Society News

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Everyone at AGA sends our congratulations to AGA President John Carethers, MD, AGAF, on his appointment as the vice chancellor for health sciences at the University of California San Diego.

Dr. Carethers, who began his term as the 117th president of the AGA Institute on June 1, 2022, is returning to UC San Diego after a 13-year tenure at the University of Michigan. He will report directly to the chancellor and serve as a part of the leadership team, effective Jan. 1, 2023.

Aside from his new role at UCSD, Dr. Carethers has been an active member of AGA for more than 20 years and has served on several AGA committees, including the AGA Nominating Committee, AGA Underrepresented Minorities Committee, AGA Research Policy Committee, AGA Institute Council and the AGA Trainee & Young GI Committee.

We wish him well in this new chapter!

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Bronchiectasis Section

Antibiotics in non–cystic fibrosis bronchiectasis: new perspectives

The clearest benefit of antibiotics in managing non-cystic fibrosis bronchiectasis is for treatment of exacerbations and for chronic azithromycin use. There is a paucity of high-quality evidence for prophylactic antibiotics, though guidelines support this practice, particularly for adults with three or more exacerbations a year. A recent Cochrane database review (Spencer, et al. Cochrane Database Syst Rev. 2022;1[1]:CD013254) examined eight RCTs, with interventions ranging from 16 to 48 weeks, involving 2,180 adults and found little net benefit for prophylactic cycled antibiotics (fluoroquinolones, beta-lactams, and aminoglycosides) in terms of outcomes viz time-to-first-exacerbation and duration of exacerbations, but more than doubled the risk of emerging resistance.

Clinical equipoise exists regarding the duration of antibiotics during exacerbations. Guidelines favor 14 days. A recent RCT (Pallavi, et al. Eur Respir J. 2021;58:2004388) examined the feasibility of bacterial load-guided therapy in 47 participants with bronchiectasis requiring IV antibiotics.

Patients were randomized to either 14 days of antibiotics or treatment guided by bacterial load (BLGG). The 88% of participants in the BLGG group were able to stop antibiotics by day 8, and potentially 81% of participants in the 14-day group could have stopped antibiotics at day 8. Median time to next exacerbation was much longer – 60 days (18-110 days) in the in BLGG group vs 27.5 days (12.5-60 days) in the 14-day group vs (P = .0034). A larger multicenter RCT may clarify the benefits of this approach to shortening duration of antibiotic therapy in patients with bronchiectasis exacerbations.

O’Neil Green, MBBS, FCCP
Member-at-Large

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

Intensive care telemedicine was first described in 1982 after implementation in a seven-bed, inner-city ICU using 19-inch television screens connected with intensivists at the University Hospitals of Cleveland (Grundy, et al. Crit Care Med. 1982;10[7]:471). After this proof-of-concept report, however, ICU telemedicine gained little traction for nearly 20 years, until Johns Hopkins Hospital established a continuously monitored ICU telemedicine service in a nonintensivist staffed surgical ICU. Their pre/post analysis suggested a 64% decrease in severity-adjusted ICU mortality and greater than 30% decrease in ICU length of stay, ICU complications, and costs (Rosenfeld, et al. Crit Care Med. 2000;28[12]:3925).

Along with better and less costly telemedicine technology, rapid adoption of electronic medical records, and a nationwide intensivist shortage, this and other evidence for the service’s clinical and cost effectiveness has spurred explosive growth in ICU telemedicine in the succeeding 2 decades, with at least 18% of hospitals and 28% of ICU beds supported by ICU telemedicine by 2018 (Ofoma, et al. Crit Care Explor. 2021;4[3]:e0468).

Importantly, what “ICU telemedicine” represents varies substantially across hospitals and even across ICUs within systems. Two-way audiovisual technology is the defining feature, and at a minimum, programs provide intensivists and/or nurses who respond to consultation requests. Commonly, telemedicine clinicians directly connect with patients; monitor labs, hemodynamics, and alarms; and proactively contact on-site clinicians with recommendations or place orders directly into the electronic health record depending on whether the clinician acts as the patients’ primary, co-managing, or consultant provider. A centralized hub and spoke model with telemedicine personnel located at a single, remote center is the most common and best studied ICU telemedicine design. Additional staffing may include respiratory therapists, pharmacists, and advanced practice clinicians in coverage models that range from 24/7 to nocturnal and can also differ in whether patients are monitored continuously or on an as needed basis, triggered by alarms or clinician/nursing concerns.

On-demand services may extend to support for teams responding to medical emergencies inside and sometimes outside the ICU. Another equally important role that ICU telemedicine can provide is helping ensure facilities adhere to ICU quality metrics, such as ventilator bundles, DVT prophylaxis, and daily SAT/SBT.

Unsurprisingly, integrating ICU telemedicine into an existing system is very costly and complex, requiring substantial and thoughtful process redesign to maximize fiscal and clinical return on investment. One vendor of proprietary telemedicine technology, Philips eICU, estimates an implementation cost of $50,000 to $100,000 per bed with annual overhead, software maintenance, and IT staffing of ~20% of implementation costs in addition to clinician staffing of $1-2 million per 100 beds. However, some (but not all) evidence suggests that ICU telemedicine programs pay for themselves over time. An influential report from Sentara Healthcare, an early adopter of ICU telemedicine, described equipment costs of more than $1 million for a total of 103 critical care beds but attributed savings of $460,000 per month to decreased length of stay (Coustasse, et al. The Permanente Journal. 2014;18[4]:76).

Cost savings are great, of course, but ICU telemedicine’s potential to improve clinical outcomes is the real priority. While Sentara’s early report included a 27% decrease in ICU mortality after telemedicine adoption, a 2011 meta-analysis of 13 studies, including 35 ICUs and over 40,000 patients, suggested decreased ICU mortality and LOS with a statistically significant effect on overall hospital mortality and LOS (Young, et al. Arch Intern Med. 2011;171[6]:498). This highlights the Achilles heel of ICU telemedicine evidence: the pretest/posttest studies that dominate this field and likely contribute substantially to the inconsistencies in the evidence base.

In the absence of risk adjustment and control groups, many studies observed postimplementation changes that may reflect trends in patient mix or the effects of unrelated practice changes rather than the causal influence of ICU telemedicine. In fact, in studies using more robust methods, ICU telemedicine’s effect size has been smaller or nonexistent. For example, in 2016, Kahn and colleagues used CMS data to evaluate 132 ICU telemedicine programs using 389 matched controlled hospitals. There was a slight reduction in 90-day mortality (OR=0.96, CI 0.94-0.98) with only 12% showing a statistically significant reduction in mortality. Interestingly, hospitals in urban areas demonstrated greater benefit than rural facilities (Kahn, et al. Medical Care. 2016;54[3]:319).

The heterogeneity of the studied programs (e.g., primary vs consultative role, on-demand vs proactive involvement) and recipient ICUs (e.g., rural vs tertiary care facility, presence of bedside intensivists) further hinders a clear answer to the key question: Would ICU telemedicine benefit my hospital? Fortunately, some recent, well-designed studies have attempted to understand which attributes of ICU telemedicine programs provide results and which ICUs will see the most benefit. In a cohort of 118,990 patients across 56 ICUs, four interventions were associated with lower mortality and reduced LOS: (1) evaluation of patients within 1 hour of ICU admission, (2) frequent leadership review of performance data, (3) ICU best practice compliance, and (4) prompt response to alerts (Lilly, et al. Chest. 2014;145[3]:500). Kahn and colleagues have also investigated this issue, conducting an in-depth ethnographic evaluation of 10 hospitals identified in their 2016 study to have positive, neutral, or negative outcomes after ICU telemedicine implementation (Kahn, et al. Am J Respir Crit Care Med. 2019;199[8]:970). They found that successful programs:

(1) provided consistent services matched to recipient needs;

(2) provided services both proactively and reactively without being obtrusive;

(3) embedded routine engagements unobtrusively into usual routines;

(4) had engaged leadership who set clear expectations and mediated conflicts; and

(5) had bedside clinicians who valued and sought out telemedicine participation in care.

The authors concluded that, “the true value of ICU telemedicine lies not in whether the technology exists but in how it is applied.” However, another recent analysis also suggested that, rather than telemedicine or recipient ICU design, targeting underperforming recipient ICU performance may be the key determinant of whether ICU telemedicine implementation improves outcomes (Fusaro, et al. Crit Care Med. 2019; 47[4]:501). While the finding may reflect regression to the mean, the idea that ICUs with above-expected mortality derive greater benefit from ICU telemedicine support than already well-performing ICUs is certainly logical.

As COVID-19 strained health care systems across the country, we and others found ways to use ICU telemedicine to preserve optimal care delivery for critically ill patients. Our program at Intermountain Healthcare – already supporting 17 ICUs within our 24-hospital health system, as well as 10 external ICUs with experienced critical care physicians, nurses, respiratory therapists, and pharmacists – took on increased responsibility for ICU load balancing and interhospital transfers.

Leveraging telemedicine services also helped community ICUs care for sicker, more complex patients than usual and aided nonintensivist physicians called upon to manage critically ill patients in ad hoc ICUs at referral hospitals. While the pandemic certainly stressed ICU staff, we suspect that telemedicine’s ability to balance caseloads and distribute clinical tasks helped mitigate these stresses. At age 40, ICU telemedicine is both mature and still growing, with continued expansion of bed coverage and the range of services available. Looking ahead, as we confront a national shortage of intensivists, ICU telemedicine likely represents a cost effective and efficient strategy to maintain critical care capacity with the potential to ensure low-cost, high-quality care for all, regardless of location.
 

Dr. Graham and Dr. Peltan are with the Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah; and Dr. Peltan is also with the Division of Pulmonary & Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah.

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

The CHEST Board of Regents (BOR) convened a hybrid meeting in Atlanta prior to the pulmonary board review course. Hopefully, many of you had the opportunity to participate in that excellent learning experience. The function of the BOR is to provide direction and oversight for the organization’s strategy and goals, including the development of the many programs that are so expertly crafted by our talented staff, with contributions from our volunteers. The BOR has adopted organizational goals and metrics around our four key pillars, including: education, people, products, and growth. Our EVP/CEO, Dr. Robert Musacchio, opened the meeting with a review of the organization’s mid-year progress toward achieving these annual goals. Despite the current economic turmoil and need for flexibility in our COVID landscape, CHEST is on track to meet or exceed the majority of the stated goals. The team continues efforts to achieve our key metrics related to increasing learners, members, and growth in revenue – we anticipate the upcoming annual meeting will only bolster our progress.

Every BOR meeting includes a report from the Finance Committee, which is thoroughly reviewed by the BOR. CHEST investments have fared no better than the rest of the country, but our investment advisors assure us that things will improve.

Similar updates were given by the President of the CHEST Foundation, Dr. Ian Nathanson, who noted that the Foundation will be celebrating its 25th anniversary during CHEST 2022. I would like to personally encourage you to donate and make this year the best year of fundraising. We are eager to bolster our community and patients after the long journey through COVID. Every donation enables more investment in creating access to the profession and in piloting programs across our communities that improve access to care. Thank you to those who have already contributed.

The morning session was completed with excellent presentations by the Chief Learning Officer/Education SVP, Richard Schuch and Publisher/Communications SVP, Nicki Augustyn. Rich provided an update on the education strategy and how it will change to keep up with the ever-changing needs of learners. He also made the observation that CHEST cannot do this alone, and partnering with companies to assist in new methods of content delivery will be important for the future of the organization. Nicki presented data regarding the current membership structure, as well as the effect of the pandemic on membership over the last 2 years.

In the afternoon session, the BOR and staff spent over 2 hours on the topic of advocacy. CHEST has become more active in the area of advocacy for both patients and the medical profession, specifically in the areas of pulmonary, critical care, and sleep medicine. The Health Policy and Advocacy Committee (HPAC) currently has workgroups working in five different areas, including: oxygen, pulmonary rehabilitation, coding and billing, noninvasive ventilation, and tobacco and vaping. However, CHEST is often asked to sign on to or support the advocacy efforts of other organizations, including other medical societies, patient groups, and industry groups. At times, the decision to support or not support is easy. While there is a process to make that decision, this session helped better define the process and started to create some norms around when CHEST itself should lead its own statement on a particular issue.

The BOR will meet a total of six times this year, either remotely or in person, to make certain that CHEST continues to fulfill its mission “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.”

Cardiovascular Medicine & Surgery Section

Emerging role of cardiopulmonary obstetric critical care

Despite being a developed country, maternal morbidity and mortality rates in some counties in the United States mirror that of third world countries, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.

In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.

A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.

Bindu Akkanti, MD, FCCP, Member-at-Large

Mark Warner, MD, FCCP, Member-at-Large

Cardiovascular Medicine & Surgery Section

Emerging role of cardiopulmonary obstetric critical care

Despite being a developed country, maternal morbidity and mortality rates in some counties in the United States mirror that of third world countries, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.

In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.

A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.

Bindu Akkanti, MD, FCCP, Member-at-Large

Mark Warner, MD, FCCP, Member-at-Large

Cardiovascular Medicine & Surgery Section

Emerging role of cardiopulmonary obstetric critical care

Despite being a developed country, maternal morbidity and mortality rates in some counties in the United States mirror that of third world countries, with 23.8 women dying per 100,000 live births (Hoyert DL, Miniño AM. Maternal mortality in the United States. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020). The care of this vulnerable population testifies to the quality of care provided across the country. Some of these poor outcomes are directly attributed to in-hospital deaths due to preexisting or newly discovered heart or lung diseases, such as valvular heart diseases, cardiomyopathies, pulmonary arterial hypertension, eclampsia, or other etiologies. With the development of advanced heart and lung programs across the nation capable of providing mechanical circulatory support and extracorporeal life support, we believe that incorporating a heart-lung-OB team approach to high-risk cases can identify knowledge gaps early and predict and prevent maternal complications.

In this proposed model, patients funnel to the hub facility to be cared for by a team of intensive care physicians, advanced heart failure physicians, cardiovascular and obstetric anesthesiologists, and maternal/fetal medicine physicians, with the potential addition of an adult ECMO team member.

A team huddle, using a virtual platform, would be organized by a designated OB coordinator at the patient’s admission with follow-up huddles every 2 to 3 days, to ensure the team stays engaged through delivery into the postpartum period. Value could be added with subsequent cardiac or pulmonary rehabilitation. With an emphasis on shared decision making, we can make it a national priority to save every woman during the birthing process.

Bindu Akkanti, MD, FCCP, Member-at-Large

Mark Warner, MD, FCCP, Member-at-Large

Lung Transplant Section

Strengthening lung transplant education

The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. Lung transplant education has not kept pace with this growth, and, currently, there are limited avenues and variable models of training. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.

Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:

–Increase access to specialized transplant education for PCCM fellows.

–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.

–Increase collaboration between the transplant fellowship programs to address gaps in training.

Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large

Lung Transplant Section

Strengthening lung transplant education

The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. Lung transplant education has not kept pace with this growth, and, currently, there are limited avenues and variable models of training. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.

Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:

–Increase access to specialized transplant education for PCCM fellows.

–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.

–Increase collaboration between the transplant fellowship programs to address gaps in training.

Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large

Lung Transplant Section

Strengthening lung transplant education

The number of lung transplants (LT) performed reached an all-time high in 2019 with a 52.3% increase over the previous decade. Transplants are being performed in older and sicker patients with 35% of recipients being over 65 years of age and 25% with lung allocation scores (LAS) over 60. (Valapour, et al. Am J Transplant. 2021;21[Suppl 2]:441). This growth has led to an increased demand for transplant pulmonologists. Lung transplant education has not kept pace with this growth, and, currently, there are limited avenues and variable models of training. There are about 15 dedicated LT fellowship programs located at 68 transplant centers with widely variable curricula. The vast majority of the 160 general pulmonary and critical care medicine (PCCM) fellowship programs do not have access to hands-on clinical transplant training and are guided by vague ACGME guidelines. A U.S. national survey (Town JA, et al. Ann Am Thorac Soc. 2016;13[4]:568) of PCCM programs found that about 41% of centers did not have a transplant curriculum, and training was very variable. Another report found that a structured educational LT curriculum at a transplant center was associated with improved performance of PCCM fellows (Hayes, et al. Teach Learn Med. 2013;25[1]:59). The lack of a structured curriculum and wide variability coupled with lack of information about the training pathways impedes effective training.

Recognizing these issues, the lung transplant steering committee developed two webinars for the online CHEST learning portal (tinyurl.com/53pnne2k). These provide resources and information for fellows and junior faculty interested in a transplant pulmonology career as well as discuss needs and opportunities to develop a program for specialized training in LT. There is need for a multipronged approach addressing:

–Increase access to specialized transplant education for PCCM fellows.

–Develop a uniform structured curriculum for lung transplant education engaging the PCCM and transplant fellowship program directors as stakeholders.

–Increase collaboration between the transplant fellowship programs to address gaps in training.

Hakim Azhfar Ali, MBBS, FCCP
Member-at-Large

Occupational & Environmental Health Section

Quaternary ammonium compounds: exposure and lung disease

Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).

While these products reduce the risk of COVID-19 transmission, the increase in use has had unintended consequences. Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.

Maeve MacMurdo, MBChB
Member-at-Large

Abirami Subramanian, MD, MPH
Member-at-Large

Occupational & Environmental Health Section

Quaternary ammonium compounds: exposure and lung disease

Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).

While these products reduce the risk of COVID-19 transmission, the increase in use has had unintended consequences. Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.

Maeve MacMurdo, MBChB
Member-at-Large

Abirami Subramanian, MD, MPH
Member-at-Large

Occupational & Environmental Health Section

Quaternary ammonium compounds: exposure and lung disease

Quaternary ammonium compounds (QACS) are a common ingredient in many major commercial disinfectant products. During the COVID pandemic, the use of QACS increased due to their efficacy in inactivating enveloped viruses such as SARS-COV-2 (Hora, et al. Environ Sci & Technol Letters. 2020;7[9]:622).

While these products reduce the risk of COVID-19 transmission, the increase in use has had unintended consequences. Increasing data suggest a link between QAC exposure and occupational lung disease (Migueres, et al. J Allergy Clin Immunol Pract. 2021;9[9]:3387). Historically, exposure to QACs has been highest in health care workers. This is reflected in the increased risk of obstructive lung disease seen among nursing and operating room staff (Xie, et al. JAMA Netw Open. 2021;4[9] :e2125749). In the setting of enhanced COVID-19 cleaning protocols, QACS are increasingly utilized outside of the health care setting. Custodians and janitorial staff may face increased and potentially underrecognized exposure to these compounds. In addition to the direct harms of COVID-19, we may see an increase in occupational obstructive lung disease as a result of cleaning product exposure. Early diagnosis and exposure removal is crucial to prevent a new epidemic of occupational asthma.

Maeve MacMurdo, MBChB
Member-at-Large

Abirami Subramanian, MD, MPH
Member-at-Large

Palliative and End-of-Life Care Section

Time-limited trials of critical care

Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. Core elements of TLT include utilizing the multidisciplinary team caring for the patient, evaluating for any prior advanced care planning, using clear and concise communication, acknowledging uncertainty, and collaborating with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).

Bradley Hayward, MD
Member-at-Large

Palliative and End-of-Life Care Section

Time-limited trials of critical care

Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. Core elements of TLT include utilizing the multidisciplinary team caring for the patient, evaluating for any prior advanced care planning, using clear and concise communication, acknowledging uncertainty, and collaborating with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).

Bradley Hayward, MD
Member-at-Large

Palliative and End-of-Life Care Section

Time-limited trials of critical care

Many patients die in the ICU, often after long courses of aggressive interventions, with potentially nonbeneficial treatments. Surrogate decision makers are tasked with decisions to initiate or forgo treatments based on recommendations from clinicians in the face of prognostic uncertainty and emotional duress. A strategy that has been adopted by ICU clinicians to address this has been proposing a “time-limited trial” (TLT) of ICU-specific interventions. A TLT involves clinicians partnering with patients and their surrogate decision makers in a shared decision-making model, proposing initiation of treatments for a set time, evaluating for specific measures of what is considered beneficial, and deciding to continue treatment or stop if without benefit. Core elements of TLT include utilizing the multidisciplinary team caring for the patient, evaluating for any prior advanced care planning, using clear and concise communication, acknowledging uncertainty, and collaborating with palliative care teams (Vink EE, et al. Intensive Care Med. 2018;44:1369). Recent research about TLT in the ICU has found that when executed well, TLTs can improve quality of care and provide patients with the care they desire and can benefit from (Vink, et al). Additionally, the use of an education intervention for ICU clinicians regarding protocolled TLT interventions was associated with improved quality of family meetings, and, importantly, a reduced intensity and duration of ICU treatments (Chang DW, et al. JAMA Intern Med. 2021;181[6]:786).

Bradley Hayward, MD
Member-at-Large

In February, The American College of Chest Physicians (CHEST), the American Thoracic Society, and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine. The recipient of the grant was announced recently, and CHEST spoke with him about his background and the project that earned him the award.

George Alba, MD, is a pulmonary and critical care physician investigator at Massachusetts General Hospital. Dr. Alba studied English Literature and Biology as an undergraduate at Washington University in St. Louis, where he worked in a developmental biology laboratory; earned his MD at the Mount Sinai School of Medicine, where he graduated AOA with Distinction in Medical Education; and then completed both Internal Medicine and Pulmonary and Critical Care Medicine training at Massachusetts General Hospital.

CHEST

During his fellowship, Dr. Alba specialized in pulmonary and critical care medicine because he appreciated the variety that comes with working in the intensive care unit.

“I love the medical complexity, the physiology, and the decision-making,” said Dr. Alba. “I’ve always enjoyed all aspects of clinical medicine, so it was hard to choose a path, but the benefit of the ICU is that it allows me to take care of a spectrum of medical illness across all subspecialties.”

He continued, “What I loved about pulmonary, specifically, was that I could see patients in the hospital and in the ICU, perform procedures, and still have a longitudinal relationship with patients in the clinic, which gave me a very flexible, wide grasp of medicine.”

Growing up in a close-knit Cuban family and community, Dr. Alba was raised speaking Spanish at home and learned English primarily in school. Being bilingual helped him in medicine greatly: in clinic, in the hospital, and in the ICU, he is able to communicate directly with Spanish-speaking patients and their families. This became critically important during the COVID-19 pandemic when Chelsea, a primarily Hispanic community in Boston, was disproportionately impacted. The patients greatly benefited from Spanish-speaking clinicians to communicate with their family members who were unable to visit due to the infection control policies in place.

As an instructor of medicine at Harvard Medical School and pulmonary and critical care physician at Massachusetts General, Dr. Alba is actively engaged in clinical care, teaching, and research focusing primarily on mechanisms of pulmonary vascular dysfunction in lung disease.

Dr. Alba’s AMFDP award project is titled “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” and through the proposed scientific aims, he looks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS.) He is being co-mentored by Bradley Maron, MD, a pulmonary vascular disease researcher at Brigham and Women’s Hospital, and Eric Schmidt, MD, an endothelial biologist and expert in animal models of acute lung injury at Massachusetts General Hospital.

This is especially relevant research during the COVID-19 pandemic, as patients with severe lung injury frequently develop clotting in the lung blood vessels. Dr. Alba’s prior work demonstrated that NEDD9 is a pulmonary endothelial protein that is upregulated by hypoxia, that it binds to activated platelets to promote platelet adhesion and clotting, and that inhibition of NEDD9-platelet interactions with a custom antibody can decrease clotting in the lungs of animals. He recently showed that pulmonary endothelial NEDD9 is increased in patients with ARDS who demonstrate blood vessel clotting.

Now, Dr. Alba seeks to use a custom-made anti-NEDD9 antibody to block platelet adhesion in animal models of ARDS to decrease the extent of lung injury. While aspirin and anticoagulants have been unhelpful in treating ARDS in prior trials, Dr. Alba believes that circulating pulmonary endothelial protein NEDD9 can serve as a biomarker to identify subgroups of ARDS who may benefit from earlier targeted antithrombotic therapy.

Dr. Alba hopes that one day the anti-NEDD9 antibody may become one such therapeutic option for patients. The AMFDP will help support his ongoing work.

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, he inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: It allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Dr. Alba continued, “Programs like the Robert Wood Johnson Foundation initiative that specifically try to increase the number of individuals traditionally underrepresented in academia are key and would not be possible without the support of groups like CHEST, the American Lung Association, and the American Thoracic Society.

These programs help folks who may have other external barriers to being in academia, including socioeconomic pressures, lack of resources – financial or otherwise – or simply not knowing what opportunities are available to them. Programs [like AMFDP] that can alleviate some of these additional pressures go a long way to improve the diversity of the medical workforce.”

Dr. Alba is also committed to paying it forward: “I want to ensure that the type of invested mentorship I experienced to help get me this far is not a matter of serendipity for the fortunate few, but rather a standard for all students and trainees, especially those from underrepresented backgrounds.”

In February, The American College of Chest Physicians (CHEST), the American Thoracic Society, and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine. The recipient of the grant was announced recently, and CHEST spoke with him about his background and the project that earned him the award.

George Alba, MD, is a pulmonary and critical care physician investigator at Massachusetts General Hospital. Dr. Alba studied English Literature and Biology as an undergraduate at Washington University in St. Louis, where he worked in a developmental biology laboratory; earned his MD at the Mount Sinai School of Medicine, where he graduated AOA with Distinction in Medical Education; and then completed both Internal Medicine and Pulmonary and Critical Care Medicine training at Massachusetts General Hospital.

CHEST

During his fellowship, Dr. Alba specialized in pulmonary and critical care medicine because he appreciated the variety that comes with working in the intensive care unit.

“I love the medical complexity, the physiology, and the decision-making,” said Dr. Alba. “I’ve always enjoyed all aspects of clinical medicine, so it was hard to choose a path, but the benefit of the ICU is that it allows me to take care of a spectrum of medical illness across all subspecialties.”

He continued, “What I loved about pulmonary, specifically, was that I could see patients in the hospital and in the ICU, perform procedures, and still have a longitudinal relationship with patients in the clinic, which gave me a very flexible, wide grasp of medicine.”

Growing up in a close-knit Cuban family and community, Dr. Alba was raised speaking Spanish at home and learned English primarily in school. Being bilingual helped him in medicine greatly: in clinic, in the hospital, and in the ICU, he is able to communicate directly with Spanish-speaking patients and their families. This became critically important during the COVID-19 pandemic when Chelsea, a primarily Hispanic community in Boston, was disproportionately impacted. The patients greatly benefited from Spanish-speaking clinicians to communicate with their family members who were unable to visit due to the infection control policies in place.

As an instructor of medicine at Harvard Medical School and pulmonary and critical care physician at Massachusetts General, Dr. Alba is actively engaged in clinical care, teaching, and research focusing primarily on mechanisms of pulmonary vascular dysfunction in lung disease.

Dr. Alba’s AMFDP award project is titled “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” and through the proposed scientific aims, he looks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS.) He is being co-mentored by Bradley Maron, MD, a pulmonary vascular disease researcher at Brigham and Women’s Hospital, and Eric Schmidt, MD, an endothelial biologist and expert in animal models of acute lung injury at Massachusetts General Hospital.

This is especially relevant research during the COVID-19 pandemic, as patients with severe lung injury frequently develop clotting in the lung blood vessels. Dr. Alba’s prior work demonstrated that NEDD9 is a pulmonary endothelial protein that is upregulated by hypoxia, that it binds to activated platelets to promote platelet adhesion and clotting, and that inhibition of NEDD9-platelet interactions with a custom antibody can decrease clotting in the lungs of animals. He recently showed that pulmonary endothelial NEDD9 is increased in patients with ARDS who demonstrate blood vessel clotting.

Now, Dr. Alba seeks to use a custom-made anti-NEDD9 antibody to block platelet adhesion in animal models of ARDS to decrease the extent of lung injury. While aspirin and anticoagulants have been unhelpful in treating ARDS in prior trials, Dr. Alba believes that circulating pulmonary endothelial protein NEDD9 can serve as a biomarker to identify subgroups of ARDS who may benefit from earlier targeted antithrombotic therapy.

Dr. Alba hopes that one day the anti-NEDD9 antibody may become one such therapeutic option for patients. The AMFDP will help support his ongoing work.

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, he inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: It allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Dr. Alba continued, “Programs like the Robert Wood Johnson Foundation initiative that specifically try to increase the number of individuals traditionally underrepresented in academia are key and would not be possible without the support of groups like CHEST, the American Lung Association, and the American Thoracic Society.

These programs help folks who may have other external barriers to being in academia, including socioeconomic pressures, lack of resources – financial or otherwise – or simply not knowing what opportunities are available to them. Programs [like AMFDP] that can alleviate some of these additional pressures go a long way to improve the diversity of the medical workforce.”

Dr. Alba is also committed to paying it forward: “I want to ensure that the type of invested mentorship I experienced to help get me this far is not a matter of serendipity for the fortunate few, but rather a standard for all students and trainees, especially those from underrepresented backgrounds.”

In February, The American College of Chest Physicians (CHEST), the American Thoracic Society, and the American Lung Association announced a partnership with the prestigious Harold Amos Medical Faculty Development Program (AMFDP), a Robert Wood Johnson Foundation initiative, to sponsor a scholar in pulmonary and critical care medicine. The recipient of the grant was announced recently, and CHEST spoke with him about his background and the project that earned him the award.

George Alba, MD, is a pulmonary and critical care physician investigator at Massachusetts General Hospital. Dr. Alba studied English Literature and Biology as an undergraduate at Washington University in St. Louis, where he worked in a developmental biology laboratory; earned his MD at the Mount Sinai School of Medicine, where he graduated AOA with Distinction in Medical Education; and then completed both Internal Medicine and Pulmonary and Critical Care Medicine training at Massachusetts General Hospital.

CHEST

During his fellowship, Dr. Alba specialized in pulmonary and critical care medicine because he appreciated the variety that comes with working in the intensive care unit.

“I love the medical complexity, the physiology, and the decision-making,” said Dr. Alba. “I’ve always enjoyed all aspects of clinical medicine, so it was hard to choose a path, but the benefit of the ICU is that it allows me to take care of a spectrum of medical illness across all subspecialties.”

He continued, “What I loved about pulmonary, specifically, was that I could see patients in the hospital and in the ICU, perform procedures, and still have a longitudinal relationship with patients in the clinic, which gave me a very flexible, wide grasp of medicine.”

Growing up in a close-knit Cuban family and community, Dr. Alba was raised speaking Spanish at home and learned English primarily in school. Being bilingual helped him in medicine greatly: in clinic, in the hospital, and in the ICU, he is able to communicate directly with Spanish-speaking patients and their families. This became critically important during the COVID-19 pandemic when Chelsea, a primarily Hispanic community in Boston, was disproportionately impacted. The patients greatly benefited from Spanish-speaking clinicians to communicate with their family members who were unable to visit due to the infection control policies in place.

As an instructor of medicine at Harvard Medical School and pulmonary and critical care physician at Massachusetts General, Dr. Alba is actively engaged in clinical care, teaching, and research focusing primarily on mechanisms of pulmonary vascular dysfunction in lung disease.

Dr. Alba’s AMFDP award project is titled “Pulmonary Endothelial NEDD9 and Acute Lung Injury,” and through the proposed scientific aims, he looks to advance NEDD9 antagonism as a potential therapeutic target in acute respiratory distress syndrome (ARDS.) He is being co-mentored by Bradley Maron, MD, a pulmonary vascular disease researcher at Brigham and Women’s Hospital, and Eric Schmidt, MD, an endothelial biologist and expert in animal models of acute lung injury at Massachusetts General Hospital.

This is especially relevant research during the COVID-19 pandemic, as patients with severe lung injury frequently develop clotting in the lung blood vessels. Dr. Alba’s prior work demonstrated that NEDD9 is a pulmonary endothelial protein that is upregulated by hypoxia, that it binds to activated platelets to promote platelet adhesion and clotting, and that inhibition of NEDD9-platelet interactions with a custom antibody can decrease clotting in the lungs of animals. He recently showed that pulmonary endothelial NEDD9 is increased in patients with ARDS who demonstrate blood vessel clotting.

Now, Dr. Alba seeks to use a custom-made anti-NEDD9 antibody to block platelet adhesion in animal models of ARDS to decrease the extent of lung injury. While aspirin and anticoagulants have been unhelpful in treating ARDS in prior trials, Dr. Alba believes that circulating pulmonary endothelial protein NEDD9 can serve as a biomarker to identify subgroups of ARDS who may benefit from earlier targeted antithrombotic therapy.

Dr. Alba hopes that one day the anti-NEDD9 antibody may become one such therapeutic option for patients. The AMFDP will help support his ongoing work.

“Growing up, I saw through my father’s example how education unlocks opportunities. Our community came together to help him on this path. Now a retired doctor of osteopathy in neonatology, he inspired me to pursue a career in medicine,” said Dr. Alba. “This award comes at a critical time in my junior faculty career: It allows me to continue pursuing my research in a meaningful way while also gaining new skills that will be critical for my ongoing career development.”

Dr. Alba continued, “Programs like the Robert Wood Johnson Foundation initiative that specifically try to increase the number of individuals traditionally underrepresented in academia are key and would not be possible without the support of groups like CHEST, the American Lung Association, and the American Thoracic Society.

These programs help folks who may have other external barriers to being in academia, including socioeconomic pressures, lack of resources – financial or otherwise – or simply not knowing what opportunities are available to them. Programs [like AMFDP] that can alleviate some of these additional pressures go a long way to improve the diversity of the medical workforce.”

Dr. Alba is also committed to paying it forward: “I want to ensure that the type of invested mentorship I experienced to help get me this far is not a matter of serendipity for the fortunate few, but rather a standard for all students and trainees, especially those from underrepresented backgrounds.”

Respiratory-Related Sleep Disorders Section

Sleep health and fatigue mitigation during medical training

Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).

Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.

A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.

Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.

Aesha Jobanputra, MD
Section Member

Sreelatha Naik, MD
Member-at-Large

Respiratory-Related Sleep Disorders Section

Sleep health and fatigue mitigation during medical training

Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).

Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.

A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.

Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.

Aesha Jobanputra, MD
Section Member

Sreelatha Naik, MD
Member-at-Large

Respiratory-Related Sleep Disorders Section

Sleep health and fatigue mitigation during medical training

Medical trainees may experience acute or chronic sleep deprivation due to extended work hours and shift-work sleep schedules. Extended work hours may lead to serious medical errors, percutaneous injuries, prolonged task completion, and car crashes or near misses while driving (Landrigan, et al. N Engl J Med. 2004;351:1838; Ayas, et al. JAMA. 2006;296[9]:1055; Taffinder, et al. Lancet. 1998;352[9135]:1191; Barger, et al. N Engl J Med. 2005 Jan 13;352[2]:125).

Chronic sleep restriction also results in neurobehavioral and cognitive dysfunction without a proportionate increase in self-perceived sleepiness [Belenky, et al. J Sleep Res. 2003;12[1]:1; Van Dongen, et al. Sleep. 2003;26[2]:117). In 1987, when sleep deprivation was cited as a major cause of 18-year-old Libby Zion’s death, the ACGME restricted residents from working more than 80 hours per week. ACGME mandates that training programs provide yearly fatigue mitigation education.

A “Sleep Alertness and Fatigue Education in Residency” module may be purchased through the American Academy of Sleep Medicine. While one-time education opportunities are available, there remains a need for access to longitudinal, individualized tools during varying rotations and circumstances, as education alone has not been shown to improve sleep quality (Mazar D, et al. J Clin Sleep Med. 2021;17[6]:1211). The American Thoracic Society Early Career Professional Working Group offers individualized lectures to training programs. Wake Up and Learn is a sleep education program for children and teens that is currently being expanded for medical trainees.

Further data are needed to see if longitudinal and individualized support can promote better sleep quality among trainees.

Aesha Jobanputra, MD
Section Member

Sreelatha Naik, MD
Member-at-Large