling discharge instructions and orders. Then, the resident calls the patient and reviews their hospitalization. If a patient does not answer, the resident leaves a voicemail that complies with the Health Insurance Portability and Accountability Act.

When patients answer the call, the resident follows a script (Appendix). Residents are encouraged to ask patients open-ended questions and address any new needs. They also discuss changes in symptoms, medications, functional status, and remind the patient about follow-up appointments. If imaging or specific orders were missed at discharge, the residents notify the chief resident, lead hospitalist, or deputy associate chief of staff for medical service. If additional laboratory tests need to be ordered, the resident devises a follow-up plan. If needed, specialty referrals can be placed. When residents feel there are multiple items that need to be addressed or if they notice any major concerns, they can recommend the patient present to the emergency department for evaluation. The chief resident, lead hospitalist, and deputy associate chair for medical service are available to assist with discussions about complex medical situations or new concerning symptoms. Residents document their encounters in the Computerized Patient Record System health record and any tests that need follow-up. This differs from the standard of care follow-up programs, which are conducted by primary care medicine nurses and do not fully discuss the hospitalization.

Implementation

This program was implemented as a 1-week elective for interested residents and part of the clinic rotation. The internal medicine medical service analyst pulls all discharges on Friday, which are then provided to the residents. The residents on rotation work through the discharges and find teaching team patients to follow up with and call.

Findings

Implementation of this program has yielded many benefits. The reminder of the importance of a primary care appointment has motivated patients to continue following up on an outpatient basis. Residents were also able to capture lapses in patient understanding. Residents could answer forgotten questions and help patients understand their admission pathology without time pressures. Residents have identified patients with hypoglycemia due to changed insulin regimens, set up specialist follow-up appointments, and provided additional education facilitating adherence. Additionally, several residents have expressed satisfaction with the ability to practice their communication skills. Others appreciated contributing to future patient successes.

While the focus on this article has been to share the program description, we have tabulated preliminary data. In January 2023, there were 239 internal medicine admissions; 158 admissions (66%) were teaching team patients, and 97 patients (61%) were called by a resident and spoken to regarding their care. There were 24 teaching team readmissions within 30 days, and 10 (42%) received a follow-up phone call. Eighty-one admitted patients were treated by nonteaching teams, 10 (12%) of whom were readmissions. Comparing 30-day readmission rates, 10 nonteaching team patients (12%), 10 teaching team patients (6.3%) who talk to a resident in the transition of care program were readmitted, and 24 teaching team patients who did not talk to a resident (10%) were readmitted.

The OETVC transition of care program was planned, formulated, and implemented without modeling after any other projects or institutions. This program aimed to utilize our residents as resources for patients.

Transition of care is defined as steps taken in a clinical encounter to assist with the coordination and continuity of patient care transferring between locations or levels of care.⁵ A 2018 study evaluating the utility of transition of care programs on adults aged ≥ 60 years found a reduction in rehospitalization rates, increased use of primary care services, and potential reduction in home health usage.⁶

In 2021, Johns Hopkins University School of Medicine implemented a program after polling residents and discovering their awareness of gaps in the transition of care.⁷ In 2002, pharmacists evaluated the impact of follow-up telephone calls to recently hospitalized patients. This group of pharmacists found that these calls were associated with increased patient satisfaction, resolution of medication-related problems and fewer emergency department returns.⁸

Our program differs from other transition of care programs in that resident physicians made the follow-up calls to patients. Residents could address all aspects of medical care, including new symptoms, new prescriptions, adverse events, and risk factors for readmission, or order new imaging and medications when appropriate. In the program, residents called all patients discharged after receiving care within their team. Calls were not based on risk assessments. The residents were able to speak with 61% of discharged patients. When readmission rates were compared between patients who received a resident follow-up phone call and those who did not, patients receiving the resident phone call were readmitted at a lower rate: 6.3% vs 10%, respectively.

While our data suggest a potential trend of decreased readmission, more follow-up over a longer period may be needed. We believe this program can benefit patients and our model can act as a template for other institutions interested in starting their own programs.

Challenges

Although our process is efficient, there have been some challenges. The discharge is created by the medical service management analyst and then sent to the chief resident, but there was concern that the list could be missed if either individual was unavailable. The chairperson for the department of medicine and their secretary are now involved in the process. To reduce unanswered telephone calls, residents use OETVC phones. Health Insurance Portability and Accountability Act-compliant voicemails providing a time for a follow-up call were implemented. As a result, veterans have answered their phones more regularly and are more aware of calls. Orders are generally placed by the chief resident, lead hospitalist, or chair of the medical service to ensure follow-up because residents are on rotation for 1 week at a time. Access to a physician also allows patients to discuss items unrelated to their hospitalization, introducing new symptoms, or situations requiring a resident to act with limited data.

CONCLUSIONS

The transition of care follow-up program described in this article may be beneficial for both internal medicine residents and patients. Second- and third-year residents are developing a better understanding of the trajectory of many illnesses and are given the opportunity to retrospectively analyze what they would do differently based on knowledge gained from their chart reviews. They are also given the opportunity to work on communication skills and explain courses of illnesses to patients in an easy-to-understand format without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, condition, and follow-up. This program will continue to address barriers to care and adapt to improve the success of care transitions.

The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m² of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.

The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.¹ Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.²

In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.

Curriculum Planning

Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.

A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.³ In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.

Program Description

Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.

This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.

Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.^4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.

After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.

Objectives

The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).

IMPLEMENTATION

The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.

The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.

Survey Responses

To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.

Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.

DISCUSSION

The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.

Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.⁶ It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.⁷ Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.

The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.

From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.

Challenges

The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.

Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.

CONCLUSIONS

Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.

Acknowledgments

The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.

The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m² of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.

The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.¹ Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.²

In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.

Curriculum Planning

Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.

A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.³ In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.

Program Description

Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.

This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.

Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.^4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.

After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.

Objectives

The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).

IMPLEMENTATION

The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.

The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.

Survey Responses

To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.

Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.

DISCUSSION

The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.

Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.⁶ It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.⁷ Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.

The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.

From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.

Challenges

The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.

Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.

CONCLUSIONS

Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.

Acknowledgments

The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.

The Central Texas Veteran’s Health Care System (CTVHCS) in Temple, Texas, is a 189-bed teaching hospital. CTVHCS opened the Center for Innovation and Learning (CIL) in 2022. The CIL has about 279 m² of simulation space that includes high- and low-fidelity simulation equipment and multiple laboratories, which can be used to simulate inpatient and outpatient settings. The CIL high-fidelity manikins and environment allow learners to be immersed in the simulation for maximum realism. Computer and video systems provide clear viewing of training, which allows for more in-depth debriefing and learning. CIL simulation training is used by CTVHCS staff, medical residents, and medical and physician assistant students.

The utility of technology in medical education is rapidly evolving. As noted in many studies, simulation creates an environment that can imitate real patients in the format of a lifelike manikin, anatomic regions stations, clinical tasks, and many real-life circumstances.¹ Task trainers for procedure simulation have been widely used and studied. A 2020 study noted that simulation training is effective for developing procedural skills in surgery and prevents the decay of surgical skills.²

In reviewing health care education curriculums, we noted that most of the rapid response situations are learned through active patient experiences. Rapid responses are managed by the intensive care unit and primary care teams during the day but at night are run primarily by the postgraduate year 2 (PGY2) night resident and intern. Knowing these logistics and current studies, we decided to build a rapid response simulation curriculum to improve preparedness for PGY1 residents, medical students, and physician assistant students.

Curriculum Planning

Planning the simulation curriculum began with the CTVHCS internal medicine chief resident and registered nurse (RN) educator. CTVHCS data were reviewed to identify the 3 most common rapid response calls from the past 3 years; research on the most common systems affected by rapid responses also was evaluated.

A 2019 study by Lyons and colleagues evaluated 402,023 rapid response activations across 360 hospitals and found that respiratory scenarios made up 38% and cardiac scenarios made up 37%.³ In addition, the CTVHCS has limited support in stroke neurology. Therefore, the internal medicine chief resident and RN educator decided to run 3 evolving rapid response scenarios per session that included cardiac, respiratory, and neurological scenarios. Capabilities and limitations of different high-fidelity manikins were discussed to identify and use the most appropriate simulator for each situation. Objectives that met both general medicine and site-specific education were discussed, and the program was formulated.

Program Description

Nightmare on CIL Street is a simulation-based program designed for new internal medicine residents and students to encounter difficult situations (late at night, on call, or when resources are limited; ie, weekends/holidays) in a controlled simulation environment. During the simulation, learners will be unable to transfer the patient and no additional help is available. Each learner must determine a differential diagnosis and make appropriate medical interventions with only the assistance of a nurse. Scenarios are derived from common rapid response team calls and low-volume/high-impact situations where clinical decisions must be made quickly to ensure the best patient outcomes. High-fidelity manikins that have abilities to respond to questions, simulate breathing, reproduce pathological heart and breath sounds and more are used to create a realistic patient environment.

This program aligns with 2 national Veterans Health Administration priorities: (1) connect veterans to the soonest and best care; and (2) accelerate the Veterans Health Administration journey to be a high-reliability organization (sensitivity to operations, preoccupation with failure, commitment to resilience, and deference to expertise). Nightmare on CIL Street has 3 clinical episodes: 2 cardiac (A Tell-Tale Heart), respiratory (Don’t Breathe), and neurologic (Brain Scan). Additional clinical episodes will be added based on learner feedback and assessed need.

Each simulation event encompassed all 3 episodes that an individual or a team of 2 learners rotate through in a round-robin fashion. The overarching theme for each episode was a rapid response team call with minimal resources that the learner would have to provide care and stabilization. A literature search for rapid response team training programs found few results, but the literature assisted with providing a foundation for Nightmare on CIL Street.^4,5 The goal was to completely envelop the learners in a nightmare scenario that required a solution.

After the safety brief and predata collection, learners received a phone call with minimal information about a patient in need of care. The learners responded to the requested area and provided treatment to the emergency over 25 minutes with the bedside nurse (who is an embedded participant). At the conclusion of the scenario, a physician subject matter expert who has been observing, provided a personalized 10-minute debriefing to the learner, which presented specific learning points and opportunities for the learner’s educational development. After the debriefing, learners returned to a conference room and awaited the next call. After all learners completed the 3 episodes, a group debriefing was conducted using the gather, analyze, summarize debriefing framework. The debriefing begins with an open-ended forum for learners to express their thoughts. Then, each scenario is discussed and broken down by key learning objectives. Starting with cardiac and ending with neurology, the logistics of the cases are discussed based on the trajectory of the learners during the scenarios. Each objective is discussed, and learners are allowed to ask questions before moving to the next scenario. After the debriefing, postevent data were gathered.

Objectives

The program objective was to educate residents and students on common rapid response scenarios. We devised each scenario as an evolving simulation where various interventions would improve or worsen vital signs and symptoms. Each scenario had an end goal: cardioversion (cardiac), intubation (respiratory), and transfer (neurologic). Objectives were tailored to the trainees present during the specific simulation (Table).

IMPLEMENTATION

The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.

The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.

Survey Responses

To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.

Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.

DISCUSSION

The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.

Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.⁶ It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.⁷ Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.

The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.

From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.

Challenges

The greatest challenge for Nightmare on CIL Street was the ability to pull internal medicine residents from their clinical duties to participate in the simulation. As there are many moving parts to their clinical scheduling, residents do not always have sufficient coverage to participate in training. There were also instances where residents needed to cover for another resident preventing them from attending the simulation. In the future, this program will schedule residents months in advance and will have the simulation training built into their rotations.

Medical and physician assistant students were pulled from their ward rotations as well. They rotate on a 2-to-4-week basis and often had already experienced the simulation the week prior, leaving out students for the following week. With more longitudinal planning, students can be pulled on a rotating monthly basis to maximize their participation. Another challenge was deciding whether residents should partner or experience the simulation on their own. After some feedback, it was noted that residents preferred to experience the simulation on their own as this improves their learning value. With the limited resources available, only rotating 3 residents on a scenario limits the number of trainees who can be reached with the program. Running this program throughout an academic year can help to reach more trainees.

CONCLUSIONS

Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Our trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation. They felt better prepared and had developed a better systematic approach for the future.

Acknowledgments

The authors thank Pawan Sikka, MD, George Martinez, MD and Braden Anderson, MD for participating as physician experts and educating our students. We thank Naomi Devers; Dinetra Jones; Stephanie Garrett; Sara Holton; Evelina Bartnick; Tanelle Smith; Michael Lomax; Shaun Kelemen for their participation as nurses, assistants, and simulation technology experts.