Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage: A Pilot Randomized Clinical Trial.
Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage: A Pilot Randomized Clinical Trial.
复制标题
DOI：
10.1001/jamanetworkopen.2023.13569
复制
发表时间：
2023-05-01
影响因子：
13.8
通讯作者：
White, Douglas B.
中科院分区：
文献类型：
--
作者：
Mohan, Deepika;Elmer, Jonathan;Arnold, Robert M.;Forsythe, Raquel M.;Fischhoff, Baruch;Rak, Kimberly;Barnes, Jaqueline L.;White, Douglas B.
有意识的练习（有教练提供即时、个性化的表现反馈的目标导向训练）能否改善创伤分诊中的诊断推理？在这项新的刻意练习干预的试点随机临床试验中，93%的参与者接受了3次计划的辅导课程，大多数参与者（93%）将这些课程描述为有趣和有价值的。在模拟过程中，干预组医生的分诊决定比对照组医生的分诊决定更有可能遵守临床实践指南。刻意练习干预在实验室中是可行的、可接受的和有效的，为未来的3期临床试验奠定了基础。非创伤中心伤后分诊时的诊断错误导致了可预防的发病率和死亡率。测试一种新型刻意练习干预的可行性、可接受性和初步效果，以改善创伤分诊中的诊断推理。这项试点随机临床试验是在2022年1月1日至3月31日期间在72名急诊医生的全国便利样本中在线进行的，没有随访。参与者被随机分配接受常规护理（即被动控制）或故意练习干预，包括每周3次，30分钟的视频会议，在此期间，医生玩定制的，基于理论的视频游戏，同时由内容专家（教练）观察，他们提供关于诊断推理的即时，个性化反馈。使用普罗克特框架的实施研究的结果，可行性，保真度，可接受性，通过和适当的干预措施进行了评估，通过审查视频的辅导课程，并与参与者进行汇报采访。一个有效的在线模拟被用来评估干预对行为的影响，并使用混合效应logistic回归比较了控制和干预医生之间的分类。使用意向治疗方法分析实施结果，但未使用模拟的参与者被排除在疗效分析之外。该研究招募了72名医生（平均[SD]年龄，43.3 [9.4]岁; 44名男性[61%]），但由于教练的可用性，干预组的医生注册人数限制为30人。医生在20个州工作; 62人（86%）获得急诊医学委员会认证。该干预措施以高保真度提供，30名医生中有28名（93%）完成了3次辅导课程，教练提供了95%的课程内容（642/674）。对照组36名医生中有21名（58%）参与了结果评估;干预组30名医生中有28名（93%）参与了半结构化访谈，干预组30名医生中有26名（87%）参与了结果评估。干预组中的大多数医生（93% [26/28]）将会议描述为娱乐和有价值的;大多数（88% [22/25]）肯定了采用所讨论原则的意图。改进的建议包括提供更多的时间与教练和解决背景障碍，以分流。在模拟过程中，干预组医生的分诊决策比对照组更可能遵守临床实践指南（比值比; 13.8，95%CI，2.8-69.6; P = 0.001）。在这项试点随机临床试验中，指导是可行的，可接受的，并对模拟创伤分诊决策有很大的影响，为3期试验奠定了基础。ClinicalTrials.gov 标识符：NCT 05168579这项在急诊医生中进行的试点随机临床试验测试了一种新型故意实践干预的可行性、可接受性和初步效果，以改善创伤分诊中的诊断推理。
Can deliberate practice (goal-oriented training with a coach who provides immediate, personalized performance feedback) improve diagnostic reasoning in trauma triage? In this pilot randomized clinical trial of a novel deliberate practice intervention, 93% of participants received 3 planned coaching sessions, and most participants (93%) described the sessions as entertaining and valuable. During a simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than the triage decisions of physicians in the control group. The deliberate practice intervention was feasible, acceptable, and effective in the laboratory, setting the stage for a future phase 3 clinical trial. Diagnostic errors made during triage at nontrauma centers contribute to preventable morbidity and mortality after injury. To test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage. This pilot randomized clinical trial was conducted online in a national convenience sample of 72 emergency physicians between January 1 and March 31, 2022, without follow-up. Participants were randomly assigned to receive either usual care (ie, passive control) or a deliberate practice intervention, consisting of 3 weekly, 30-minute, video-conferenced sessions during which physicians played a customized, theory-based video game while being observed by content experts (coaches) who provided immediate, personalized feedback on diagnostic reasoning. Using the Proctor framework of outcomes for implementation research, the feasibility, fidelity, acceptability, adoption, and appropriateness of the intervention was assessed by reviewing videos of the coaching sessions and conducting debriefing interviews with participants. A validated online simulation was used to assess the intervention’s effect on behavior, and triage among control and intervention physicians was compared using mixed-effects logistic regression. Implementation outcomes were analyzed using an intention-to-treat approach, but participants who did not use the simulation were excluded from the efficacy analysis. The study enrolled 72 physicians (mean [SD] age, 43.3 [9.4] years; 44 men [61%]) but limited registration of physicians in the intervention group to 30 because of the availability of the coaches. Physicians worked in 20 states; 62 (86%) were board certified in emergency medicine. The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions and with coaches delivering 95% of session components (642 of 674). A total of 21 of 36 physicians (58%) in the control group participated in outcome assessment; 28 of 30 physicians (93%) in the intervention group participated in semistructured interviews, and 26 of 30 physicians (87%) in the intervention group participated in outcome assessment. Most physicians in the intervention group (93% [26 of 28]) described the sessions as entertaining and valuable; most (88% [22 of 25]) affirmed the intention to adopt the principles discussed. Suggestions for refinement included providing more time with the coach and addressing contextual barriers to triage. During the simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than those in the control group (odds ratio; 13.8, 95% CI, 2.8-69.6; P = .001). In this pilot randomized clinical trial, coaching was feasible and acceptable and had a large effect on simulated trauma triage decisions, setting the stage for a phase 3 trial. ClinicalTrials.gov Identifier: NCT05168579 This pilot randomized clinical trial conducted among emergency physicians tests the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage.
登录
查看更多内容
医学诊断错误的发生率。
影响因子：
5.4
作者：
Graber ML
通讯作者：
Graber ML
影响因子：
13.8
作者：
Jarman MP;Jin G;Weissman JS;Ash AS;Tjia J;Salim A;Haider A;Cooper Z
通讯作者：
Cooper Z
影响因子：
9
作者：
Demetriades, D;Martin, M;Chan, L
通讯作者：
Chan, L
DOI：
10.1097/acm.0b013e318217e119
发表时间：
2011-06
期刊：
Academic medicine : journal of the Association of American Medical Colleges
影响因子：
--
作者：
McGaghie WC;Issenberg SB;Cohen ER;Barsuk JH;Wayne DB
通讯作者：
Wayne DB
影响因子：
--
作者：
Mohan, Deepika;Rosengart, Matthew R.;Barnato, Amber E.
通讯作者：
Barnato, Amber E.