“First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

From the 8/7/2020 newsletter

Invited Commentary

 

 “First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

 

Sondra Zabar, MD and Kinga Eliasz, PhD MS – New York University Grossman School of Medicine

 

Drs. Zabar and Eliasz are on the team that instituted the “First Night-OnCall” (FNOC) experience for trainees. In this essay, they describe the experience of modifying FNOC and running “FNOC 2020” in the pandemic era…

 

The transition from medical student to resident is difficult and dicey for patient safety in the best of times. In the US, virtually all recently-graduated medical students begin their residency training as interns on or about July 1. It has been reported that, in some academic settings, hospital-based risk-adjusted mortality rate goes up 4-8% in the first two months of a new residency year. While the cause of this bump in mortality is contested, we take seriously our responsibility to ensure all new house officers are as prepared as possible for unfamiliar clinical settings and dramatic increase in patient care responsibilities.

In COVID-19 times, everyone is looking at this transition through a new lens. Last spring, almost all near-graduate medical students across the country were pulled off their final clinical rotations. At the same time, these medical students needed to be ready to join the pandemic front lines on July 1 as interns. Special attention was needed for the safety of our patients, learners, staff, and faculty. We needed to design effective instruction to empower communities of learners with both the core values and outstanding diagnostic and communication skills that would be needed during a pandemic.

We knew that evidence-based orientation-to-residency strategies based on experiential learning and performance-based assessment are the most efficient and effective approaches to set expectations and build a resilient, unified workforce in this new era of practice.

How would we do this?

 

Adapting and Implementing First Night-onCall (FNOC) to the COVID-19 Era

We first created and implemented First Night-onCall (FNOC) at NYU Grossman School of Medicine (NYUGSOM) in 2017, a large-scale, authentic, immersive simulation developed to support incoming interns, address the hospital’s need to improve early escalation of seriously ill hospitalized patients, and cultivate our medical center’s culture of safety from Day One of residency. FNOC provided a collaborative, immersive “on call” simulation experience for all incoming interns across many of our largest residency programs. The program was so well-received by interns, faculty, and leadership, that it is now a core component of the residency orientation experience.

This year, FNOC – developed in collaboration with our simulation center (NYSIM) and core GME faculty – was adapted to the COVID-19 pandemic with the following goals:

1. Demonstrate the institution’s commitment to supporting both intern and patient safety.
2. Solidify each intern’s core knowledge base using WISE-onCall (WOC) Modules, a transition-to-residency curriculum on common safety issues which is part of the Aquifer collection of online clinical learning tools.
3. Reinforce the importance to patient safety of checking two patient identifiers and the appropriate escalation of urgent care.
4. Ensure each intern could properly “don and doff” Personal Protective Equipment (PPE).
5. Address interns’ concerns and comfort with caring for COVID-19 patients.
6. Provide a forum for interns to meet their peers and leaders, voice their concerns, and understand resources available to them.

To accomplish these goals, “FNOC 2020 COVID Edition” orientation included the following features:

1. Priming pre-work:  Incoming interns were asked to complete at least five out of the available twelve WISE-onCall online modules.
2. Shortened, in-person three-hour immersive simulations: New interns, in small groups, were challenged to:

o   Don/doff PPE and engage in a mannequin-based team simulation.

o   Evaluate a decompensating, hypotensive patient and activate a rapid response team (escalation) using remote standardized patient and nurse interactions, where learners were assessed using behaviorally-anchored checklists.

o   Recognize a mislabeled blood culture bottle.

o   Conduct an effective patient handoff.

o   Engage in a faculty facilitated debriefing of the entire experience emphasizing COVID-19 specific concerns.

 

Assessing Interns’ Concerns Prior to FNOC 2020

At the start of FNOC, interns reported being concerned about having adequate access to appropriate PPE. They worried about virus exposure despite the use of PPE. They felt unprepared, uncomfortable, intimidated, and anxious. They recognized they needed additional PPE don/doffing training and ventilator management. Despite their concerns and skills deficits, they were committed to caring for COVID-19 patients and were eager to learn current care protocols, and care for patients. 

Prior to FNOC 2020 COVID Edition, only 13% of the 215 participating interns from twenty-two residency programs reported having had seen, and only 19% felt comfortable with, providing care for a COVID-19 patient. Although 42% of the brand-new interns reported having ever witnessed a medical error, only 26% reported any formal patient safety training, and only 2% had any experience reporting a medical error.

 

FNOC 2020 was successful

Assessing and addressing our new interns’ knowledge and attitude regarding caring for COVID-19 patients was critical.

The impact of the session was reassuring for our institution.  80% of the interns reported greater comfort caring for a COVID-19 patient. This year, for the first time, 94% of entering interns completed more than the required number of WISE-onCall modules and over 90% agreed that the modules increased readiness-for-internship by providing a framework to organize clinical information. Almost all interns endorsed that FNOC 2020 was an effective, fun, and engaging way to learn patient safety, and 100% felt that it was an overall good approach to improve readiness-for-internship.

Patient safety awareness was also improved. They were reminded of the importance of checking two patient identifiers, and properly donning/doffing PPE. After FNOC 2020, 91% of interns reported that they were more comfortable speaking to a supervisor, to escalate an urgent situation and report a medical error.

 

As medical educators we must challenge ourselves to create engaging, immersive, innovative, and flexible simulation group experiences such as FNOC that can be rapidly adapted to the educational needs of any level of learners. In our experience, a deliberately-designed experiential orientation reduces the variability seen in entering interns, builds community and instills aspirational institutional norms – generating a culture of safety for patients.

 

 

Sondra Zabar, MD is a Professor of Medicine and Director of the Division of General Internal Medicine at the NYU Grossman School of Medicine, and Affiliate Professor of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She is a national award-winning medical education researcher with expertise in performance-based assessment of clinical competence.

Kinga Eliasz, PhD MS is a Postdoctoral Research Scientist and Assessment and Evaluation Analyst in the Research on Medical Education and Outcomes (ROMEO) Unit of the Program for Medical Education Innovation and Research (PrMEIR), Division of General Internal Medicine and Clinical Innovation, NYU Grossman School of Medicine. She is also a Deputy Editor of Teaching and Learning in Medicine: An International Journal.