Background: Our hospitalist group has seen a rise in the number of Advanced Practice providers (APP) due to increasing patient workload. The APPs come from varying backgrounds, are within 2 years of graduation and have had little experience in evaluating common emergent and nonemergent presentations on the hospital medicine service. Our current practice is for a newly hired APP to undergo 12 weeks of on hands training under a senior APP prior to independent practice. Both physician and APP leadership felt this period was insufficient for independent practice. 75% of onboarding APPs felt they were not ready for independent practice and felt uncomfortable managing acute cross cover issues at the end of this training period according to our needs survey. This may affect patient safety, especially when patients acutely decompensate during cross cover.
Purpose: We designed a simulation-based activity with the aim of exposing onboarding APPs to common clinical presentations including emergent and non-emergent scenarios in order to improve comfort level in diagnosis and management.
Description: We identified the top eight scenarios likely to be encountered while admitting and while providing cross cover based on diagnoses codes and common consensus of authors. These were: Congestive heart failure, Pneumonia, Cirrhosis and spontaneous bacterial peritonitis, Acute Coronary syndrome, Acute gastrointestinal bleed, Acute respiratory failure, Code stroke and septic shock.A high fidelity, manikin-based simulation scenario was designed for each diagnosis. For each scenario standard of care was determined by literature review and consensus of authors. The care plan was divided into 4 categories: laboratory data, imaging, medication/interventions, and subspecialty consultation. A detailed checklist containing critical actions pertaining to each of the categories was developed. Each action was scored as yes or no.Eight APPs met inclusion criteria (hired within last 12 months and graduated within the last 2 years). They were randomly divided into two cohorts of four each. Cohort 1 participated in the course lasting a full day (8 hours). We plan to run the course for Cohort 2 in the next few months. Each scenario followed standard simulation format of pre-brief, simulation and debrief. The learners worked through each case in a group, taking turns to lead a scenario. The scenario was evaluated by a faculty observer using the checklist described above. Each scenario was followed by a debriefing session where the details of the case were discussed with a focus on gaps in knowledge using the results from the checklist.Learner’s perceived benefit, engagement in the course and comfort level in managing each diagnoses pre and post course was assessed using a Likert scale.
Conclusions: Feedback indicated an increase in learner comfort level in managing acute respiratory failure, acute coronary syndrome, acute gastrointestinal bleed, pneumonia and cirrhosis. Most learners were very comfortable managing congestive heart failure prior to the course and only one reported improvement in managing stroke after the course. A simulation-based curriculum focused on managing acute IM scenarios appears promising to onboard new APP’s prior to starting independent practice. However larger sample size, comparison with control cohort that did not participate in simulation, supervising physician feedback are needed before any valid conclusions can be made regarding efficacy of the course.