Nasir Bhatti | Johns Hopkins University (original) (raw)

Papers by Nasir Bhatti

Chest, 2020

To evaluate the practice of creation of tracheostomies during the initial phases of the COVID-19 ... more To evaluate the practice of creation of tracheostomies during the initial phases of the COVID-19 pandemic, with a focus on clinical outcomes and sedation parameters. METHODS: We enrolled 45 consecutive COVID-19 positive adult patients whom a consult for tracheostomy was placed at Johns Hopkins Hospital between 4/16/2020 and 5/22/2020. A total of 38 tracheostomies were performed at the time of censoring. Five of the patients were extubated before performance of tracheostomy and two were awaiting creation of tracheostomy. Data was collected via manual extraction on clinical outcomes, sedative medication use for the 48 hours pre-and 48 hours posttracheostomy. RESULTS: Baseline characteristics of the 45 patients include a median age of 62, BMI of 30, with an even split of Male:Female (23:22). The median days of intubation before tracheostomy was 20 (range: 5-36), median days from consult for tracheostomy to performance of tracheostomy was 3. A multidisciplinary team across specialties performed the tracheostomy consults with Interventional Pulmonary performing 18, Otolaryngology 13, General Surgery 9, Thoracic Surgery 5. 29 of the tracheostomies were performed percutaneously. A bronchoalveolar lavage, tracheal aspirate, or sputum sample was obtained on the day of performance of the tracheostomy and 35 of the 38 were negative for COVID-19. The samples were sent a median of 23.5 days after the initial positive test. Mortality on date of censoring was 7 (15.6%) including 5 (13.2%) of the patients with tracheostomy. 10 (22.2%) had been discharged including 9 (23.7%) of the patients with tracheostomy. Sedation and analgesia (total dose in 48 hours pre-(PR) and 48 hours post post-tracheostomy (PO)) expressed as median dosage for patients receiving that medication:-Dexmedetomidine (mcg/kg/hr):

Surgical competency is traditionally considered as an ability to perform surgery successfully. Ho... more Surgical competency is traditionally considered as an ability to perform surgery successfully. However, patient outcomes do not depend only on the surgical skills of a surgeon which calls for the revision of the concept of surgical competency. Surgical competency is a combination of skills which allow the surgeon to successfully apply his knowledge and skills to understand and make necessary changes according to the needs and circumstances of an individual patient to solve the clinical problem. Accordingly, the assessment of competency depends on various factors; however, patient outcomes are the ultimate result of the surgeons’performance. Patient outcomes can be measured in terms of mortality, morbidity, resolution of patient’s symptoms, length of stay, complication rates, functional status, quality of life, satisfaction with treatment results, readmission rates and healthcare costs. As every surgical specialty is different with wide range of procedures, the skills that determine ...

The Laryngoscope, 2012

To test the validity, reliability, and feasibility of an evaluation tool designed to measure the ... more To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. Prospective validation study. A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills-based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showi...

Otolaryngology - Head and Neck Surgery, 2008

Otolaryngology residency programs have been mandated by the ACGME to demonstrate teaching and ass... more Otolaryngology residency programs have been mandated by the ACGME to demonstrate teaching and assessment of core competencies. Operative competency is an essential part of patient care in otolaryngology. Currently there are no reliable, valid and feasible mechanisms and instruments to objectively evaluate operative competency. A recent survey of program directors in otolaryngology reveals lack of objective instruments for this assessment. We presented a miniseminar on general and targeted needs assessment and reviewed current practice in other surgical specialties at 2007 academy meeting. We wish to present an update on progress made since then through six 6-minute talks each followed by four minutes of interactive discussion. 1) Concept of developing instruments for objective assessment of operative competency in the context of a curriculum. The underpinning of this curriculum will be a benchmark of surgical competency required for graduating residents. 2) Results of a pilot project involving objective assessment of tonsillectomy and tracheostomy by internal and external evaluators will be discussed. 3) Analysis of trends noted from the survey of program directors will be presented. 4) Report on a survey of recent otolaryngology graduates for identifying their perspective on current and ideal assessment mechanisms will be discussed. Simulators are slowly gaining a role in teaching and assessment of operative competency in otolaryngology and other specialties. 5) Discussion of currently available simulators and their perceived role in residency training in otolaryngology in the near future. 6) Setting up and maintaining effective remedial mechanisms for surgically challenged residents without disrupting existing rotation schedules.

Otolaryngology - Head and Neck Surgery, 2009

setting. Among these interventions, the use of injected botulinum toxin has become common in the ... more setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge that patients seek consultation for. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of the hyaluronic acid based agents created a significant increase in acceptance and demand for filler substances by patients. More recently approved and soon to be approved fillers promise to increase the application. Laser and light technologies, including laser hair removal, offer intervention for an increasingly large number of clinical issues including the treatment of wrinkles, hyperpigmentation, cutaneous vascular lesions, rosacea, unwanted hair, and other agingrelated skin conditions. Finally, representing low cost effective treatments over new technology, the practitioner will find the availability of skin care services, particularly the use of various chemical peeling agents to be a useful adjunct in the office setting. The purpose of the miniseminar is to present an upto-date review of safe, effective, office-based procedures that the otolaryngologist may have available to patients in their office. The presentations will review the pertinent pharmacology, physics where applicable, and anatomy. Technique, preoperative and post procedure issues will be discussed. The clinical photo-rich presentations will demonstrate technique and patient selection. The prevention and management of complications will be reviewed. This miniseminar will update the attendees that have previous training in these procedures and serve as an introduction to those that are exploring these procedures. EDUCATIONAL OBJECTIVES: 1) To understand the current use of botulinum toxin for cosmetic procedures. 2) To understand the use of various lasers for cosmetic indications. 3) To understand the use of fillers.

Journal of surgical education, Jan 5, 2018

A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospita... more A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scor...

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Sep 1, 2017

Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obst... more Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obstructive sleep apnea (OSA) and (2) to test the reliability and evaluate the feasibility of this OSCE while assessing residents' clinical skills in multiple core competencies via the standardized patient methodology. Study Design Development of assessment tool. Setting Johns Hopkins Medicine Simulation Center. Subjects and Methods Residents of the Department of Otolaryngology-Head and Neck Surgery at The Johns Hopkins University School of Medicine were invited to participate. A 2-station OSCE was developed. The first station used a standardized patient, and the encounter was videotaped for later evaluation by medical faculty not familiar with the participants being tested. The second was a computer-based station developed per a modified Delphi technique, based on feedback from otolaryngology and sleep medicine faculty involved in the care of patients with OSA. Checklists were developed...

Advances in medical education and practice, 2017

Students pursuing a medical career in the US are subject to standardized testing at regular inter... more Students pursuing a medical career in the US are subject to standardized testing at regular intervals. These standardized tests not only quantify the milestones students have already achieved, but also define the path for future achievements. The purpose of these examinations is to help students become self-directed, lifelong learners - an essential attribute of a medical professional. However, whether preparing for these examinations actually makes students such disciplined learners needs to be examined. Especially during residency training with its limited time and unpredictable exposure, trainees must learn in the most efficient way for their learning styles, and thus develop attributes that will be helpful to them in their medical career. In this review, we propose that a personalized, learner-centered approach tailored to residents' educational needs and preferences can not only fulfill learning interests and objectives but also serve as a time-efficient and cost-effective ...

Journal of Critical Care, 2017

Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. A... more Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes. Materials and Methods: In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventyseven patients received nonstandard tracheostomy tubes (cases) and 154 received standard tracheostomy tubes (controls). Results: Sex, endotracheal tube size, severity of illness, and computerized tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance >4.4 cm and endotracheal tube sizes ≥8.0 were associated with nonstandard tracheostomy.

Anesthesia and analgesia, 2015

Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening co... more Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level perfo...

Journal of medical speech-language pathology, 2014

To describe the types of talking tracheostomy tubes available, present four case studies of criti... more To describe the types of talking tracheostomy tubes available, present four case studies of critically ill patients who used a specialized tracheostomy tube to improve speech, discuss their advantages and disadvantages, propose patient selection criteria, and provide practical recommendations for medical care providers. Retrospective chart review of patients who underwent tracheostomy in 2010. Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%) received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy. Among the percutaneous tracheostomy patients, speech-language pathologists were consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients received a talking tracheostomy tube, and all four were able to speak successfully while on the mechanical ventilator even though they were unable to tolerate cuff deflation. Talking tracheostomy tubes allow patients who are unable to tolerate-cuff deflation to achieve phonation....

ORL-head and neck nursing : official journal of the Society of Otorhinolaryngology and Head-Neck Nurses, 2014

Tracheostomies are performed to improve health-related quality of life (QOL) in patients requirin... more Tracheostomies are performed to improve health-related quality of life (QOL) in patients requiring prolonged mechanical ventilation. As the lengths of stay in intensive care units (ICU) increase and higher rates of tracheostomies are becoming more prevalent, issues regarding patient perceptions of their own prognoses and outcomes after tracheostomy can considerably impact QOL and in turn their care and recovery. Whether tracheostomy improves QOL, however, has not been studied adequately. Current studies investigating QOL have been limited to pre- and post-ICU admission, have relied on surrogate measures such as clinical outcomes and proxy reports, and have used inadequate instruments, failing to capture all domains of QOL. Studies using a robust instrument to investigate QOL in the ICU before and after tracheostomy are lacking. To explore the feasibility of assessing patient-reported QOL of mechanically ventilated ICU patients with a tracheostomy. A prospective longitudinal pilot st...

The Laryngoscope, 2014

REPLACE THIS BOX WITH YOUR ORGANIZATION'S HIGH RESOLUTION LOGO Objectives: To measure the effect ... more REPLACE THIS BOX WITH YOUR ORGANIZATION'S HIGH RESOLUTION LOGO Objectives: To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors which can help to overcome the distractions. Methods: Ten PGY2-6 residents and 2 faculty members from Johns Hopkins otolaryngology department were recruited and asked to deepen the dissection at sinodural angle on Voxel-man mastoidectomy simulator. They were asked to perform the task under four conditions; 1) no distractors, 2) differentiation and counting of a specific alarm sound among different sounds played in the background while performing the surgical task, 3) simultaneous performance of simple arithmetic task of moderate difficulty, 4) simultaneous performance of the task with both sets of distractors combined. Results: Time taken for the task (p=0.02) and error scores (p=0.002) increased under third and fourth conditions. The ability to multitask and response to surgical and cognitive task improved with increasing level of experience of the participants. Conclusions: Distractions lead to impaired dexterity and an increase in the incidence of errors. However, experience and deliberate practice can help achieve the ability to multitask without compromising the operative performance.

Journal of Graduate Medical Education, 2012

Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outc... more Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project in July 2001 to improve the quality of resident education through competency-based learning. The purpose of this systematic review is to determine and explore the perceptions of program directors regarding challenges to implementing the ACGME Outcome Project. Methods We used the PubMed and Web of Science databases and bibliographies for English-language articles published between January 1, 2001, and February 17, 2012. Studies were included if they described program directors' opinions on (1) barriers encountered when attempting to implement ACGME competency-based education, and (2) assessment methods that each residency program was using to implement competency-based education. Articles meeting the inclusion criteria were screened by 2 researchers. The grading criterion was created by the authors and used to assess the quality of each study. Results The survey-based data...

The Laryngoscope, 2014

Objectives/Hypothesis: To examine the effects of a learner-centered educational curriculum for Jo... more Objectives/Hypothesis: To examine the effects of a learner-centered educational curriculum for Johns Hopkins otolaryngology-head and neck surgery residents in improving their otolaryngology training examination (OTE) scores. We hypothesized that trainees who attend a learner-centered program demonstrate improved performance on OTEs. Study Design: Prospective longitudinal study. Methods: In September 2008, a resident-designed educational curriculum was implemented to better prepare residents for their OTE. These mandatory sessions, led by faculty members, were held for an hour every week, during in which residents were tested on their knowledge of high-yield topics. Residents were expected to be prepared on pathophysiology, diagnosis, and treatment of the selected diseases. In 2011, residents were given responsibility to lead these sessions. OTE scores from 2002 to 2012 were analyzed to see whether there was any improvement after the implementation of this curriculum. Results: Clustered linear regression analysis revealed significant improvement of OTE scores with subsequent interventions. During a 3-year period (2009-2011) after the first intervention, there was a significant increase (P 5.01) of 0.69 in mean national and 0.78 in mean group stanine scoring. Similarly, after the second intervention in 2011, a further increment of 1.36 in mean national and 1.58 in mean group stanine scoring was seen (P 5.001). Conclusions: Residents OTE stanines improved significantly after the implementation of a learner-centered educational curriculum. This finding suggests that trainees are able to perform better when involved in planning and implementing the educational curriculum.

The Laryngoscope, 2013

Objectives/Hypothesis: This study explores the influence of selected factors on achievement of co... more Objectives/Hypothesis: This study explores the influence of selected factors on achievement of competency in mastoid surgery. Study Design: A prospective study of surgical performance and a retrospective survey of learner and training factors. Methods: The longitudinal performance of 15 residents was evaluated using the mastoidectomy task-based checklist (TBC). The influence of surgical experience, resident interest, and training factors (course attendance, voluntary use of simulation laboratory) was also examined and compared for the acquisition of distinct levels of technical skill difficulty (cortical mastoidectomy vs. facial recess). Results: Ninety-six observations made during the first otology rotation were analyzed. Cortical mastoidectomy tasks showed positive associations with cumulated case numbers (

The Laryngoscope, 2014

Objectives/Hypothesis: To develop and assess the feasibility of a new standardized protocol to gu... more Objectives/Hypothesis: To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design: Descriptive review of quality improvement project. Methods: A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results: Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion: The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety.

The Laryngoscope, 2012

To this date the effect of the time taken to complete an evaluation on the psychometric propertie... more To this date the effect of the time taken to complete an evaluation on the psychometric properties of the instrument has not been reported. The goal of our study was to assess the effect of time taken to complete an evaluation on its validity. Cross-sectional validation study. The global and checklist parts of tonsillectomy, mastoidectomy, rigid bronchoscopy, and endoscopic sinus surgery were used in the operating room by the otolaryngology faculty to evaluate the surgical skills of the residents. We categorized evaluations into two groups depending on the time taken to complete an evaluation (group A ≤ 6 days, group B >6 days). Construct validity was calculated for both groups by comparing the mean global and checklist scores of the residents across advancing postgraduate year levels. A total of 468 evaluations, consisting of global and checklist parts, were completed for 29 residents by 32 evaluators. Mean number of days taken to complete an evaluation was 7.7 days. For all the evaluations completed within a 6-day time period, the construct validity was significant for both global and checklist parts of the four instruments. In cases of the evaluations completed after 6 days, the construct validity was significant for the tonsillectomy instrument only. Our results indicate that the time taken to complete an evaluation has a significant effect on the construct validity of the objective instrument. In the future, efforts should be focused on faculty development to ensure timely completion of the evaluation for a more valid assessment process.

Chest, 2020

To evaluate the practice of creation of tracheostomies during the initial phases of the COVID-19 ... more To evaluate the practice of creation of tracheostomies during the initial phases of the COVID-19 pandemic, with a focus on clinical outcomes and sedation parameters. METHODS: We enrolled 45 consecutive COVID-19 positive adult patients whom a consult for tracheostomy was placed at Johns Hopkins Hospital between 4/16/2020 and 5/22/2020. A total of 38 tracheostomies were performed at the time of censoring. Five of the patients were extubated before performance of tracheostomy and two were awaiting creation of tracheostomy. Data was collected via manual extraction on clinical outcomes, sedative medication use for the 48 hours pre-and 48 hours posttracheostomy. RESULTS: Baseline characteristics of the 45 patients include a median age of 62, BMI of 30, with an even split of Male:Female (23:22). The median days of intubation before tracheostomy was 20 (range: 5-36), median days from consult for tracheostomy to performance of tracheostomy was 3. A multidisciplinary team across specialties performed the tracheostomy consults with Interventional Pulmonary performing 18, Otolaryngology 13, General Surgery 9, Thoracic Surgery 5. 29 of the tracheostomies were performed percutaneously. A bronchoalveolar lavage, tracheal aspirate, or sputum sample was obtained on the day of performance of the tracheostomy and 35 of the 38 were negative for COVID-19. The samples were sent a median of 23.5 days after the initial positive test. Mortality on date of censoring was 7 (15.6%) including 5 (13.2%) of the patients with tracheostomy. 10 (22.2%) had been discharged including 9 (23.7%) of the patients with tracheostomy. Sedation and analgesia (total dose in 48 hours pre-(PR) and 48 hours post post-tracheostomy (PO)) expressed as median dosage for patients receiving that medication:-Dexmedetomidine (mcg/kg/hr):

Surgical competency is traditionally considered as an ability to perform surgery successfully. Ho... more Surgical competency is traditionally considered as an ability to perform surgery successfully. However, patient outcomes do not depend only on the surgical skills of a surgeon which calls for the revision of the concept of surgical competency. Surgical competency is a combination of skills which allow the surgeon to successfully apply his knowledge and skills to understand and make necessary changes according to the needs and circumstances of an individual patient to solve the clinical problem. Accordingly, the assessment of competency depends on various factors; however, patient outcomes are the ultimate result of the surgeons’performance. Patient outcomes can be measured in terms of mortality, morbidity, resolution of patient’s symptoms, length of stay, complication rates, functional status, quality of life, satisfaction with treatment results, readmission rates and healthcare costs. As every surgical specialty is different with wide range of procedures, the skills that determine ...

The Laryngoscope, 2012

To test the validity, reliability, and feasibility of an evaluation tool designed to measure the ... more To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. Prospective validation study. A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills-based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology-head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showi...

Otolaryngology - Head and Neck Surgery, 2008

Otolaryngology residency programs have been mandated by the ACGME to demonstrate teaching and ass... more Otolaryngology residency programs have been mandated by the ACGME to demonstrate teaching and assessment of core competencies. Operative competency is an essential part of patient care in otolaryngology. Currently there are no reliable, valid and feasible mechanisms and instruments to objectively evaluate operative competency. A recent survey of program directors in otolaryngology reveals lack of objective instruments for this assessment. We presented a miniseminar on general and targeted needs assessment and reviewed current practice in other surgical specialties at 2007 academy meeting. We wish to present an update on progress made since then through six 6-minute talks each followed by four minutes of interactive discussion. 1) Concept of developing instruments for objective assessment of operative competency in the context of a curriculum. The underpinning of this curriculum will be a benchmark of surgical competency required for graduating residents. 2) Results of a pilot project involving objective assessment of tonsillectomy and tracheostomy by internal and external evaluators will be discussed. 3) Analysis of trends noted from the survey of program directors will be presented. 4) Report on a survey of recent otolaryngology graduates for identifying their perspective on current and ideal assessment mechanisms will be discussed. Simulators are slowly gaining a role in teaching and assessment of operative competency in otolaryngology and other specialties. 5) Discussion of currently available simulators and their perceived role in residency training in otolaryngology in the near future. 6) Setting up and maintaining effective remedial mechanisms for surgically challenged residents without disrupting existing rotation schedules.

Otolaryngology - Head and Neck Surgery, 2009

setting. Among these interventions, the use of injected botulinum toxin has become common in the ... more setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge that patients seek consultation for. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of the hyaluronic acid based agents created a significant increase in acceptance and demand for filler substances by patients. More recently approved and soon to be approved fillers promise to increase the application. Laser and light technologies, including laser hair removal, offer intervention for an increasingly large number of clinical issues including the treatment of wrinkles, hyperpigmentation, cutaneous vascular lesions, rosacea, unwanted hair, and other agingrelated skin conditions. Finally, representing low cost effective treatments over new technology, the practitioner will find the availability of skin care services, particularly the use of various chemical peeling agents to be a useful adjunct in the office setting. The purpose of the miniseminar is to present an upto-date review of safe, effective, office-based procedures that the otolaryngologist may have available to patients in their office. The presentations will review the pertinent pharmacology, physics where applicable, and anatomy. Technique, preoperative and post procedure issues will be discussed. The clinical photo-rich presentations will demonstrate technique and patient selection. The prevention and management of complications will be reviewed. This miniseminar will update the attendees that have previous training in these procedures and serve as an introduction to those that are exploring these procedures. EDUCATIONAL OBJECTIVES: 1) To understand the current use of botulinum toxin for cosmetic procedures. 2) To understand the use of various lasers for cosmetic indications. 3) To understand the use of fillers.

Journal of surgical education, Jan 5, 2018

A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospita... more A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scor...

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, Sep 1, 2017

Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obst... more Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obstructive sleep apnea (OSA) and (2) to test the reliability and evaluate the feasibility of this OSCE while assessing residents' clinical skills in multiple core competencies via the standardized patient methodology. Study Design Development of assessment tool. Setting Johns Hopkins Medicine Simulation Center. Subjects and Methods Residents of the Department of Otolaryngology-Head and Neck Surgery at The Johns Hopkins University School of Medicine were invited to participate. A 2-station OSCE was developed. The first station used a standardized patient, and the encounter was videotaped for later evaluation by medical faculty not familiar with the participants being tested. The second was a computer-based station developed per a modified Delphi technique, based on feedback from otolaryngology and sleep medicine faculty involved in the care of patients with OSA. Checklists were developed...

Advances in medical education and practice, 2017

Students pursuing a medical career in the US are subject to standardized testing at regular inter... more Students pursuing a medical career in the US are subject to standardized testing at regular intervals. These standardized tests not only quantify the milestones students have already achieved, but also define the path for future achievements. The purpose of these examinations is to help students become self-directed, lifelong learners - an essential attribute of a medical professional. However, whether preparing for these examinations actually makes students such disciplined learners needs to be examined. Especially during residency training with its limited time and unpredictable exposure, trainees must learn in the most efficient way for their learning styles, and thus develop attributes that will be helpful to them in their medical career. In this review, we propose that a personalized, learner-centered approach tailored to residents' educational needs and preferences can not only fulfill learning interests and objectives but also serve as a time-efficient and cost-effective ...

Journal of Critical Care, 2017

Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. A... more Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes. Materials and Methods: In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventyseven patients received nonstandard tracheostomy tubes (cases) and 154 received standard tracheostomy tubes (controls). Results: Sex, endotracheal tube size, severity of illness, and computerized tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance >4.4 cm and endotracheal tube sizes ≥8.0 were associated with nonstandard tracheostomy.

Anesthesia and analgesia, 2015

Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening co... more Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level perfo...

Journal of medical speech-language pathology, 2014

To describe the types of talking tracheostomy tubes available, present four case studies of criti... more To describe the types of talking tracheostomy tubes available, present four case studies of critically ill patients who used a specialized tracheostomy tube to improve speech, discuss their advantages and disadvantages, propose patient selection criteria, and provide practical recommendations for medical care providers. Retrospective chart review of patients who underwent tracheostomy in 2010. Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%) received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy. Among the percutaneous tracheostomy patients, speech-language pathologists were consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients received a talking tracheostomy tube, and all four were able to speak successfully while on the mechanical ventilator even though they were unable to tolerate cuff deflation. Talking tracheostomy tubes allow patients who are unable to tolerate-cuff deflation to achieve phonation....

ORL-head and neck nursing : official journal of the Society of Otorhinolaryngology and Head-Neck Nurses, 2014

Tracheostomies are performed to improve health-related quality of life (QOL) in patients requirin... more Tracheostomies are performed to improve health-related quality of life (QOL) in patients requiring prolonged mechanical ventilation. As the lengths of stay in intensive care units (ICU) increase and higher rates of tracheostomies are becoming more prevalent, issues regarding patient perceptions of their own prognoses and outcomes after tracheostomy can considerably impact QOL and in turn their care and recovery. Whether tracheostomy improves QOL, however, has not been studied adequately. Current studies investigating QOL have been limited to pre- and post-ICU admission, have relied on surrogate measures such as clinical outcomes and proxy reports, and have used inadequate instruments, failing to capture all domains of QOL. Studies using a robust instrument to investigate QOL in the ICU before and after tracheostomy are lacking. To explore the feasibility of assessing patient-reported QOL of mechanically ventilated ICU patients with a tracheostomy. A prospective longitudinal pilot st...

The Laryngoscope, 2014

REPLACE THIS BOX WITH YOUR ORGANIZATION'S HIGH RESOLUTION LOGO Objectives: To measure the effect ... more REPLACE THIS BOX WITH YOUR ORGANIZATION'S HIGH RESOLUTION LOGO Objectives: To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors which can help to overcome the distractions. Methods: Ten PGY2-6 residents and 2 faculty members from Johns Hopkins otolaryngology department were recruited and asked to deepen the dissection at sinodural angle on Voxel-man mastoidectomy simulator. They were asked to perform the task under four conditions; 1) no distractors, 2) differentiation and counting of a specific alarm sound among different sounds played in the background while performing the surgical task, 3) simultaneous performance of simple arithmetic task of moderate difficulty, 4) simultaneous performance of the task with both sets of distractors combined. Results: Time taken for the task (p=0.02) and error scores (p=0.002) increased under third and fourth conditions. The ability to multitask and response to surgical and cognitive task improved with increasing level of experience of the participants. Conclusions: Distractions lead to impaired dexterity and an increase in the incidence of errors. However, experience and deliberate practice can help achieve the ability to multitask without compromising the operative performance.

Journal of Graduate Medical Education, 2012

Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outc... more Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project in July 2001 to improve the quality of resident education through competency-based learning. The purpose of this systematic review is to determine and explore the perceptions of program directors regarding challenges to implementing the ACGME Outcome Project. Methods We used the PubMed and Web of Science databases and bibliographies for English-language articles published between January 1, 2001, and February 17, 2012. Studies were included if they described program directors' opinions on (1) barriers encountered when attempting to implement ACGME competency-based education, and (2) assessment methods that each residency program was using to implement competency-based education. Articles meeting the inclusion criteria were screened by 2 researchers. The grading criterion was created by the authors and used to assess the quality of each study. Results The survey-based data...

The Laryngoscope, 2014

Objectives/Hypothesis: To examine the effects of a learner-centered educational curriculum for Jo... more Objectives/Hypothesis: To examine the effects of a learner-centered educational curriculum for Johns Hopkins otolaryngology-head and neck surgery residents in improving their otolaryngology training examination (OTE) scores. We hypothesized that trainees who attend a learner-centered program demonstrate improved performance on OTEs. Study Design: Prospective longitudinal study. Methods: In September 2008, a resident-designed educational curriculum was implemented to better prepare residents for their OTE. These mandatory sessions, led by faculty members, were held for an hour every week, during in which residents were tested on their knowledge of high-yield topics. Residents were expected to be prepared on pathophysiology, diagnosis, and treatment of the selected diseases. In 2011, residents were given responsibility to lead these sessions. OTE scores from 2002 to 2012 were analyzed to see whether there was any improvement after the implementation of this curriculum. Results: Clustered linear regression analysis revealed significant improvement of OTE scores with subsequent interventions. During a 3-year period (2009-2011) after the first intervention, there was a significant increase (P 5.01) of 0.69 in mean national and 0.78 in mean group stanine scoring. Similarly, after the second intervention in 2011, a further increment of 1.36 in mean national and 1.58 in mean group stanine scoring was seen (P 5.001). Conclusions: Residents OTE stanines improved significantly after the implementation of a learner-centered educational curriculum. This finding suggests that trainees are able to perform better when involved in planning and implementing the educational curriculum.

The Laryngoscope, 2013

Objectives/Hypothesis: This study explores the influence of selected factors on achievement of co... more Objectives/Hypothesis: This study explores the influence of selected factors on achievement of competency in mastoid surgery. Study Design: A prospective study of surgical performance and a retrospective survey of learner and training factors. Methods: The longitudinal performance of 15 residents was evaluated using the mastoidectomy task-based checklist (TBC). The influence of surgical experience, resident interest, and training factors (course attendance, voluntary use of simulation laboratory) was also examined and compared for the acquisition of distinct levels of technical skill difficulty (cortical mastoidectomy vs. facial recess). Results: Ninety-six observations made during the first otology rotation were analyzed. Cortical mastoidectomy tasks showed positive associations with cumulated case numbers (

The Laryngoscope, 2014

Objectives/Hypothesis: To develop and assess the feasibility of a new standardized protocol to gu... more Objectives/Hypothesis: To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design: Descriptive review of quality improvement project. Methods: A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results: Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion: The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety.

The Laryngoscope, 2012

To this date the effect of the time taken to complete an evaluation on the psychometric propertie... more To this date the effect of the time taken to complete an evaluation on the psychometric properties of the instrument has not been reported. The goal of our study was to assess the effect of time taken to complete an evaluation on its validity. Cross-sectional validation study. The global and checklist parts of tonsillectomy, mastoidectomy, rigid bronchoscopy, and endoscopic sinus surgery were used in the operating room by the otolaryngology faculty to evaluate the surgical skills of the residents. We categorized evaluations into two groups depending on the time taken to complete an evaluation (group A ≤ 6 days, group B >6 days). Construct validity was calculated for both groups by comparing the mean global and checklist scores of the residents across advancing postgraduate year levels. A total of 468 evaluations, consisting of global and checklist parts, were completed for 29 residents by 32 evaluators. Mean number of days taken to complete an evaluation was 7.7 days. For all the evaluations completed within a 6-day time period, the construct validity was significant for both global and checklist parts of the four instruments. In cases of the evaluations completed after 6 days, the construct validity was significant for the tonsillectomy instrument only. Our results indicate that the time taken to complete an evaluation has a significant effect on the construct validity of the objective instrument. In the future, efforts should be focused on faculty development to ensure timely completion of the evaluation for a more valid assessment process.