TY - JOUR
AU - PhD, Terrie Vasilopoulos,
AB - ABSTRACT Introduction: Naval Surface Forces provide care in austere environments with unique facility, personnel, and material limitations that can put the patient at risk without proper consideration of these circumstances. Tailored shipboard education currently exists but is greatly dependent on the time, preferences, expertise, and ability of a single teaching officer, allowing for significant variability in the level of training. Materials and Methods: One hundred and twenty-two individuals were trained in 19 topics presented over 12 months through the Naval Surface Forces Pacific Command Medical Readiness Division to all surface providers on Naval Base San Diego. Participants completed pre- and post-course assessments for each training session based on the objectives of the lesson, as well as reassessments and subjective course critiques every 3 months. Results: Fifteen of 19 courses showed more than 20% improvement, with a range of improvement from 21 to 67%, and an average of 30% (95% confidence interval: 26.1–33.8, p < 0.001). Short-term follow-up showed higher-than-baseline scores at 6-, 9-, and 12-month follow-up; these were significantly higher than nonattendees (p = 0.003, 0.05, 0.004, respectively). Students who reported being either very confident or very confident and comfortable with teaching the content increased from 40.6% before the course to 60.8% after the course. Pre- (p = 0.02) and post- (p = 0.01) course level of confidence was directly correlated to students' assessment of the courses' applicability, with increasing level of confidence correlating to a perceived increase in applicability of the material. Conclusion: This study demonstrates improvement in Naval surface provider knowledge and attitudes in a variety of subject areas after implementation of a novel curriculum tailored specifically to address the unique considerations for practice at sea. Material was beneficial to all trainees despite significant differences in training background. Confidence gained as a result of the course was directly correlated to perceived relevance of the material, but not to educational background. Future work could investigate the use of curriculum in deployed providers and incorporation into current training of the OPNAVINST 6400.1c, Appendix A. INTRODUCTION Naval Surface Forces depend on the ability of shipboard medical providers to work in remote locations, at times isolated from higher echelons of care, with facility, personnel, and materiel limitations which may not be typical of shore-based treatment environments. These systemic limitations have the potential to contribute to medical errors,1,2 a consideration which emphasizes the importance of provider preparedness to minimize risk to the patient. Continuing development of pertinent knowledge, skill, and training in this context is of the utmost importance; however, it is complicated by significant variations in education background and treatment responsibilities between Independent Duty Corpsmen (IDCs), General Medical Officers (GMOs), and Senior Medical Officers (SMOs) as well as by treatment considerations unique to each platform, including working space, manpower support, formulary, materiel, and medical transport capabilities. As currently implemented, Naval surface provider continuing education is centered on one-on-one training with a designated medical supervisor. In this setting, the instructor has the ability to tailor material to individuals' strengths and weaknesses, pursue collaborative activities that focus on relevant application of knowledge, and use discussion instead of lecture for transfer of knowledge, all of which have demonstrated educational benefit.3,–7 Despite the potential strengths of this format, variable contact time and teaching methodology in practice can limit its effectiveness. Additionally, each supervisor has unique teaching skills and expertise on the basis of background and experiences, leading to significant variation in quality of education. In an effort to mitigate limitations imposed by the diversity of trainees, their operational constraints, and variability in supervisor-related factors, this prospective cohort study evaluated the effectiveness of a novel supplemental continuing education curriculum for Navy surface providers. MATERIALS AND METHODS Through the Naval Surface Forces Pacific Command Medical Readiness Division, 158 surface medical providers were trained in 19 topics presented to surface providers on commands based out of Naval Base San Diego from 2015 to 2016. Curriculum was developed on the basis of the medical competency areas outlined in OPNAVINST 6400.1c, Appendix A,8 with additions from a committee of providers with significant shipboard experience, to be delivered in 32 sessions over 18 months. Training sessions were 45 to 90 minutes long, with one or two topics covered more than 90 minutes. Emphasis was placed on recognition and treatment of urgent and emergent conditions. Sessions were taught in a variety of formats, including flipped classroom (where class content was made available online before the class so that class time could focus on application and consolidation of content),7 hands-on skills training, question and answer, case-based discussion, and lecture. Session facilitators were chosen on the basis of teaching acumen, subject matter expertise, and previous shipboard experience. Teaching of diagnosis, treatment, and management focused on modalities unique to the participants' formulary and available materiel, referred to as the Authorized Medical Allowance List, as well as considerations for medical transport to a higher echelon of care or management afloat. Instructors created course material (sample outline of sessions in Tables I and II) and assessment questions with feedback from a panel of providers experienced in shipboard medical care. TABLE I. Example Curricula: “Airway Management at Sea” Airway Management at Sea   Objectives    • Define patent/protected airway    • Review pertinent airway pathology    • Discuss and demonstrate basic airway management techniques    • Discuss and demonstrate advanced airway management techniques   30-minute lecture   60-minute workshop   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Define patent/protected airway     a. Anatomic airway     b. Airway protection and reflexes      i. Innervation      ii. Assessment using Glasgow Coma Scale     c. Oxygenation      i. Measurement      ii. Signs and symptoms of hypoxia     d. Ventilation      i. Measurement      ii. Signs and symptoms of hypercarbia      iii. Strength assessment (especially with Chemical, Biological, Radiological, Nuclear, and Explosive materials exposure)    3. Pathology (give categories and elicit examples from students)     a. Obstructive—edema, foreign body, vocal cord paralysis, abscess, burn     b. Trauma—tracheal injury, penetrating injury     c. Neurologic—impaired reflexes, neurotrauma, intoxicants    4. Assessment     a. Talk to patient—voice quality, hoarseness     b. History/exam—signs of trauma, secretions, mental status, soot or singed nose hairs, resp exam     c. Vitals/diagnostics—pulse oximetry, capnography, arterial blood gas, chest X-ray     d. Seizure case discussion— Boatswain's Mate 3rd Class sitting on bench at sick call starts having tonic-clonic seizures; how to first proceed (initial assessment and intervention use as lead-in to workshop)  Break for 5 minutes (room configuration changes as needed)  Small groups of no more than 5, preferably 2 to 3  Stations with dummy, airway supplies (endotracheal tubes, syringe, stylet, lube, oropharyngeal airways, nasopharyngeal airways, laryngoscopes, mask, ambu, laryngeal mask airways, king laryngeal tubes), dummy cleaning supplies    5. Management techniques—discussion done in small groups facilitated by small group leaders     a. Non-invasive techniques and indications (as applicable on the basis of platform)      i. Supplemental O2 (nasal cannula, simple mask, nonrebreather)      ii. Continuous positive airway pressure      iii. Mask ventilation  Discuss context of use and considerations before intervention as well as alternate techniques if primary intervention is unsuccessful     b. Invasive techniques      i. LMA      ii. King LT      iii. Intubation    6. Postintubation management     a. Ventilator settings (as applicable)     b. Sedation (platform based)     c. Operational considerations (emergent vs urgent intubations in at sea in the context of available shipboard resources)    7. Complete post-test    8. Review test answers  Airway Management at Sea   Objectives    • Define patent/protected airway    • Review pertinent airway pathology    • Discuss and demonstrate basic airway management techniques    • Discuss and demonstrate advanced airway management techniques   30-minute lecture   60-minute workshop   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Define patent/protected airway     a. Anatomic airway     b. Airway protection and reflexes      i. Innervation      ii. Assessment using Glasgow Coma Scale     c. Oxygenation      i. Measurement      ii. Signs and symptoms of hypoxia     d. Ventilation      i. Measurement      ii. Signs and symptoms of hypercarbia      iii. Strength assessment (especially with Chemical, Biological, Radiological, Nuclear, and Explosive materials exposure)    3. Pathology (give categories and elicit examples from students)     a. Obstructive—edema, foreign body, vocal cord paralysis, abscess, burn     b. Trauma—tracheal injury, penetrating injury     c. Neurologic—impaired reflexes, neurotrauma, intoxicants    4. Assessment     a. Talk to patient—voice quality, hoarseness     b. History/exam—signs of trauma, secretions, mental status, soot or singed nose hairs, resp exam     c. Vitals/diagnostics—pulse oximetry, capnography, arterial blood gas, chest X-ray     d. Seizure case discussion— Boatswain's Mate 3rd Class sitting on bench at sick call starts having tonic-clonic seizures; how to first proceed (initial assessment and intervention use as lead-in to workshop)  Break for 5 minutes (room configuration changes as needed)  Small groups of no more than 5, preferably 2 to 3  Stations with dummy, airway supplies (endotracheal tubes, syringe, stylet, lube, oropharyngeal airways, nasopharyngeal airways, laryngoscopes, mask, ambu, laryngeal mask airways, king laryngeal tubes), dummy cleaning supplies    5. Management techniques—discussion done in small groups facilitated by small group leaders     a. Non-invasive techniques and indications (as applicable on the basis of platform)      i. Supplemental O2 (nasal cannula, simple mask, nonrebreather)      ii. Continuous positive airway pressure      iii. Mask ventilation  Discuss context of use and considerations before intervention as well as alternate techniques if primary intervention is unsuccessful     b. Invasive techniques      i. LMA      ii. King LT      iii. Intubation    6. Postintubation management     a. Ventilator settings (as applicable)     b. Sedation (platform based)     c. Operational considerations (emergent vs urgent intubations in at sea in the context of available shipboard resources)    7. Complete post-test    8. Review test answers  View Large TABLE I. Example Curricula: “Airway Management at Sea” Airway Management at Sea   Objectives    • Define patent/protected airway    • Review pertinent airway pathology    • Discuss and demonstrate basic airway management techniques    • Discuss and demonstrate advanced airway management techniques   30-minute lecture   60-minute workshop   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Define patent/protected airway     a. Anatomic airway     b. Airway protection and reflexes      i. Innervation      ii. Assessment using Glasgow Coma Scale     c. Oxygenation      i. Measurement      ii. Signs and symptoms of hypoxia     d. Ventilation      i. Measurement      ii. Signs and symptoms of hypercarbia      iii. Strength assessment (especially with Chemical, Biological, Radiological, Nuclear, and Explosive materials exposure)    3. Pathology (give categories and elicit examples from students)     a. Obstructive—edema, foreign body, vocal cord paralysis, abscess, burn     b. Trauma—tracheal injury, penetrating injury     c. Neurologic—impaired reflexes, neurotrauma, intoxicants    4. Assessment     a. Talk to patient—voice quality, hoarseness     b. History/exam—signs of trauma, secretions, mental status, soot or singed nose hairs, resp exam     c. Vitals/diagnostics—pulse oximetry, capnography, arterial blood gas, chest X-ray     d. Seizure case discussion— Boatswain's Mate 3rd Class sitting on bench at sick call starts having tonic-clonic seizures; how to first proceed (initial assessment and intervention use as lead-in to workshop)  Break for 5 minutes (room configuration changes as needed)  Small groups of no more than 5, preferably 2 to 3  Stations with dummy, airway supplies (endotracheal tubes, syringe, stylet, lube, oropharyngeal airways, nasopharyngeal airways, laryngoscopes, mask, ambu, laryngeal mask airways, king laryngeal tubes), dummy cleaning supplies    5. Management techniques—discussion done in small groups facilitated by small group leaders     a. Non-invasive techniques and indications (as applicable on the basis of platform)      i. Supplemental O2 (nasal cannula, simple mask, nonrebreather)      ii. Continuous positive airway pressure      iii. Mask ventilation  Discuss context of use and considerations before intervention as well as alternate techniques if primary intervention is unsuccessful     b. Invasive techniques      i. LMA      ii. King LT      iii. Intubation    6. Postintubation management     a. Ventilator settings (as applicable)     b. Sedation (platform based)     c. Operational considerations (emergent vs urgent intubations in at sea in the context of available shipboard resources)    7. Complete post-test    8. Review test answers  Airway Management at Sea   Objectives    • Define patent/protected airway    • Review pertinent airway pathology    • Discuss and demonstrate basic airway management techniques    • Discuss and demonstrate advanced airway management techniques   30-minute lecture   60-minute workshop   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Define patent/protected airway     a. Anatomic airway     b. Airway protection and reflexes      i. Innervation      ii. Assessment using Glasgow Coma Scale     c. Oxygenation      i. Measurement      ii. Signs and symptoms of hypoxia     d. Ventilation      i. Measurement      ii. Signs and symptoms of hypercarbia      iii. Strength assessment (especially with Chemical, Biological, Radiological, Nuclear, and Explosive materials exposure)    3. Pathology (give categories and elicit examples from students)     a. Obstructive—edema, foreign body, vocal cord paralysis, abscess, burn     b. Trauma—tracheal injury, penetrating injury     c. Neurologic—impaired reflexes, neurotrauma, intoxicants    4. Assessment     a. Talk to patient—voice quality, hoarseness     b. History/exam—signs of trauma, secretions, mental status, soot or singed nose hairs, resp exam     c. Vitals/diagnostics—pulse oximetry, capnography, arterial blood gas, chest X-ray     d. Seizure case discussion— Boatswain's Mate 3rd Class sitting on bench at sick call starts having tonic-clonic seizures; how to first proceed (initial assessment and intervention use as lead-in to workshop)  Break for 5 minutes (room configuration changes as needed)  Small groups of no more than 5, preferably 2 to 3  Stations with dummy, airway supplies (endotracheal tubes, syringe, stylet, lube, oropharyngeal airways, nasopharyngeal airways, laryngoscopes, mask, ambu, laryngeal mask airways, king laryngeal tubes), dummy cleaning supplies    5. Management techniques—discussion done in small groups facilitated by small group leaders     a. Non-invasive techniques and indications (as applicable on the basis of platform)      i. Supplemental O2 (nasal cannula, simple mask, nonrebreather)      ii. Continuous positive airway pressure      iii. Mask ventilation  Discuss context of use and considerations before intervention as well as alternate techniques if primary intervention is unsuccessful     b. Invasive techniques      i. LMA      ii. King LT      iii. Intubation    6. Postintubation management     a. Ventilator settings (as applicable)     b. Sedation (platform based)     c. Operational considerations (emergent vs urgent intubations in at sea in the context of available shipboard resources)    7. Complete post-test    8. Review test answers  View Large TABLE II. Example Curricula: “Shock on the Waterfront!” SHOCK ON THE WATERFRONT!   Objectives    • Review underlying pathophysiology of shock    • Review diagnosis/classification of shock    • Understand considerations for initial treatment of shock on the basis of platform    • Discuss the management of shock in the austere environment   45-minute lecture/case-based discussion   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Review of shock pathophysiology (go over any questions from handouts/slideshow and briefly touch on/review slides for those who haven't had a chance to look at them ahead of time)     a. Definition—profound and widespread reduction in effective delivery of oxygen/other nutrients to tissues that results in reversible progressing to permanent cellular injury     b. Stages of shock      i. Preshock—compensated change in hemodynamics      ii. Shock—increased reduction in effective blood volume, decrease in CO and activation of mediators      iii. End organ dysfunction—decreased urine output, altered mental status, acidosis → altered cellular metabolism, etc. (ask for examples from audience, then review slide)     c. Determinants of shock—loss of effective blood volume, hypoperfusion, oxygen consumption/delivery mismatch, microcirculatory homeostasis     d. Mediators of inflammation in shock—toxins, oligo- and polypeptides, fatty acid derivatives, calcium (summarize and keep simple; is beyond the scope for most students)    3. Review of diagnosis/classification     a. Features by organ system      i. Brain—decreased level of consciousness, altered mental status      ii. Cardiovascular—hemodynamic changes      iii. Lungs—tachypnea, dyspnea      iv. Kidneys—urine output      v. Skin—perfusion changes     b. Classes of shock      i. Hypovolemic (start discussion with class at this point, bringing in real examples from experienced practitioners or theoretical cases)      ii. Distributive (ask about mechanism/pathology leading to this type of shock and lead this in to case discussions)      iii. Cardiogenic–man-down scenario, reaction after medication given at sick call scenario      iv. Obstructive patient presenting with burn/after firefighting scenario    4. Treatment considerations (talk about variations by platform in available options and relative importance in terms of urgency in triage/transport; before showing slide, ask students from different platforms what they would use for treatment component)     a. Access     b. Monitoring     c. Resuscitation—fluids vs. blood vs. walking blood bank and when to activate     d. Pressors/medications—recommendations for shore facilities → platform specific    5. Management considerations (allow the most time for this section)     a. Management of treatment team (discuss platform specific care team organization, assigning of tasks and facility use)     b. Medical evacuation preparation (stress importance for planning ahead to know what support is available/transport times and variables to affect transport in including advance discussions with your MEDEVAC coordinator)     c. Care coordination (discuss command and health provider concerns)     d. Transport—who and what goes with patient    6. Questions    7. Complete post-test    8. Review test answers  SHOCK ON THE WATERFRONT!   Objectives    • Review underlying pathophysiology of shock    • Review diagnosis/classification of shock    • Understand considerations for initial treatment of shock on the basis of platform    • Discuss the management of shock in the austere environment   45-minute lecture/case-based discussion   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Review of shock pathophysiology (go over any questions from handouts/slideshow and briefly touch on/review slides for those who haven't had a chance to look at them ahead of time)     a. Definition—profound and widespread reduction in effective delivery of oxygen/other nutrients to tissues that results in reversible progressing to permanent cellular injury     b. Stages of shock      i. Preshock—compensated change in hemodynamics      ii. Shock—increased reduction in effective blood volume, decrease in CO and activation of mediators      iii. End organ dysfunction—decreased urine output, altered mental status, acidosis → altered cellular metabolism, etc. (ask for examples from audience, then review slide)     c. Determinants of shock—loss of effective blood volume, hypoperfusion, oxygen consumption/delivery mismatch, microcirculatory homeostasis     d. Mediators of inflammation in shock—toxins, oligo- and polypeptides, fatty acid derivatives, calcium (summarize and keep simple; is beyond the scope for most students)    3. Review of diagnosis/classification     a. Features by organ system      i. Brain—decreased level of consciousness, altered mental status      ii. Cardiovascular—hemodynamic changes      iii. Lungs—tachypnea, dyspnea      iv. Kidneys—urine output      v. Skin—perfusion changes     b. Classes of shock      i. Hypovolemic (start discussion with class at this point, bringing in real examples from experienced practitioners or theoretical cases)      ii. Distributive (ask about mechanism/pathology leading to this type of shock and lead this in to case discussions)      iii. Cardiogenic–man-down scenario, reaction after medication given at sick call scenario      iv. Obstructive patient presenting with burn/after firefighting scenario    4. Treatment considerations (talk about variations by platform in available options and relative importance in terms of urgency in triage/transport; before showing slide, ask students from different platforms what they would use for treatment component)     a. Access     b. Monitoring     c. Resuscitation—fluids vs. blood vs. walking blood bank and when to activate     d. Pressors/medications—recommendations for shore facilities → platform specific    5. Management considerations (allow the most time for this section)     a. Management of treatment team (discuss platform specific care team organization, assigning of tasks and facility use)     b. Medical evacuation preparation (stress importance for planning ahead to know what support is available/transport times and variables to affect transport in including advance discussions with your MEDEVAC coordinator)     c. Care coordination (discuss command and health provider concerns)     d. Transport—who and what goes with patient    6. Questions    7. Complete post-test    8. Review test answers  View Large TABLE II. Example Curricula: “Shock on the Waterfront!” SHOCK ON THE WATERFRONT!   Objectives    • Review underlying pathophysiology of shock    • Review diagnosis/classification of shock    • Understand considerations for initial treatment of shock on the basis of platform    • Discuss the management of shock in the austere environment   45-minute lecture/case-based discussion   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Review of shock pathophysiology (go over any questions from handouts/slideshow and briefly touch on/review slides for those who haven't had a chance to look at them ahead of time)     a. Definition—profound and widespread reduction in effective delivery of oxygen/other nutrients to tissues that results in reversible progressing to permanent cellular injury     b. Stages of shock      i. Preshock—compensated change in hemodynamics      ii. Shock—increased reduction in effective blood volume, decrease in CO and activation of mediators      iii. End organ dysfunction—decreased urine output, altered mental status, acidosis → altered cellular metabolism, etc. (ask for examples from audience, then review slide)     c. Determinants of shock—loss of effective blood volume, hypoperfusion, oxygen consumption/delivery mismatch, microcirculatory homeostasis     d. Mediators of inflammation in shock—toxins, oligo- and polypeptides, fatty acid derivatives, calcium (summarize and keep simple; is beyond the scope for most students)    3. Review of diagnosis/classification     a. Features by organ system      i. Brain—decreased level of consciousness, altered mental status      ii. Cardiovascular—hemodynamic changes      iii. Lungs—tachypnea, dyspnea      iv. Kidneys—urine output      v. Skin—perfusion changes     b. Classes of shock      i. Hypovolemic (start discussion with class at this point, bringing in real examples from experienced practitioners or theoretical cases)      ii. Distributive (ask about mechanism/pathology leading to this type of shock and lead this in to case discussions)      iii. Cardiogenic–man-down scenario, reaction after medication given at sick call scenario      iv. Obstructive patient presenting with burn/after firefighting scenario    4. Treatment considerations (talk about variations by platform in available options and relative importance in terms of urgency in triage/transport; before showing slide, ask students from different platforms what they would use for treatment component)     a. Access     b. Monitoring     c. Resuscitation—fluids vs. blood vs. walking blood bank and when to activate     d. Pressors/medications—recommendations for shore facilities → platform specific    5. Management considerations (allow the most time for this section)     a. Management of treatment team (discuss platform specific care team organization, assigning of tasks and facility use)     b. Medical evacuation preparation (stress importance for planning ahead to know what support is available/transport times and variables to affect transport in including advance discussions with your MEDEVAC coordinator)     c. Care coordination (discuss command and health provider concerns)     d. Transport—who and what goes with patient    6. Questions    7. Complete post-test    8. Review test answers  SHOCK ON THE WATERFRONT!   Objectives    • Review underlying pathophysiology of shock    • Review diagnosis/classification of shock    • Understand considerations for initial treatment of shock on the basis of platform    • Discuss the management of shock in the austere environment   45-minute lecture/case-based discussion   IDC/GMO/SMO   Curriculum Outline    1. Complete pretest    2. Review of shock pathophysiology (go over any questions from handouts/slideshow and briefly touch on/review slides for those who haven't had a chance to look at them ahead of time)     a. Definition—profound and widespread reduction in effective delivery of oxygen/other nutrients to tissues that results in reversible progressing to permanent cellular injury     b. Stages of shock      i. Preshock—compensated change in hemodynamics      ii. Shock—increased reduction in effective blood volume, decrease in CO and activation of mediators      iii. End organ dysfunction—decreased urine output, altered mental status, acidosis → altered cellular metabolism, etc. (ask for examples from audience, then review slide)     c. Determinants of shock—loss of effective blood volume, hypoperfusion, oxygen consumption/delivery mismatch, microcirculatory homeostasis     d. Mediators of inflammation in shock—toxins, oligo- and polypeptides, fatty acid derivatives, calcium (summarize and keep simple; is beyond the scope for most students)    3. Review of diagnosis/classification     a. Features by organ system      i. Brain—decreased level of consciousness, altered mental status      ii. Cardiovascular—hemodynamic changes      iii. Lungs—tachypnea, dyspnea      iv. Kidneys—urine output      v. Skin—perfusion changes     b. Classes of shock      i. Hypovolemic (start discussion with class at this point, bringing in real examples from experienced practitioners or theoretical cases)      ii. Distributive (ask about mechanism/pathology leading to this type of shock and lead this in to case discussions)      iii. Cardiogenic–man-down scenario, reaction after medication given at sick call scenario      iv. Obstructive patient presenting with burn/after firefighting scenario    4. Treatment considerations (talk about variations by platform in available options and relative importance in terms of urgency in triage/transport; before showing slide, ask students from different platforms what they would use for treatment component)     a. Access     b. Monitoring     c. Resuscitation—fluids vs. blood vs. walking blood bank and when to activate     d. Pressors/medications—recommendations for shore facilities → platform specific    5. Management considerations (allow the most time for this section)     a. Management of treatment team (discuss platform specific care team organization, assigning of tasks and facility use)     b. Medical evacuation preparation (stress importance for planning ahead to know what support is available/transport times and variables to affect transport in including advance discussions with your MEDEVAC coordinator)     c. Care coordination (discuss command and health provider concerns)     d. Transport—who and what goes with patient    6. Questions    7. Complete post-test    8. Review test answers  View Large Participants completed pre- and post-course assessments for each training session on the basis of the objectives of the lesson as well as subjective course critiques. Additionally, reassessments were given at 3, 6, 9, and 12 months following the implementation of the curriculum. A cohort of individuals who did not attend the sessions was given online access to all course materials and was also evaluated with the same reassessment questions as the study cohort. Pre- and post-assessment questions included a mix of simple and case vignette-based multiple choice questions. Subjective feedback included questions about relevance of subject matter, pre- and post-course confidence in patient care in applicable subject areas, and factors about the sessions themselves, including length, quality of materials, and quality of instructors, graded on a 5-point qualitative scale. All analyses were conducted in JMP 12.0 (SAS Institute, Cary, North Carolina). Scores on content questions before and after the review course and at follow-up (1–2 months after review course offering across each quarter) were reported as mean percent (%) correct ± standard deviation. The curriculum included 19 content areas (Table III), with a combined score constructed by averaging performance (% correct) across these areas. Changes in content area scores pre- and post-course were analyzed via paired t test (or Wilcoxon signed ranked tests for non-normally distributed data). The follow-up examination also covered the previously described content areas, and a combined percent correct score was also created. To assess long-term retention, paired tests were conducted between postcourse scores and follow-up scores. For the subject course critique, differences in participants' pre- and post-course levels of confidence (LOCs) were evaluated with Wilcoxon signed ranked tests after converting responses to a numeric scale (1–5). Following adjustment for multiple comparisons with false discovery rate methods, p < 0.05 was considered statistically significant.9 The study was exempted from institutional review board approval per NAVMEDRSCHCENINST 3900.6 and 32 CFR 219.101(b)(1).10,11 TABLE III. List of Topics Covered Medical Triage at Sea  Evaluation and Treatment of Chest Pain  Diagnosis and Management of Shock  Respiratory Emergencies Afloat  Management of the Acute Surgical Abdomen  Treatment of Acute Pain Afloat  Shipboard Airway Management  Ultrasound Proficiency Workshop  Dental Diagnosis and Treatment for IDCs  Poison and Toxicology Afloat  Shipboard Diagnosis and Treatment of Allergic Reactions  Triage and Treatment of Shipboard Trauma  Management of Psychiatric Emergencies Afloat  Radiology for the GMO  Obstetrics/Gynecology Afloat for the IDC  Orthopedics for the Afloat Provider  Electrocardiogram Interpretation  Ophthalmologic Emergencies at Sea  Preventive Medicine for Shipboard Commands  Medical Triage at Sea  Evaluation and Treatment of Chest Pain  Diagnosis and Management of Shock  Respiratory Emergencies Afloat  Management of the Acute Surgical Abdomen  Treatment of Acute Pain Afloat  Shipboard Airway Management  Ultrasound Proficiency Workshop  Dental Diagnosis and Treatment for IDCs  Poison and Toxicology Afloat  Shipboard Diagnosis and Treatment of Allergic Reactions  Triage and Treatment of Shipboard Trauma  Management of Psychiatric Emergencies Afloat  Radiology for the GMO  Obstetrics/Gynecology Afloat for the IDC  Orthopedics for the Afloat Provider  Electrocardiogram Interpretation  Ophthalmologic Emergencies at Sea  Preventive Medicine for Shipboard Commands  View Large TABLE III. List of Topics Covered Medical Triage at Sea  Evaluation and Treatment of Chest Pain  Diagnosis and Management of Shock  Respiratory Emergencies Afloat  Management of the Acute Surgical Abdomen  Treatment of Acute Pain Afloat  Shipboard Airway Management  Ultrasound Proficiency Workshop  Dental Diagnosis and Treatment for IDCs  Poison and Toxicology Afloat  Shipboard Diagnosis and Treatment of Allergic Reactions  Triage and Treatment of Shipboard Trauma  Management of Psychiatric Emergencies Afloat  Radiology for the GMO  Obstetrics/Gynecology Afloat for the IDC  Orthopedics for the Afloat Provider  Electrocardiogram Interpretation  Ophthalmologic Emergencies at Sea  Preventive Medicine for Shipboard Commands  Medical Triage at Sea  Evaluation and Treatment of Chest Pain  Diagnosis and Management of Shock  Respiratory Emergencies Afloat  Management of the Acute Surgical Abdomen  Treatment of Acute Pain Afloat  Shipboard Airway Management  Ultrasound Proficiency Workshop  Dental Diagnosis and Treatment for IDCs  Poison and Toxicology Afloat  Shipboard Diagnosis and Treatment of Allergic Reactions  Triage and Treatment of Shipboard Trauma  Management of Psychiatric Emergencies Afloat  Radiology for the GMO  Obstetrics/Gynecology Afloat for the IDC  Orthopedics for the Afloat Provider  Electrocardiogram Interpretation  Ophthalmologic Emergencies at Sea  Preventive Medicine for Shipboard Commands  View Large RESULTS One hundred and fifty-eight individuals (n = 158) participated in this study, with 36 GMOs (22.8%), 115 IDCs (72.8%), and seven SMOs (4.4%). Fifteen of 19 content areas demonstrated statistically significant improvement from pre- to post-test in paired analyses and two areas (shock and radiology) showed a trend toward improvement (Fig. 1). Triage (pre: 62.5% ± 17.7; post: 89.4% ± 19.0) and chest pain (pre: 75.0% ± 43.3; post: 91.4% ± 18.1) were not analyzed with paired tests because of small sample size (not pictured). For all courses, mean % correct increased from 61.1% ± 19.6 before the course to 90.5% ± 10.8 immediately after the course. All participants improved from pre- to post-course in paired analyses regardless of educational background (Fig. 2). However, at both the pre- and post-course evaluations, GMO participants fared better than IDCs (p = 0.002). FIGURE 1. View largeDownload slide Pre- and post-test scores for each course with significance indicated by + (p < 0.10), * (p < 0.05), or ** (p < 0.01) and 95% confidence intervals indicated by whiskers. FIGURE 1. View largeDownload slide Pre- and post-test scores for each course with significance indicated by + (p < 0.10), * (p < 0.05), or ** (p < 0.01) and 95% confidence intervals indicated by whiskers. FIGURE 2. View largeDownload slide Pre- and post-test scores by training level. Significant difference between General Medical Officers (GMO) and Independent Duty Corpsmen (IDC) pretest scores, and GMO and IDC post-test scores indicated by ** (p < 0.01) and 95% confidence intervals indicated by whiskers. FIGURE 2. View largeDownload slide Pre- and post-test scores by training level. Significant difference between General Medical Officers (GMO) and Independent Duty Corpsmen (IDC) pretest scores, and GMO and IDC post-test scores indicated by ** (p < 0.01) and 95% confidence intervals indicated by whiskers. Follow-up results at 6 and 12 months after implementation of curriculum were significantly better compared to baseline (p < 0.001). For the third and fourth quarters, though pretest scores for those who did not attend the training sessions were significantly higher than the pretest scores for those who did, they still had lower follow-up results compared to those who attended the sessions (p = 0.05 and p = 0.004, respectively) as shown in Figure 3. FIGURE 3. View largeDownload slide Follow-up post-test results for all material with comparison between those who attended the course (returning) and those who did not (not returning) with significance indicated by + (p < 0.10), * (p < 0.05), or ** (p < 0.01) and 95% confidence intervals indicated by whiskers. FIGURE 3. View largeDownload slide Follow-up post-test results for all material with comparison between those who attended the course (returning) and those who did not (not returning) with significance indicated by + (p < 0.10), * (p < 0.05), or ** (p < 0.01) and 95% confidence intervals indicated by whiskers. Seventy-one (n = 71) students completed the subjective course critique (Table IV). A majority of respondents were IDC (72.9%) and had 8 hours or fewer of postgraduate training in subject areas reviewed in this course (88.5%). Most of respondents thought the course material was applicable or very applicable (65.7%), supplementary material was helpful or very helpful (68.6%) facilitators were knowledgeable or very knowledgeable (89.6%) and the course length was optimal (83.1%). TABLE IV. Subjective Survey Results With Results by Number and Percentage of Respondents Topic  Number of Respondents  Percentage  Course Effect on Practice   No Change  8  11.6   Small Change in Practice  13  18.8   Moderate Change in Practice  32  46.4   Significant Change in Practice  15  21.7   I Will Practice Completely Differently  1  1.5  Course Applicability   Not Applicable  1  1.4   Minimally Applicable  5  7.1   Somewhat Applicable  18  25.7   Applicable  35  50.0   Very Applicable  11  15.7  Helpfulness of Course Materials   Not Helpful  1  1.4   Minimally Helpful  8  11.5   Somewhat Helpful  13  18.6   Helpful  39  55.7   Very Helpful  9  12.9  Course Facilitator Expertise   No Knowledge of Subject Matter  0  0.0   Significant Lack of Knowledge  1  1.5   Somewhat Knowledgeable  6  9.0   Knowledgeable  28  41.8   Very Knowledgeable  32  47.8  Time for Course   Too Little  0  0.0   Enough  51  83.1   Too Long  10  16.4  Topic  Number of Respondents  Percentage  Course Effect on Practice   No Change  8  11.6   Small Change in Practice  13  18.8   Moderate Change in Practice  32  46.4   Significant Change in Practice  15  21.7   I Will Practice Completely Differently  1  1.5  Course Applicability   Not Applicable  1  1.4   Minimally Applicable  5  7.1   Somewhat Applicable  18  25.7   Applicable  35  50.0   Very Applicable  11  15.7  Helpfulness of Course Materials   Not Helpful  1  1.4   Minimally Helpful  8  11.5   Somewhat Helpful  13  18.6   Helpful  39  55.7   Very Helpful  9  12.9  Course Facilitator Expertise   No Knowledge of Subject Matter  0  0.0   Significant Lack of Knowledge  1  1.5   Somewhat Knowledgeable  6  9.0   Knowledgeable  28  41.8   Very Knowledgeable  32  47.8  Time for Course   Too Little  0  0.0   Enough  51  83.1   Too Long  10  16.4  View Large TABLE IV. Subjective Survey Results With Results by Number and Percentage of Respondents Topic  Number of Respondents  Percentage  Course Effect on Practice   No Change  8  11.6   Small Change in Practice  13  18.8   Moderate Change in Practice  32  46.4   Significant Change in Practice  15  21.7   I Will Practice Completely Differently  1  1.5  Course Applicability   Not Applicable  1  1.4   Minimally Applicable  5  7.1   Somewhat Applicable  18  25.7   Applicable  35  50.0   Very Applicable  11  15.7  Helpfulness of Course Materials   Not Helpful  1  1.4   Minimally Helpful  8  11.5   Somewhat Helpful  13  18.6   Helpful  39  55.7   Very Helpful  9  12.9  Course Facilitator Expertise   No Knowledge of Subject Matter  0  0.0   Significant Lack of Knowledge  1  1.5   Somewhat Knowledgeable  6  9.0   Knowledgeable  28  41.8   Very Knowledgeable  32  47.8  Time for Course   Too Little  0  0.0   Enough  51  83.1   Too Long  10  16.4  Topic  Number of Respondents  Percentage  Course Effect on Practice   No Change  8  11.6   Small Change in Practice  13  18.8   Moderate Change in Practice  32  46.4   Significant Change in Practice  15  21.7   I Will Practice Completely Differently  1  1.5  Course Applicability   Not Applicable  1  1.4   Minimally Applicable  5  7.1   Somewhat Applicable  18  25.7   Applicable  35  50.0   Very Applicable  11  15.7  Helpfulness of Course Materials   Not Helpful  1  1.4   Minimally Helpful  8  11.5   Somewhat Helpful  13  18.6   Helpful  39  55.7   Very Helpful  9  12.9  Course Facilitator Expertise   No Knowledge of Subject Matter  0  0.0   Significant Lack of Knowledge  1  1.5   Somewhat Knowledgeable  6  9.0   Knowledgeable  28  41.8   Very Knowledgeable  32  47.8  Time for Course   Too Little  0  0.0   Enough  51  83.1   Too Long  10  16.4  View Large There were significant differences in respondent pre- and post-course LOC (p < 0.001). Notably, the combined proportion of respondents who reported being either very confident or very confident and comfortable with teaching the content increased from 40.6% before the course to 60.8% after the course (Fig. 4). Pre- (p = 0.02) and post- (p = 0.01) LOC was directly correlated to students' assessment of the course's applicability, with LOC rising with a perceived increase in applicability. FIGURE 4. View largeDownload slide Pre- and post-course level of confidence on a 5-point scale with 1 = unable to treat patients with conditions taught in course, 2 = would treat patient/no or minimal confidence, 3 = able to treat with confidence, 4 = very confident in treatment, and 5 = confidence in treatment and teaching of concepts to other practitioners. FIGURE 4. View largeDownload slide Pre- and post-course level of confidence on a 5-point scale with 1 = unable to treat patients with conditions taught in course, 2 = would treat patient/no or minimal confidence, 3 = able to treat with confidence, 4 = very confident in treatment, and 5 = confidence in treatment and teaching of concepts to other practitioners. DISCUSSION This prospective study of a multimodal, longitudinal curriculum for continuing education tailored to afloat providers demonstrated significant improvement in attitudes and knowledge pertinent to practice at sea that persisted up to 12 months after the study intervention. The demonstrated effectiveness of the curriculum at improving knowledge and confidence was approximately equivalent regardless of level of pre- or post-graduate education. To our knowledge, few other studies have looked at delivery of curriculum to providers of different education levels,12,–14 and none compared change in knowledge after their intervention on the basis of education level. These findings likely reflect a relatively similar deficit across all groups in the understanding and application of specialized knowledge. In contrast to previous reports, however, the course attendees had significantly different levels of exposure to the material taught, especially the more general medical concepts (diagnosis and treatment). Though improvements from pre- to post-course correlated inversely based on education level and increased postgraduate training, all trainees showed significant improvement. This reflects the ability of a single curriculum to provide benefit to students of different education levels. Confidence improved as a result of the course regardless of level of education. It correlated, however, with perceived relevance of the course to shipboard practice. Those who felt the course was minimally applicable or not applicable were more likely to report low confidence post-training. There was no correlation in confidence and precourse scores in this group, possibly indicating that the subjects' improvement was related in part to the perceived utility of the material, consistent with previous literature.15,–18 Helping students to see the relevance of this material to their practice could potentially improve outcomes for future iterations of this curriculum. The degree of knowledge retention demonstrated here at 6 and 12 months was consistent with previously published data,19,–27 though these studies evaluated courses instead of single lessons. Though 3- and 9-month training showed no difference from baseline, the scores were significantly elevated compared to nonattendees, which may reflect student or question sampling for a given test. Significant deficits existed in almost all subjects targeted for continuous refresher training; these deficits may necessitate the use of a more robust program to approximate students' knowledge levels during graduate training.28 It remains to be seen if the 18-month cycle of this curriculum is too long for maintenance of knowledge in conjunction with study materials created by the instructors and one-on-one training sessions, though efforts are ongoing to measure long-term retention of this curriculum. Limitations of this study include lack of randomization, high turnover among the study cohort, and failure to evaluate skills associated with hands-on training sessions. Because this study does not include a review of all topics, it is possible the results here are not applicable to other subjects. Though it was demonstrated that area-specific knowledge and attitudes toward treatment were changed as a result of this intervention, it remains to be seen if these changes persist over a longer time interval. Future research could be directed at developing multimedia materials (e.g., videos, podcasts) for independent study and for application of training to underway/deployed commands. Given limitations of current one-on-one training, feedback from supervisors on use of curriculum materials to guide such training could be investigated. Finally, short-term data look promising, but long-term assessment of knowledge and skill retention should be evaluated in assessing the effectiveness of this curriculum. In conclusion, we show the benefit of a targeted, multimodal continuing education curriculum for Naval surface providers to knowledge and attitudes affecting shipboard medical practice. 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TI - Effect of Novel Continuing Medical Education Curriculum on Attitudes and Understanding of Primary Care Medicine for the Naval Surface Provider
JF - Military Medicine
DO - 10.7205/MILMED-D-17-00022
DA - 2017-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/effect-of-novel-continuing-medical-education-curriculum-on-attitudes-KX80R5wzQK
SP - e1841
EP - e1848
VL - 182
IS - 9
DP - DeepDyve
ER -