Conclusion: A hybrid simulation program can identify gaps, characterize the overall quality of evaluation, and improve immediate attitudes and knowledge in the team based assessment of child abuse. A gap was identified in the recognition of true accidental injuries. The foundation of a forensic injury evaluation is the FIH and the ordering of appropriate medical tests.The lack of association between these elements and correct diagnosis suggests that physicians may not have appropriate diagnostic approaches in cases of possible abuse. The strong association between case type (AB or AC) and correct diagnosis indicates that pre-conceived notions about a case of possible abuse may be the driving factor in physician end diagnosis.
1. Bannon MJ, Carter YH. Pediatricians and child protection: the need for effective education and training. Arch Dis Child 2003;88: 560-2.
2. Shabde N. Child protection training for pediatricians. Arch Dis Child 2006; 91: 639-41.
3. Narayan AP, Socolar RS, St. Claire K. Pediatric residency training in child abuse and neglect in the United States. Pediatrics. 2006;117(6):2215-2221.
4. Dubowitz H. Child abuse programs and pediatric residency training. Pediatrics. 1988;82:477-480.
5. Ward MG, Bennett S, Plint AC, King WJ, Jabbour M, Gaboury I. Child protection: a neglected area of pediatric residency training. Child Abuse & Neglect. 2004;28:1113-1122.
6. Giardino AP, Brayden RM, Sugarman JM. Residency training in child sexual abuse evaluation. Child Abuse & Neglect. 1998;22:331-336.
7. Flaherty EG, Sege R, Hurley TP, Baker A. Strategies for saving and improving children’s lives. Pediatrics. 2008;122(Supplement 1):S18-S20.
8. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. Journal of the American Medical Association. 1999;281:621-626.
9. Anderst JD, Kellogg N, Jung I. Is the diagnosis of child physical abuse changed when child protective services consults a child abuse pediatrics subspecialty group as a second opinion? Child Abuse & Neglect. 2009;33:481-489.
10. Ellaway RH, Kneebone R, Lachapelle K, Topps D. Practica continua: connecting and combining simulation modalities for integrated teaching, learning and assessment. Medical Teacher. 2009;31:725-731.
1065 Initial Validation of the Internal Medicine Simulated Practical Exam (IMSPE) for Third Year Medical Students
Moshe Feldman, PhD2, Gonzalo Bearman, MD, MPH, FACP1, Jeffrey Kushinka, MD3, Cheryl Bodamer, PhD, MPH, RN2, Ellen Brock, MD, MPH2, and Alan Dow, MD, MSHA1
1VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE, RICHMOND, VA, USA and 2CENTER FOR HUMAN SIMULATION AND PATIENT SAFETY, VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE, RICHMOND, VA, USA and 3INTERNAL MEDICINE, VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE, RICHMOND, VA, USA
Introduction/Background: Medical student competency in Patient Care is generally evaluated by ratings from faculty and supervising housestaff.1 These ratings are often unreliable due to inconsistent assessment contexts and inadequate faculty training, even when using tools such as the mini-CEX.2 Simulation could provide a more standardized competency-based assessment of Patient Care by allowing students to demonstrate a level of competency through real-time management of standardized scenarios with consistent assessment processes and without threatening patient safety. To test this idea, we developed an Internal Medicine Simulated Practical Exam (IMSPE) to assess competency in Patient Care including medical knowledge, diagnostic skills, and clinical management skills. We hypothesize that the use of a robust simulation based exam tool will allow for a more reliable assessment of Patient Care that adds value to existing assessments.
Methods: A prospective study design was used to evaluate initial validity evidence for the IMSPE, which consists of a 52-item photo quiz, a 10-item evaluation using the Harvey cardiopulmonary simulator, and a 16-item evaluation using the iSTAN high fidelity simulator. The photo quiz required students to demonstrate medical knowledge and diagnostic skills by interpreting X-rays, EKGs and diagnosing common dermatologic and ophthalmologic conditions. The Harvey simulator component tested students’ auscultation skills for common cardiopulmonary conditions. The iSTAN simulator component provided a standardized, high fidelity, real-time assessment of common, acute medical conditions including asthma, sepsis, and myocardial infarction requiring participants to interpret clinical findings, determine diagnoses, and initiate an evaluation and management plan. All assessment items were multiple choice questions with responses entered electronically. Performance on the IMSPE was compared to student performance on other existing assessments including the written Shelf exam, a quiz that approximates the Shelf exam, Step 2 scores, clinical evaluations, OSCE scores, and overall clerkship grades. Students completed an evaluation of the learning experience after all exam responses were submitted.
Results: Seventy-nine 3rd year medical student volunteers participated. The IMSPE total mean score was 75.34 (SD = 7.37). IMSPE performance was positively correlated with written exam scores (r = .48; p < .01), text based equiz scores (r = .34; p < .01), and final clerkship grades (r = .37; p < .05). In addition, Harvey component scores were positively correlated with Step 2 scores (r = .61; p < .05). IMSPE scores were not significantly correlated with Ward scores or OSCE scores. A logistic regression analysis indicated that higher IMSPE scores were associated with an increased probability of an honors compared to a high pass or pass final grade (OR = .89; p < .05). Approximately 80% of participants agreed that simulation was better for assessing medical knowledge of cardiac murmurs, disease states, image recognition, and interpretation of physical exam findings compared to other assessments not using simulation. Ninety percent reported this was a fair exam.
Conclusion: Our results provided some validity evidence for the IMSPE as an additional assessment tool for evaluating competency in Patient Care. IMSPE scores were moderately correlated with other measures of medical knowledge, providing convergent validity evidence, and were uncorrelated with assessments related to interpersonal and communication skills such as the OSCE, providing discriminant validity evidence. In addition, correlations and logistic regression analysis supported the added value of IMSPE scores in estimating students’ final grades. Students perceived the simulated portion of the exam favorably for assessing skills related to competency in patient care. Comments reflected some technological limitations related to interpreting cardiopulmonary findings on the high fidelity mannequin and that greater time was needed per question. Future work will focus on refining the IMSPE and establishing additional evidence of the IMSPE’s utility as a valid and reliable summative assessment tool for competency in patient care.
1. Herbers, JE Jr; Noel, GL; Cooper, GS; Harvey, J; Pangaro, LN; Weaver, MJ. (1989) How accurate are faculty evaluations of clinical competence? Journal of General Internal Medicine 4(3):202-8.
2. Cook DA, Dupras DM, Beckman TJ, Thomas KG, Pankratz VS. Effect of rater training on reliability and accuracy of mini-CEX scores: A randomized, controlled trial. Journal of Internal Medicine. 2008; 24(1): 74-79.
Disclosures: Alan Dow, MD, MSHA, receives grant support from the Josiah H. Macy, Jr Foundation and the Donald W. Reynolds Foundation, and is a consultant for The Frontier Project, LLC.
1089 The Use of Web-based Observational Practice and Educational Networking Improves Simulation-based Education and Training of Central Venous Catheterization: A Pilot Study
Jeffrey Cheung, MSc (c)4, Jansen Koh, MD2, Kim MacKinnon, PhD5, Clare Brett, PhD1, Darius Bagli, MDCM3, and Adam Dubrowski, PhD4
1CURRICULUM, TEACHING, AND LEARNING, ONTARIO INSTITUTE FOR STUDIES IN EDUCATION, UNIVERSITY OF TORONTO, TORONTO, ON, CAN and 2SICKKIDS LEARNING INSTITUTE, UNIVERSITY OF TORONTO, HOSPITAL FOR SICK CHILDREN, TORONTO, ON, CAN and 3SURGERY, UNIVERSITY OF TORONTO, HOSPITAL FOR SICK CHILDREN, TORONTO, ON, CAN and 4THE WILSON CENTRE, SICKKIDS LEARNING INSTITUTE, UNIVERSITY OF TORONTO, HOSPITAL FOR SICK CHILDREN, TORONTO, ON, CAN and 5CURRICULUM, TEACHING, AND LEARNING, UNIVERSITY OF TORONTO, ONTARIO INSTITUTE FOR STUDIES IN EDUCATION, TORONTO, ON, CAN
Introduction/Background: Competency in Central Venous Catheterization (CVC) is an essential objective in several residency training programs. Simulation-based education and training (SBET) for CVC has been shown to improve performance.1 However, SBET for CVC can be a costly undertaking in terms of resources and faculty time. Exploring novel ways to improve the efficiency of SBET for CVC is important. Overcoming barriers of distance, time, and economies of scale, Web-based Learning (WBL) is a potential method of improving SBET for CVC. This pilot study sought to determine the feasibility of using preparatory Web-based Observational Practice and Education Networking (OPEN) to facilitate learning in SBET of CVC in novice learners. We hypothesized that preparatory WBL with OPEN would improve the efficiency of SBET for CVC.
Methods: Upon institutional ethical approval, fifteen medical students enrolled for SBET on CVC were randomized into 1 of the 3 treatment arms of the study, each differing in the type of preparatory material received on CVC: Traditional Reading Material (TM), Observational Practice (OP) and Observational Practice with Education Networking (OPEN). All materials were made available online through email, for the TM group, or a custom-built WBL course for the OP and OPEN groups (Figure 1). Students attended 2 sessions in our simulation laboratory, a preparatory session and a SBET workshop within a two-week interval. For the first session, all students were given their respective preparatory material, with a five minute session for the OP and OPEN groups on familiarization of the website. All students were subsequently left on their own to review the materials. The SBET workshop comprised of a video lesson on CVC and a live demonstration followed by deliberate practice trials and individualized feedback on a CVC part task trainer. Each trial was scored on a modified validated checklist2 (total achievable score of 28). Participants had to achieve a perfect score in 2 consecutive trials in order to complete the workshop. A blinded educator experienced in SBET provided feedback. The following data were collected for each participant: number of trials to achieve competency, checklist score on the first trial, total time required for deliberate practice, and the total time required for the entire workshop.
Results: The average number of trials to achieve competency in CVC for TM, OP and OPEN groups was 6, 4.3 and 4 trials respectively. The average checklist score for TM, OP and OPEN groups on their first trial was 14, 18 and 21 respectively. The average total time score for all trials for TM, OP and OPEN groups were 111, 77 and 48 minutes respectively. The average total time required for completing the workshop for each participant in the TM, OP and OPN groups was 90, 82 and 70 minutes respectively. Based on these averages and variability, sample size calculation showed that we will require at least 9 students in each group to reach statistical significance.
Conclusion: This study demonstrated a consistent trend: those with preparation through OPEN outperformed those in the OP group, who in turn outperformed those in the TM group. A reduced number of attempts to achieve competency, improved checklist scores on first trials, decreased times to reach competency through deliberate practice, and decreased overall SBET workshop time were associated with OPEN and OP WBL. Though underpowered, this trend merits a future RCT with at least 9 participants per group and refinement of the WBL intervention. Preparation through Web-based OPEN has the potential to improve the efficiency of SBET of CVC.
1. Use of Simulation-Based Education to Improve Outcomes of Central Venous Catheterization: A Systematic Review and Meta-Analysis. Irene W.Y.Ma, Mary E. Brindle, Paul E. Ronksley, Daine L. Lorenzetti, Reg S. Sauve, William A. Ghali. Acad Med. Sept 2011; 86(9): 1137-1147.
2. Use of Simulation-Based Mastery Learning to Improve the Quality of Central Venous Catheter Placement in a Medical Intensive Care Unit. Jeffrey H. Barsuk, William C. McGaghie, Elaine R. Cohen, Jayshankar S. Balachandran, Diana B. Wayne. J of Hosp Med. Sept 2009; 4(7): 397-403.
1097 Does a Female Patient Simulator Decrease the Quality of Resuscitation Care Delivered by Bystanders?
Chelsea Kramer, MA1, Nicole Percival, MSc, BSc3, Matthew Wilkins4, and Jeff Caird, PhD2
1HUMAN FACTORS, CAE PROFESSIONAL SERVICES, OTTAWA, ON, CAN and 2HUMAN FACTORS, UNIVERSITY OF CALGARY, CALGARY, AB, CAN and 3HUMAN FACTORS, RESEARCH AND INNOVATION CENTRE, UNIVERSITY OF CALGARY, CALGARY, AB, CAN and 4PSYCHOLOGY, UNIVERSITY OF CALGARY, CALGARY, AB, CAN
Introduction/Background: The purpose of this study was to determine the effect that a female patient had on the quality of resuscitation care during a sudden cardiac arrest (SCA). Previous studies have not examined the influence of patient sex on the ability of laypersons to effectively use an automated external defibrillator (AED). Female simulators, with the exception of birthing simulators, tend to be less widely available, although one-half of the population is female. A variety of social norms, including gender interaction, was expected to inhibit the removal of clothing by laypersons using an AED on a female patient in cardiac arrest.
Methods: A training version of a Medtronic LifePak CR+ AED was used on a METI iStan during a simulated SCAscenari.1 iStan was modified into a woman (i.e., iSam) using a wig, clothing, make-up and breasts (see Figure 1). Ceiling mounted directional microphones and video cameras recorded participant interactions with equipment during the SCA scenario. See Figure 1. The METI iStan was modified into an older woman (i.e., iSam). The common incorrect AED pad placement is shown with the bra partially removed. The Biomedical Ethics Committee certified the study and 30 participants volunteered. The 17 females and 13 males were undergraduate students (Mean age = 23.8 years). Ten participants had basic CPR-only training in the past five years. Participants were told that effective and timely use of the AED was necessary to save iSam’s life and to follow all directions provided by the AED. The experimenter left the room under the premise that they were calling for an ambulance.
Results: The video and audio from the SCA scenario was recorded by Noldus Recorder, coded with Noldus Observer XT (v. 9.0) and analyzed using Predictive Analytic Software (SPSS, v. 18). The Medtronic LifePak CR+ AED verbally prompts participants to remove all clothing from the patient’s chest. This step ensures direct pad application to bare skin, obstructions to pad placement can be addressed (i.e., medication patches, pacemakers) and issues resulting from clothing conductivity (i.e., underwire bras) can be eliminated. Only 40% of participants removed both the shirt and bra from the female patient’s chest. In comparison, previous studies with iStan reported 100% clothing removal.1 Of particular interest, only one male removed the bra from the chest of the female patient. When interviewed on their decision not to remove the bra, participants most often responded that they only needed to remove enough clothing to place the pads. Concerned for patient modesty, they did not want to remove more clothing than necessary. Underwire conductivity was not taken into account.
Conclusion: The use of a female patient simulator was shown to limit the removal of clothing from a patient during a SCA scenario. Observations of participant video and audio data indicate that the placement of the pads on the female patient are farther apart, which may limit the detection of ventricular-tachycardia and ventricular-fibrillation and the delivery of an effective shock. From a safety standpoint, the underwire in bras, if left on during shock, may cause burns to the patient. The results of this study may be optimistic. Bystander interaction with actual female patients during cardiac arrest may produce even less clothing removal and potentially longer shock delivery times. The assumption that only male patient simulators are necessary to train and understand the behavior of caregivers in a range of social contexts should be questioned. Current female simulator add-ons (e.g., chest plates, genitalia) lack realism. Particularly troubling is the expectation that parts can be interchanged on the male frame to adequately represent both genders. Simulator manufacturers should consider expanding their limited female mannequin products.
1. Percival N, Caird, JK. Layperson and nurse performance using two automated external defibrillators. Healthc Syst Ergon & Patient Saf.Boca Raton, FL: CRC Press; 2011.241–244 pp.
Disclosures: Chelsea Kramer, MA is a consultant for CAE Professional Services.
1099 Evaluation of Differences in Care Provided During a Novel, Thematically Paired Simulation Assessment Between Adult and Pediatric Populations
Yuemi An-Grogan, MD2, David Salzman, MD1, Umakanth Avula, MS, BS2, and John Vozenilek, MD, FACEP2
1EMERGENCY MEDICINE, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA and 2SIMULATION TECHNOLOGY AND IMMERSIVE LEARNING, NORTHWESTERN UNIVERSITY, FEINBERG SCHOOL OF MEDICINE, CHICAGO, IL, USA
Introduction/Background: Pediatric emergency medicine (PEM) has grown through research and specialized curricula. However, despite ongoing efforts of post-graduate training programs and certification boards to educate providers, both trainees and board-certified physicians in EM often express discomfort and exposure deficits to pediatric emergency cases and pediatric critical care. According to Langhan et al, in a study surveying board certified EM physicians, participants reported that while 76% and 60% were completely prepared to handle adult CPR and adult trauma, respectively, only 24% and 27% were prepared to handle pediatric CPR and pediatric trauma resuscitations. However, the majority of pediatric patients are treated in general emergency departments. Pediatric critical cases are so rare that other methods of training, such as simulation, can be utilized to improve provider skills and comfort levels, and ultimately, patient outcomes. The purpose of our study was to evaluate for existing differences in delivery of care when an EM provider is presented with two similar simulated patient care encounters related to toxicological emergencies. We hypothesized that there are objective differences in care provided to adult and pediatric populations.
Methods: In this IRB approved, randomized, cross-over study occurring in our simulation center, all participants managed a series of cases individually. Half the participants were exposed to an adult case first (Digoxin overdose) while the other half engaged in a pediatric case first (Beta-blocker overdose). Both scenarios started with a nearly identical stem and followed a similar pre-determined course where the patient presented altered, with hypotension and bradycardia, and required similar management by the provider. Participants were blinded to the cases prior to the start of the session. Participants were evaluated using a checklist consisting of various tasks divided into major categories: history of present illness (HPI), physical exam, initial management, data acquisition, treatment and disposition. In addition, all participants completed pre and post-session questionnaires indicating self-assessments of skill and patient age group preference. Participant’s performance was evaluated using Sign rank and McNemar’s tests. Time-to-event analysis on critical actions was done using Kaplan-Meier principles. Lastly, subjective preference was compared to objective performance.
Results: The effect of case order on resident performance was analyzed and there was no significant difference found between groups. Subgroup analysis showed that HPI and disposition scores were better in the pediatric case, but treatment scores were better in the adult case. Five critical actions including ordering an EKG, administering atropine, voicing a diagnosis, checking a bedside glucose and ordering a chemistry panel showed time-to-performance differences and all five actions were performed earlier in the adult case (p<0.05). In both pre and post-session surveys, 75% and 96.9% (respectively) of the residents stated they were more comfortable in treating adult toxicity cases, but only about 34.3% actually performed better in the adult case (p<0.05). Only 9.4% of residents stated they were equally comfortable managing pediatric and adult toxicities.
Conclusion: This study identifies a discrepancy in management provided between pediatric and adult simulated toxicological scenarios by EM residents at a single institution. To our knowledge this is the first study directly evaluating for differences in emergency care provided between both populations. These initial findings merit further investigation with regards to generalizability to other institutions and practicing physicians. Additionally, this can serve as the first step in a needs assessment to identify gaps in curricular design and practice implementation for residency programs, as well as future maintenance of certification programs.
1. Bourgeois FT, Shannon MW. Emergency care for children in pediatric and general emergency departments. Pediatr Emerg Care. 2007; 23(2): 94-102.
2. Langhan M, Keshavarz R, Richardson LD. How comfortable are emergency physicians with pediatric patients? J Emerg Med. 2004; 26(4): 465-9.
1110 Do Role-specific Colored Vests on Code Team Members Improve CPR Performance During Simulated Emergencies?
Ruth Thomas, MSN4, Jill Sanko, MS, ARNP-BC1, Beatriz Valdes, MSN, MBA2, Guillermo Valdes, DNP, MSN-HCS, RN-BC2, Ilya Shekhter, MS, MBA5, and Lisa Rosen, MA3
1MIAMI, FL, USA and 2NURSING EDUCATION, JACKSON HEALTH SYSTEM, MIAMI, FL, USA and 3CENTER FOR PATIENT SAFETY, UNIVERSITY OF MIAMI, MIAMI, FL, USA and 4ANESTHESIOLOGY, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA and 5CENTER FOR PATIENT SAFETY, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA
Introduction/Background: Sudden cardiac arrest (SCA) is the leading cause of death among adults in the United States with approximately 325,000 fatalities each year.1 Although cardiopulmonary resuscitation (CPR) is a simple lifesaving technique to revive SCA victims, survival outcomes continue to remain low for in-hospital arrests. Correct CPR performance has been difficult to achieve and measure due to the emergent nature of the situation and chaos at the scene.2 However, the use of simulation technology to re-create emergency situations, such as SCA, allows investigators to identify and correct poor CPR performance measures without patient harm. Because survival rates decrease drastically with each passing minute after an SCA event, we have focused on the timeliness of resuscitation measures in simulated codes. We hypothesized that when providers wear colored vests (See Figure 1) identifying specific roles during the performance of CPR, time required to implement four primary emergency measures (ventilation, compressions, medication administration, and defibrillation) will be reduced and team performance in simulation improved.
Methods: Two-hundred and sixty nurses participated in a study conducted in a simulation setting using a SimMan or Resusci-Anne CPR-D (mannequin) over an eight-month period. Twenty groups of nurses participated in each arm (control/intervention), and each group consisted of five to eight team members. The intervention group wore different colored vests for role assignments (team leader, ventilation, compression, medication administration, defibrillation, IV nurse, recorder, and circulator), and the roles were pre-assigned. A five-minute scenario assessed the timeliness of the team’s performance of the following resuscitation measures: two to five cycles of compressions and ventilation, placement of the defibrillator pads and electrical shock, and the administration of the first round of resuscitation medications as recommended by the American Heart Association (AHA) 2010 guidelines. The Ottawa Checklist was used to measure team performance in the following five categories: problem solving, situational awareness, leadership, resource utilization, and communication.3
Results: A two-sample t-test was used to compare time to implement emergency measures and team performance scores among the two groups. Groups wearing colored vests were faster in starting compressions, ventilations, and defibrillation (See Table 1). There was no significant difference in the timeliness of medication administration between the groups. Also, the overall total scores in team performance were significantly better in the intervention group.
Conclusion: Our results suggest that delays in initiating CPR measures may be associated with the number of nurses available during a code and unclear role assignments for the various tasks. Physicians and respiratory therapists usually perform specific roles (team leader and airway manager) during a code while nurses have to assume multiple roles (give medications, set up and run the defibrillator, record code events, and start IVs). Since the colored vests are pre-assigned there are no delays in initiating specific tasks because nurses do not have to figure out their role. Therefore, a simple technique such as role assignment before a code may dramatically improve the coordination of the CPR team, provide faster start times, and lead to better in-hospital SCA survival outcomes. The use of colored vests by nurses during CPR may also help achieve AHA’s Emergency Cardiovascular Care 2020 goals of improving SCA survival outcomes.
1. American Heart Association Lean and Live: Heart Disease and Stroke statistics 2010 update at a glance American Heart Association.
2. Abella Bs, Sandbo N, Vassilatos P, Alvarado Jp, O’Hearn N, Wigder HN, Hoffman P, Tynus K, Vanden Hoek TL, Becker LB. Chest compression rates during cardiopulmonary resuscitation Are suboptimal a prospective study during in-hospital cardiac arrest Circulation 2005 Feb 1;111(4):428-34. UI: 15687130.
3. Kim J, Neilipovitz D, Cardinal P, and Chiu M. A comparison of global rating scale and checklist scores in the validation of an evaluation tool to assess performance in the resuscitation of critically ill patients during simulated emergencies (Abbreviated as “CRM Simulator Study IB”) Simulation in Healthcare: The Journal of The Society for Medical Simulation. Spring 2009 4(1):6-16. UI: 19212245.
1118 Using a Spatial Task to Measure Laparoscopic Mental Workload: Initial Results
Erik Prytz, MS4, Michael Montano, MS4, Rebecca Kennedy, MS4, Mark Scerbo, PhD4, Rebecca Britt, MD3, Stephen Davis, MD2, and Dimitrios Stefanidis, MD, PhD, FACS1
1SURGERY, CAROLINAS MEDICAL CENTER, CHARLOTTE, NC, USA and 2OBSTETRICS and GYNECOLOGY, EASTERN VIRGINIA MEDICAL SCHOOL, NORFOLK, VA, USA and 3SURGERY, EASTERN VIRGINIA MEDICAL SCHOOL, NORFOLK, VA, USA and 4PSYCHOLOGY, OLD DOMINION UNIVERSITY, NORFOLK, VA, USA
Introduction/Background: Performing laparoscopic surgery is more mentally demanding than traditional surgery in part because surgeons must operate in three-dimensional space while viewing a two-dimensional display. Consequently, laparoscopy places significant demands on visual attention and requires a great deal of practice to achieve proficiency. Presently, there is no standard method to measure the mental demands imposed by laparoscopic surgery. However, Stefanidis and his colleagues have used the secondary task technique to assess mental workload.1,2 According to Wickens’ multiple resource theory, pools of attentional resources are distinguished by three dimensions: processing stages (perceptual/cognitive and response), processing codes (verbal and spatial), and processing modalities (auditory and vision) with the visual processing modality separated into focal and peripheral channels.3 Two tasks that draw upon the same pool of resources can interfere with one another and increase mental workload. Thus, a secondary task that competes for the same resources as a primary task should be sensitive to differences in mental workload. A secondary spatial task was developed that requires the same visual processing needed for judging the position of objects on a laparoscopic display. Thus, our objective was to determine if the new secondary task could distinguish differences in mental workload associated with several different tasks in an FLS laparoscopic box trainer.
Methods: Sixteen undergraduate students with no prior laparoscopic experience were recruited to participate in this IRB approved study. They were asked to perform three primary tasks on a box trainer: 1) tracing the outlines of images on a computerized drawing tablet using a stylus attached to a laparoscopic instrument, 2) the FLS peg transfer task, and 3) the FLS cutting task. The secondary task presented observers with images of four balls in a simulated tunnel, superimposed at 50% transparency over the primary task display to ensure that both tasks were viewed with focal vision. The images were presented for 300 msec every 4 seconds. On half of the presentations, one ball changed its position and participants had to verbally identify those shifts in position. Participants performed the secondary task by itself and in conjunction with the primary tasks. The experiment used a within-subjects design with four task conditions: tracing task, peg transfer task, cutting task, and a baseline measure of the secondary task by itself.
Results: The percent correct responses on the secondary task were analyzed with a repeated measures ANOVA and showed a significant main effect, F(3, 45) = 41.285, p < .001, partial η2= .747. Bonferroni-corrected post hoc tests showed that percent correct scores on the secondary task were lower when performed in conjunction with the tracing task (M =80%, SE = 2.5%), p < .001, the peg transfer task (M = 72.4%, SE = 3.3%), p < .001, and the cutting task (M = 62%, SE = 3.3%), p < .001, compared to performing the secondary task alone (M = 92.7%, SE = 2.0%). Further, secondary task scores were significantly lower on cutting than the peg transfer task, p = .007.
Conclusion: The results show that the spatial secondary task was indeed sensitive to the mental workload associated with the laparoscopic tasks. Scores on the secondary task declined when performed in conjunction with each laparoscopic task. Further, secondary task performance with the cutting task was poorer than with the peg task, suggesting that the cutting task is much more mentally demanding. These initial results show that the secondary task can provide an objective index of mental workload that can complement traditional metrics of speed and accuracy on laparoscopic tasks. Future research will use this task to identify laparoscopic conditions that deprive surgeons of the spare attentional resources needed to multi-task effectively in the OR.
1. Stefanidis, D., Scerbo, M.W., Korndorffer, J. R. Jr., & Scott, D.J. (2007). Redefining simulator proficiency using automaticity theory. The American Journal of Surgery, 193, 502-506.
2. Stefanidis, D., Scerbo, M.W., Smith, W., Acker, C.E., & Montero, P.N. (2012). Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: A randomized controlled trial. Annals of Surgery, 255, 30-37.
3. Wickens, C. D. (2002). Multiple resources and performance prediction. Theoretical Issues in Ergonomic Science, 3, 159-177.
Disclosures: Mark Scerbo, PhD, receives grant support from SimQuest, LLC. Dimitrios Stefanidis, MD, PhD, FACS receives grant support from Ethicon Endosurgery, and is a consultant for Ethicon, Bard, and Gore.
1122 Simulated Ventricular Fibrillation in an Anesthetized Pediatric Patient
Nancy Tofil, MD, MEd5, Collin King, MD, MPH2, Jennifer Dollar, MD3, Seth Jarrell, MS1, Jerri Zinkan, MPH, RN5, Amber Youngblood, BSN, RN4, Dawn Taylor Peterson, PhD, EdS, MEd5, and Marjorie Lee White, MD, MPPM, MEd5
1UNIVERSITY OF ALABAMA BIRMINGHAM, BIRMINGHAM, AL, USA and 2PEDIATRICS, UNIVERSITY OF ALABAMA BIRMINGHAM, BIRMINGHAM, AL, USA and 3ANESTHESIOLOGY, UNIVERSITY OF ALABAMA BIRMINGHAM, CHILDREN’S HOSPITAL OF ALABAMA, BIRMINGHAM, AL, USA and 4NURSING EDUCATION, UNIVERSITY OF ALABAMA BIRMINGHAM, CHILDREN’S HOSPITAL OF ALABAMA, BIRMINGHAM, AL, USA and 5PEDIATRIC SIMULATION CENTER, UNIVERSITY OF ALABAMA BIRMINGHAM, CHILDREN’S HOSPITAL OF ALABAMA, BIRMINGHAM, AL, USA
Introduction/Background: Pediatric emergencies in anesthesia are rare, and therefore exposure to these critical events depends on the residency program.1 In the operating room, anesthesia residents are designated as the leader when a pediatric patient goes into cardiac arrest.2 Literature shows that simulation of critical intraoperative events improves performance of anesthesia residents in the attainment of event specific skills.3 The purpose of this study was to evaluate time to recognition of cardiac arrest in a pediatric prone patient and to expose all learners to the difficulties of managing emergencies in prone patients.
Methods: Simulation sessions were designed for anesthesia residents and were conducted monthly for a total of 13 months. Each team, consisting of one or two anesthesia residents, participated in a scripted scenario in which a patient undergoing posterior spinal fusion surgery experiences decreased blood pressure, metabolic acidosis, hypothermia, and hyperkalemia from blood products. The patient was prone due to the nature of the procedure, and hyperkalemia resulted in ventricular fibrillation three minutes into the case. The simulation sessions were viewed by simulation staff, and times to critical events were recorded for each team. The teams were debriefed with a script and checklist of expected actions after each case to improve consistency. Evaluation questions were designed using a Likert scale and were filled out by each participant.
Results: Thirteen groups totaling 24 anesthesia residents participated in this study. Eleven of the 13 groups consisted of pairs and the remaining two groups consisted of individual participants. Table 1 shows the number of groups which completed each action and the time to events from the beginning of ventricular fibrillation.
Although the average time to recognize ventricular fibrillation was one minute and 15 seconds, defibrillation was not requested for another 40 seconds. Only five out of the 13 groups (38%) recognized hyperkalemia as the cause of the arrest. Ten out of the 13 groups (76%) ordered an arterial blood gas showing hyperkalemia and only 31% of these gave calcium. The learning themes most commonly mentioned by the participants involved debriefing (n=9), practice of rare but critical events (n=7), and teamwork (n=3). Participants’ combined course satisfaction scores were 4.96 out of 5 regarding the quality and content of the course. Individual participants noted that the course was a helpful learning experience, and that they would recommend this course to others. Participants’ combined scores regarding their ability to apply the concepts, knowledge, and skills learned compared to other clinical experiences were 4.92 out of 5. Recommendations for improvement included adding more simulation cases to the anesthesia curriculum.
Conclusion: Pediatric dysrhythmias are rare. Thus, anesthesia residents should consider hyperkalemia in an intraoperative arrest, and aggressive treatment must be initiated. Based on the results of our study, the average time to recognition of ventricular fibrillation was one minute and 15 seconds with only 38% of the groups recognizing hyperkalemia as the cause. Therefore time to defibrillation and recognition of hyperkalemia by anesthesia residents could be improved. Exposure to multiple critical events through simulation is an effective and safe means of providing anesthesia residents with the skills needed to respond effectively in these rare events.
1. Fehr JJ, Boulet JR, Waldrop WB. Simulation-based assessment of pediatric anesthesia skills. ANESTHESIOLOGY. 2011 Dec;115(6):1308-15. PubMed PMID: 22037637.
2. Howard-Quijano KJ, Stiegler MA, Huang YM. Anesthesiology residents’ performance of pediatric resuscitation during a simulated hyperkalemic cardiac arrest. ANESTHESIOLOGY. 2010 Apr;112(4):993-7. PubMed PMID: 20234308.
3. Park CS, Rochlen LR, Yaghmour E. Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training. ANESTHESIOLOGY. 2010 Jan;112(1):202-11. PubMed PMID: 20010420.
1162 Interdisciplinary Team Training Leads to a Successful Management of a Rare Obstetric Emergency
David Marzano, MD1, and Pamela Andreatta, PhD2
1OBSETRICS and GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS and GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA
Introduction/Background: Simulated interdisciplinary team training fulfills several goals: contextual aspects, repetition, and the ability to analyze performance. Several challenges to using simulation include: participant buy-in, time constraints that conflict from the different disciplines involved, and most importantly the lack of evidence of the transfer of abilities to applied practice. We present a case of a rare obstetric emergency, AIDP/Guillain Barre, that demonstrates the transfer of competencies from a simulation based training program that led to the successful interdisciplinary management of an actual clinical emergency.
Methods: Evaluate the transfer of abilities acquired through a prescribed interdisciplinary simulation-based training program targeting the management of Obstetric emergencies. We ran weekly, 2-hour, training sessions, drawing on 14 case scenarios comprised of emergency events with pregnant patient and neonate. Web portal was designed that included references, pre/post-tests. Participants included faculty, residents, nurses and ancillary staff (such as social work) from the four disciplines (Obstetrics, Emergency Medicine, Anesthesia, and Neonatology). Transfer of program acquired abilities to applied clinical performance assessed by tracking institutional clinical data using case logs and health system quality data. In identified cases, details collected included case specifics, clinical team members and whether they had participated in the OBEMAN training program. The training case was as follows: a 34 year old G2P1, 28 weeks, presents to ED, shortness of breath, stating that she “can’t get enough air,” worse with exertion. Her pregnancy uncomplicated, routine prenatal care, ROS negative The clinical objectives were as follows: acknowledges physiologic changes and challenges of pregnant patient; generates accurate DDx: Pulmonary embolism, Asthma, Pneumonia; initiates appropriate resuscitative effort. The team factors were as follows: demonstrates uses of the Birth Center Paging System, Team-leadership, Emergency communication skills (e.g., Call out/Check Back, Call for help when needed: Anesthesia, Obstetrics, Pediatrics).
Results: The clinical case presented as follows: A 25 year-old pregnant patient, admitted at 23+5-wks gestation, shortness of breath, numbness feet/hand/face; PMHx: negative; PSHx: negative; medications: prenatal vitamins; All: NKDA; POBHx: negative; PGYNHx: negative. The patient was diagnosed w/ acute inflammatory demyelinating polyneuropathy (AIDP/Guillain–Barré) and transferred to neurology service. The Obstetric team followed with close monitoring. She was discharged to acute rehabilitation floor at 26+4-weeks gestation. On day 28, she acutely aspirated. The code team was called to the unit. Attempts to re-establish an airway failed. Several hospitalists at bedside (who had not completed the program) determined the patient needed to be intubated. Following intubation, the patient experienced ventricular tachycardia and proceeded to full cardiopulmonary arrest. The second-year (PGY2) obstetric resident was paged, she correctly paged Obstetric & Neonatal emergency team (All OBEMAN trained) explicitly requested surgical instruments and neonatal resuscitation supplies. The Chief Obstetric resident and Neonatal staff arrived with instruments and supplies within 5 minutes. After 5 minutes with unsuccessful resuscitation, PGY2 performed emergency Caesarean delivery in patient’s room. The patient and her infant were successfully resuscitated, and subsequently discharged to home. The morbidity and mortality report indentified the following qualitative comments: “OBEMAN trained team members applied the following: Correct clinical intervention protocol, Activated both Birth Center & Code Team pagers, specified team members to bring required supplies, demonstrated situational awareness of resources on Rehabilitation floor, and delivered of infant after 5 minutes failed ACLS.” Specifically, both participating residents cited their OBEMAN training as giving them the confidence to proceed, despite un-trained supervising fellow unsure of required action. Untrained team members commented on quick action and calmness of the two obstetrical residents who led the code.
Conclusion: This AIDP/Guillain–Barré case recounts the results of a rare Obstetric incident where the transfer of competencies gained from simulation-based training led to successful interdisciplinary management of an actual clinical emergency. Although this was not a specific case practiced during program sessions, it demonstrates that participants were able to use lessons learned during their training and applied them to a different clinical situation: transfer of learning to applied clinical practice. Although there were favorable outcomes for the two patients, it could have gone the other way despite correct clinical and patient management.
1164 Breaking Down Barriers: A Simulation-based Course Designed to Improve Perioperative Handoff Communication
Erin Pukenas, MD1, Amanda Burden, MD1, Edward Deal, DO1, and Irwin Gratz, DO1
1ANESTHESIOLOGY, ROWAN UNIVERSITY, COOPER MEDICAL SCHOOL, CAMDEN, NJ, USA
Introduction/Background: The increased frequency of patient handoffs is an inevitable consequence of resident duty hour restrictions.1 Perioperative handoff communication is cited as a major source of medical error. Recent literature reveals that poor or inadequate patient handoffs were present in up to 43% of surgical malpractice cases involving communication failure.2 Several barriers to effective handoff communication have been identified among physicians including: physical environment, social and professional setting, hierarchy/status issues, cultural barriers, and communication medium limitations.3 Meta-analysis of current handoff literature identified patient complexity and lack of time as additional communication barriers.4 We instituted a one-day, simulation-based handoff course (SBHC) in an effort to identify and address these barriers. We described the results of this one-day SBHC at one year post-integration into an anesthesiology residency curriculum.
Methods: Ten anesthesiology residents (CA 1-3) were enrolled in this IRB-approved study. Each subject completed a pre-test, read a patient stem, and received a simulated hand-off. Another anesthesiologist arrived at the conclusion of the case to obtain report from the subject. Debriefing and didactic sessions followed the handoffs; a post-test and course evaluation were then completed by each subject. Key items addressed in the debriefing were limitations to effective handoff communication in the trainees’ daily practices. One year later, the residents returned to the simulation laboratory for assessment and participation in a simulated handoff. Debriefing focused on communication barriers and strategies employed to overcome them.
Results: Nearly 62% of subjects originally stated that others were not receptive to their handoff efforts and nearly 54% stated that there are too many time pressures to give effective handoffs. In the one-year follow-up debriefing session, 100% of residents who listed poor receivership as a barrier and 80% of those who listed time pressure indicated they had changed their handoff practice. Strategies to overcome receivership barriers included being more assertive, refusing to transfer care unless the receiver accepted a complete handoff, and concisely organizing their handoffs. Strategies to overcome time pressures included preparing the handoff in advance and having the anesthesia record available during the handoff.
Conclusion: Through this simulation-based handoff course, anesthesiology residents identified barriers to effective perioperative handoff communications processes. One year follow-up demonstrated practice changes among the course participants. Efforts to improve the current handoff communication culture within our perioperative environment are ongoing. This approach may be useful to other institutions in identifying strategies to improve perioperative handoff communication.
1. Greenburg, C.C. Patterns of Communication Breakdowns resulting in Injury to Surgical Patients. J Am Coll Surg 2007; 204(4):533-40 Pubmed PMID:17382211.
2. Kalkman, C. Handover in the perioperative care process.Curr Op Anaesth 2010; 23(6):749-753. Pubmed PMID: 21037475.
3. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005; 80:1094 -1099 Pubmed PMID: 16306279.
4. Riesenberg, L, et al. Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature. Acad Med 2009; 84:1775-1787. Pubmed PMID: 19940588.
1168 Low-hanging Fruit: Using Clementines for Laparoscopic Surgery Training in Gynecological Oncology
Pamela Andreatta, PhD2, and David Marzano, MD1
1OBSETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA
Introduction/Background: Laparoscopic surgical skills require significant practice to master due to multiple inherent factors that complicate visualization and instrument control in the operative space.1-2 Indirect visualization of the three-dimensional operative field that is presented as a two-dimensional image on a monitor has been shown to have a steep learning curve that is more easily attained using simulation-based training.3-4 The long laparoscopic instruments introduce a fulcrum effect and limit tactility between the surgeon and tissue, both of which must also be conquered before any operative laparoscopic procedure can be accomplished.5,6 These factors are all the more critical for gynecologic oncology surgery, where delicacy and instrumental mastery must be achieved in order to perform the fine, precise dissection skills required for removing tumors and metastases from vital organs, vessels and nerves.7 Oncology procedures also require significant pre-operative planning and intra-operative critical decision-making to assure that as much of the cancerous tissue can be removed, with minimal damage to normal tissues.8 At present, most laparoscopic simulation models address less complicated procedures such as laparoscopic cholecystectomy, inguinal hernia repair and tubal ligation (among others). There currently are no models designed to address the challenges associated with gynecologic laparoscopic surgical oncology.
Methods: Ethics Review Committee approval was secured for this study. We asked residents/fellows to remove the peel of a Clementine in as few pieces as possible, separate and remove all pith from and between all fruit segments, and return the Clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision-making included deciding when to complete the procedure “open” or when unacceptable segment damage would result by removing difficult to extract pith. The analogy corresponds to deciding when to leave cancerous lesions or metastases in place to be treated through other methods (radiation, chemo, etc.), rather than risking damage to the vital organs or other healthy tissues. Faculty, blinded to the training status of the subjects, assessed their video-recorded performance using a rating scale, in addition to noted objective performance measures.
Results: Scores Performed by Experience Levels
Factor Analysis using principal component analysis with no rotation and an Eigen value of 1 confirmed a single scoring construct (operative performance) with loadings from .714 to .951, and a 2-factor component matrix indicating two scoring dimensions (clinical reasoning and surgical skills). Factor loadings for surgical skills ranged from .835 to .936 accounting for 71.29% of score variance. The factor loading for clinical reasoning (.934) accounted for 10.63% of score variance. There were significant differences between the groups for the identified performance parameters of interest; F(2,39) = 59.18 p<0.001. MIS specialists and surgeons who operated at least one time per week performed significantly better than others on all parameters (p<.001). There were no significant differences between residents and gynecologists who operated less than one time per week, but both of those groups performed significantly better than novices (p<.001). These data are presented in Table 3. There were no statistical differences between the groups for completion time. These data are presented in Table 3.
Conclusion: A low-cost, easily facilitated simulation-based model for developing advanced laparoscopic surgical skills may advance the preparation of residents and fellows for gynecological oncology practice, providing a platform for development/maintenance of skills, critical thinking and clinical judgment. This model could also provide an option for laparoscopic skill development in low and limited resource environments globally.
1. Blavier A, Gaudissart Q, Cadiere G, Nyssen A. Comparison of learning curves and skill transfer between classical and robotic laparoscopy according to the viewing conditions: Implications for training. Am J Surg. 2007;194:115-21.
2. Van Sickle KR, Gallagher AG, Smith CD. The effect of escalating feedback on the acquisition of psychomotor skills for laparoscopy. Surg Endosc. 2007; 21(2): 220-224. DOI: 10.1007/s00464-005-0847-5.
3. Maithel SK, Villegas L, Stylopoulos N, Dawson S, Jones DB. Simulated laparoscopy using a head-mounted display vs traditional video monitor. Surg Endosc. 2005;19:406-11.
4. Emam TA, Hanna G, Cuschieri. Ergonomic principles of task alignment, visual display and direction of execution of laparoscopic bowel suturing. Surg Endosc. 2002;16:267-71].
5. Berguer R, Forkey DL, Smith WD. Ergonomic problems associated with laparoscopic surgery. Surg Endosc. 1999;13:466-8.
6. Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg. 1989;210:118-21.
7. Theororidis TD, Bontis JN. Laparoscopy and oncology: Where do we stand today? Annals of the New York Academy of Sciences. 2003; 997: 282–291. doi: 10.1196/annals.1290.032.
8. Kehoe SM, Ramirez PT, Abu-Rustum NR. Innovative laparoscopic surgery in gynecologic oncology. Current Oncology Reports. 2007; 9:472–477.
1171 Sticky Situations: Using Foam Stickers for Precision and Tissue Handling in Laparoscopic Training & Assessment
Pamela Andreatta, PhD2, and David Marzano, MD1
1OBSETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA
Introduction/Background: Low-cost laparoscopic surgery models that provide objective feedback about performance precision and tissue damage are not currently available. Current training models focus on factors such as time, haptecs, and completion of task. Other factors such as tissue handling, damage to tissue, and accuracy are as important if not more important than time. Our objective was to design a model for developing precise and respectful laparoscopic tissue handling skills with accompanying objective assessment measures.
Methods: Ethics Review Committee approval was secured for this study. We asked novices through expert laparoscopists to complete a series of exercises requiring fine precision and tissue handling in the placement of small foam stickers of varying size and shape (circles, squares, stars, triangles, hearts) on templates of varying density and complexity. The foam pieces were required to align exactly and undamaged within the template, and placed permanently on the template after removing the sticky-backing. All exercises were required to be completed within 20 minutes. Objective measures included the degree of offset for each piece on the template, the amount of damage apparent on each piece, the total time required to complete the exercise, and the total number of accurately placed pieces (at least one part of the piece within the correct template space). Three faculty, blinded to the identity of the subjects, scored all templates.
Results: There were significant performance differences between and across the levels of expertise on all performance parameters (p<0.05). Time: tissue/damage: accuracy ratios were the best indicators of skill; however experience performing laparoscopy was not the primary indicator of skill level. The Inter-scorer reliability between the three independent scorers was 0.98 indicating the consistency of the objective measures. Examples of two exercises are included in Table 1.
Conclusion: Low-cost, easily facilitated models using foam stickers for developing laparoscopic surgical precision and tissue handling skills may provide an affordable and portable training option without sacrificing objective performance measures, and may provide more objective evidence for assessment and evaluation than current methods of evaluation. These models also provide an option for laparoscopic skill development in low and limited resource environments globally.
1176 Simulation-augmented Education in the Rehabilitation Professions: A Scoping Review
Euson Yeung, BScPT, MEd, PhD (c)1, Adam Dubrowski, PhD2, and Heather Carnahan, PhD3
1PHYSICAL THERAPY, UNIVERSITY OF TORONTO, TORONTO, ON, CAN and 2THE WILSON CENTRE, SICKKIDS LEARNING INSTITUTE, UNIVERSITY OF TORONTO, HOSPITAL FOR SICK CHILDREN, TORONTO, ON, CAN and 3CENTRE FOR AMBULATORY CARE EDUCATION, WOMEN’S HEALTH HOSPITAL, TORONTO, ON, CAN
Introduction/Background: Simulation-augmented education is playing an increasingly important role in the development and assessment of health professionals.1 More and more, simulation-augmented strategies are shaping educational practice, policy and research in medicine and nursing,2-6 and its impact, in undergraduate training through to continuing education, has been reported in the literature.7-9 The benefits associated with simulation-augmented education are, however, context specific9; thus, the capacity for simulation to yield similar benefits in other health professions, such as the rehabilitation professions, remains unknown. It is, therefore, difficult to determine how these educational approaches can inform education practice, policy and research in the rehabilitation professions. The purpose of this review was to determine what is currently known about the use of simulation in the education of rehabilitation professionals and to identify research gaps.
Methods: We conducted a scoping review that included a literature review of published literature within relevant databases and the grey literature. Two authors independently reviewed the abstracts of the unique references against pre-determined inclusion criteria and met after reviewing a portion of these references to ensure that the criteria sufficiently met our study objectives. After the remainder of the abstracts was reviewed, the two authors met again to discuss any discrepancies in each of their included list of references until consensus was reached. Data from the included references were extracted and analyzed by one author. For each of the included articles we recorded information regarding author, year and location of study, intervention type and comparator (if any), duration of the intervention, study populations, aims of the study, methodology, outcome measures, important results, and key research priorities. We collated and summarized the data to describe the extent, range and nature of simulation-augmented education in rehabilitation as well as the gaps in the existing literature. A program evaluation framework was employed to structure data extraction and analysis.10
Results: Our search of relevant databases yielded 1429 abstracts of which 1229 were unique. Eighty-five of the unique abstracts fit the inclusion criteria and were retrieved for full review. Searching the reference lists of included articles and relevant conference proceedings produced an additional 7 and 3 abstracts respectively, while searching the grey literature did not yield any additional abstracts or reports. Upon full review, 35 references were found to address the purpose of this scoping review and underwent data extraction. We found that several forms of simulation are commonly used among rehabilitation professions for expertise development, formative and summative evaluations, and for enhancing course work and curricula. However, there is a lack of published literature concerned with the longitudinal impact of simulation-augmented educational strategies, the perspectives of accrediting bodies, and the processes that lead to successful or unsuccessful educational interventions.
Conclusion: This is the first synthesis of what is currently known about simulation-augmented education in the rehabilitation professions. To date, research has primarily focused on studies of effectiveness and on the role that simulation-augmented interventions play in assessment. While these are important investigations, more longitudinal and process-oriented studies are urgently needed so that research results can be generalized to other learner populations and be better linked to patient outcomes. This will assist stakeholders, including learners, program directors, policy makers, and potential funders to value simulation as a significant learning and assessment tool in rehabilitation education. For education program developers, the use of an evaluation model will be useful for framing future studies to examine how simulation can enhance learning experiences in the rehabilitation professions, particularly in regards to curricular processes. Licensing and accrediting bodies in the rehabilitation professions should consider publishing educational criteria or standards related to simulation-augmented interventions to inform future design of educational programs and research studies.
1. Reznick RK, MacRae H. Teaching surgical skills – changes in the wind. Med Educ. 2006; 355:2664-2669.
2. Bradley P. The history of simulation in medical education and possible future directions. Med Educ. 2006; 40:254-262.
3. Issenberg SB, McGaghie WC, Hart IR et al. Simulation technology for health care professional skills traning and assessment. J Amer Med Assoc. 1999;282(2):861-866.
4. Ravert P. An integrative review of computer-based simulation in the education process. Computers, Informatics, Nursing. 2002; 20(5):203-208.
5. Scalese RJ, ObesoVT, Issenberg SB. Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med. 2007; 23(suppl.1):46-9.
6. Maran NJ and Glavin RJ. Low- to high-fidelity simulation – a continuum of medical education? Med Educ. 2003; 37(suppl.1):22-28.
7. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005; 27(1):10-28.
8. Brydges R, Carnahan H, Rose D, Rose L, Dubrowski A. Coordinating progressive levels of simulation fidelity to maximize educational benefit. Acad Med. 2010; 85(5):806-812.
9. Lane JL, Slavin S, Ziv A. Simulation in medical education: a review. Simulat Gaming. 2001; 32(3):297-314.
10. Alkin, M.C.&Christie, C.A.(2004). The evaluation theory tree. In Alkin, M.C. (ed.), Evaluation Roots: Tracing Theorists’ Views and Influences. Chapter 2. London: Sage Publications.
1178 Is Simulation-Based Education Effective in Improving Nurse Preceptor Confidence in Providing Effective Feedback to Orientees? A Pilot Study
Sherry Chesak, MS2, Monica Farnsworth1
1MULTIDISCIPLINARY SIMULATION CENTER, MAYO CLINIC, ROCHESTER, MN, USA and 2SIMULATION CENTER, MAYO CLINIC, ROCHESTER, MN, USA
Introduction/Background: The ability to provide effective feedback is an essential skill for nurse preceptors.1 However, competence in this skill is not necessarily intuitive, and the level of expertise can vary greatly from one preceptor to another. Lack of providing effective feedback can lead to orientees’ repeated poor performances, which can have significant negative impacts on patient care as well as colleague interactions.1 It is not clear if simulation-based educational strategies are effective in improving nurse preceptors’ confidence in their ability to provide feedback to orientees, or what the most significant barriers are to implementing the skill successfully. The aims of this study were to: 1)compare critical care preceptors’ confidence levels in providing feedback before and after participating in a simulation-based education session using a five-item confidence scale, and 2) identify critical care preceptors’ perceived barriers to developing and implementing effective feedback skills. The hypothesis for the first aim is: critical care nurse preceptors’ confidence levels in providing feedback to orientees will significantly improve both immediately following a simulation-based educational intervention, and 4 months following the intervention. The results of this study will impact healthcare simulation by providing substantiation for the investment of institutional resources in this form of education for similar populations of healthcare providers, a domain in which there is currently limited knowledge. In addition, identifying barriers to developing and implementing effective feedback skills will assist in the development of future curriculum, aimed specifically at key obstacles.
Methods: This IRB approved study occurred at a large Midwestern educational healthcare institution.The intervention included 13 nurse preceptors who participated in intensive care based simulation scenarios with actors playing the roles of orientees who demonstrated challenging behaviors. The nurse learners provided feedback to the actors following the interaction. Subsequent to each scenario, the learners participated in a debriefing session, which was facilitated by masters prepared nurse educators. A pre-test/post-test design was employed to examine preceptors’ confidence levels in providing effective feedback. A post-test occurred immediately following the experience and a late post-test was administered four months following the intervention, at which point it was expected that the preceptors would have had the opportunity to employ feedback skills in the clinical setting. Changes in confidence levels from pre to post, from pre to late post, and from post to late post were evaluated using paired t-tests. A short answer questionnaire gathered qualitative information on the participants’ perceived barriers to developing and implementing effective feedback skills. Qualitative analysis was performed through identification of themes and categorization of results.
Results: Confidence levels increased significantly for questions 1 (p=.003), 3 (p=.017), 4 (p=.011), and 5 (p=.028) on the five-item scale from the pre to post assessments. Confidence levels for all questions increased significantly from the pre to the late post assessments (p=.002, .031, .026, .007, .031). There were additional statistically significant increases in confidence for questions 1 (p=.013) and 4 (p=.040) from the post to the late post assessments. Themes, which emerged regarding barriers to developing and implementing effective feedback skills, include lack of education, inadequate experience, fear of damaging the preceptor-orientee relationship, and not wanting to appear critical.
Conclusion: Simulation-based education was effective in improving critical care nurse preceptors’ confidence in providing feedback to orientees. This educational methodology should continue to be employed with this population, and larger scale studies are warranted in an attempt to replicate the results. Future curriculum content should focus on the themes identified by the preceptors as barriers to providing feedback to orientees.
1. Cantillon, P, Sargeant, J. Giving feedback in clinical settings. BMJ. 2008 Nov 10; 337:1292- 1294. doi: 10.1136/bmj.a1961.
1179 Comprehensive Program Evaluation of an Interdisciplinary Program for Managing Obstetric Emergencies
Pamela Andreatta, PhD2 and, David Marzano, MD1
1OBSETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF MICHIGAN, ANN ARBOR, MI, USA
Introduction/Background: Stress affects human performance and decision-making, and the degree of stress experienced by physicians during emergency situations has the potential to limit their effectiveness as both clinicians and team leaders. The purpose of this study was to assess the stress levels of clinical team members (leaders and non-leaders) during the management of Obstetric Emergencies.
Methods: A sample of 68 physicians, residents and nurses from Obstetrics, Emergency Medicine, Anesthesia and Neonatology participated in simulation-based drills to manage Obstetric Emergency cases as interdisciplinary teams. A total of 58 cases were included in the drills, with low, moderate or high variable difficulty ratings. Baseline, peak and mean heart rates were captured during the drills for each team member. Stress level was calculated for heart rate differentials and sustained elevations during the case. Case difficulty and team-leader status were considered in the analysis of variance. Direct measurement of clinical performance related to stress level was not measured for this study because we did not know whether or when stress responses were in effect.
Results: Mean heart rates across all cases were 81.01 (28.39) bpm for team leaders and 59.26 (18.77) bpm for non-leaders. There were significant differences between the stress levels of team leaders and non-team leaders for baseline-peak differential (p=.001), as well as sustained elevated heart rate (p=.001) across all cases. Both team leaders and non-team leaders had significant increased stress (p=.028) and sustained stress (p=.002) with increased case difficulty. Team leaders had significantly greater sustained stress (p=.004) compared to non-team leaders for all cases.
Conclusion: The results of this study demonstrated that it is possible to measure stress experienced by clinicians during simulation drills; and that although stress is experienced by all team members, team leaders have both significantly greater stress and sustained stress during the team management of Obstetric emergencies. It also confirms that stress reactions are in effect during simulated drills. These findings suggest the value of simulation-based training for developing stress inoculation behaviors to gain optimal performance for all team members, but especially for team leaders during crises. Future studies will address direct measurement of clinical performance with increased stress levels.
1184 The Impact of Transdisciplinary Simulation on Interprofessional Collaborative Practice in Women’s Health
Kymberlee Montgomery, DrNP, CRNP, BC1, Nina Multak, MPAS, PA-C3, Catherine Morse, MSN, CRNP, BC1, and Sharon Griswold-Theodorson, MD, MPH2
1NURSING, DREXEL UNIVERSITY, PHILADELPHIA, PA, USA and 2EMERGENCY MEDICINE, DREXEL UNIVERSITY COLLEGE OF MEDICINE, PHILADELPHIA, PA, USA and 3PHYSICIAN ASSISTANT, DREXEL UNIVERSITY COLLEGE OF MEDICINE, PHILADELPHIA, PA, USA
Introduction/Background: Education of health professionals is shifting to a model which supports collaboration, communication and a team-based approach to the provision of healthcare.1 This educational shift, although slow at onset, is moving forward with an increased pace. Studies suggest that promoting a collaborative team approach, incorporating joint responsibility for care, fostering clear delineation of roles, and encouraging effective communication improves patient outcomes and satisfaction and reduces medical error related to health care system failure.1-3 The goal of this inter-professional educational experience was to evaluate improvements in collaborative attitudes and behaviors among undergraduate nursing, nurse practitioner, physician assistant and medical students/residents. The implementation of simulation based education was utilized to evaluate healthcare collaboration among students in order to support the provision of safe and efficient care to patients.
Methods: This study used a pretest–post-test comparative design to measure changes in collaborative attitudes among 282 students before and after a transdisciplinary simulation experience. Collaborative attitudes were measured by the Team Attitudes Questionnaire (TAQ). Data analysis consisted of descriptive analysis, paired t-tests, and post hoc item analysis. Findings suggest significant increases in collaborative attitudes for mutual support, leadership and communication but no significant increases in attitudes for situation monitoring from pretest to post-test. Women’s health scenarios were utilized and provided students opportunities to participate in cases using standardized patients, high fidelity simulators as well as hybrid scenarios. Cases were designed by participating faculty in the Colleges of Medicine and Nursing and Health Professions who partnered for this study, modeling teamwork and communication skills for an inter-professional learning environment.
Results: A total of 282 healthcare providers and students participated in the simulation cases. Of the students who participated, 0.35% (1) were medical students, 12.8% residents (36), 44% (124) undergraduate nursing students, 26.6% (75) were nurse practitioner students (including a nurse anesthetist student), and 16.31% (46) were physician assistant students. The age range of the students was 20 years to 57 years, with 17.0% (48) 22 years old, and 13.1% 23 years (37). Results from the Team Attitude Questionnaire (TAQ), Teamwork perceptions questionnaire, Collaborative Practice Scale, and Collaborative Satisfaction with Decisions made were analyzed by a series of paired t-tests comparing pretest and post-test results. The non-parametric sign rank tests were also generated as a means of validating the paired t-test results. The primary analyses were conducted on the composite variables. When statistical significance was found, post-hoc exploratory analyses were run on the individual items to better understand what was driving the significance. The TAQ was used to compare 5 dimensions of attitude toward interdisciplinary collaboration including structure, leadership, situation monitoring, mutual support, and communication. Findings suggest that there was a significant increase in communication (24.90 to 25.60, p<.0001), in structure (23.57 to 26.59, p <.0001) and in leadership (21.95 to 27.29, p <.0001); near significant increase in situation monitoring (26.04 to 26.54, p=.0600); and near significant decrease in mutual support (24.72 to 24.28, p =.0764) from pre-test to post-test.
Conclusion: There was a significant increase in structure, leadership, and communication, but no significant increases in mutual support, and situation monitoring from pretest to post-test. Transdisciplinary simulation experiences among women’s health students may enhance mutual support and communication and promote better patient outcomes. Future research should focus on mechanisms to facilitate further improvements in interprofessional nontechnical skills to further identify how they affect improved patient care.
1. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., et al. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet, 376 (9756), 1923-1958.
2. World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. Geneva: World Health Organization. Retrieved July 30, 2012 from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf.
3. King, H. B., Battles, J., Baker, D. P. Alonso, A., Salas, E., Webster, J., et al. (2008, July). TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. In Advances in Patient Safety: New Directions and Alternative Approaches. Volume 3. Performance and tools. (Pp. 5-20). AHRQ.
1185 The Quality of Cardiopulmonary Resuscitation Using Supraglottic Airways and Intraosseous Devices: A Simulation Trial
Dena Reiter, MD2, Christopher Strother, MD2 and Scott Weingart, MD1
1EMERGENCY CRITICAL CARE, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA and 2EMERGENCY MEDICINE, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: Our objective was to assess whether using interventions such as laryngeal mask airways (LMA) and intraosseous (IO) lines lead to improved resuscitation in a simulated cardiac arrest when compared to standard methods of endotracheal intubation (ETI) and central line placement.
Methods: Emergency Medicine residents at a single academic center were grouped into teams of four. Each team participated in two simulated ventricular fibrillation cardiac arrests using a high fidelity simulator. Peripheral IV access was unobtainable. Only ETI supplies and a central line kit were available in one case (control) and in the other case those supplies were replaced by an LMA and an EZ-IO drill kit (experimental). Groups were randomized to which set up they were given first. Data examined included time to airway placement, duration and success rate of airway placement, time to vascular access, time to defibrillation, and percent hands off time.
Results: Of the participants, 44 residents in 11 teams participated. Mean time to airway was shorter in the experimental group (122.8 seconds (s) vs. 265.6 s, p = 0.001). Mean duration of airway attempt was also shorter (7.6 s vs. 22.7 s, p = 0.002). Time to access was shorter in the experimental group (49.0 s vs. 194.6 s, p = <0.001). Time to defibrillation and percent hands off time did not significantly differ between the two groups.
Conclusion: Use of an LMA and an IO device led to significantly faster establishment of an airway and vascular access in a simulated cardiac arrest. The variation in devices did not affect time to defibrillation or percent hands off time.
1189 Influence of Simulation-based Practice on Emergency Care for Patients with Dyspnea on Learning Outcome in Nursing Students
Hea Kung Hur, PhD3, Hyang Ok Choi, MS2, Ji Soo Jung, BS1, Hye Won Kang, MS1, and Gi Yon Kim, PhD3
1DEPT OF NURSING, WONJU, PRK and 2NURSING, WONJU, PRK and 3NURSING, YONSEI UNIVERSITY, WONJU COLLEGE OF MEDICINE, WONJU, PRK
Introduction/Background: Clinical simulation has become a valuable tool in the Korean nursing education. A critical step in adopting simulation-focused pedagogy in nursing education programs is determining how to integrate simulations into courses and curricula. Planning for clinical simulation should begin with identifying learning outcomes that are necessary for safe and competent nursing practice (Gaberson & Oermann, 2010). This study was conducted to evaluate (1) knowledge, critical thinking, and problem solving processes as cognitive learning outcomes, (2) self-confidence and learning attitudes as affective learning outcomes, and (3) self-reported clinical performance ability as a psychomotor learning outcome of simulation-based practice for emergency care of patients with dyspnea in Korean nursing students.
Methods: A one-group, pre-post experimental design including 28 junior nursing students of Y University in 2011 was used. Sample size was calculated using G*Power 3.1.3. The students participated in simulation-based practice, including academic lectures, simulation lab exercises, and debriefing, for 4.5 hours. The scenario was developed based on the algorithm for emergency care of patients with dyspnea (Kang & Hur, 2010). Debriefing followed the guidelines of Schneider Sarver and Senczakowicz (2010). For measurement of learning outcomes, a knowledge questionnaire (13 items) for emergency nursing care of dyspnea patients (Hur & Park, 2012) was used. A critical thinking questionnaire (15 items, 5-point Likert scale) developed by Hur and Park (2012) and a problem solving process questionnaire (7 items, 5-point Likert scale) developed by Kim and Chang (2011) were used. A self-confidence questionnaire (10 items, 10-point Likert scale) and a learning attitudes questionnaire (6 items, 5-point Likert scale), both developed by Ko et al. (2010), were used to evaluate affective learning outcomes. A self-reported clinical performance ability questionnaire (Hur & Park, 2012) was used to evaluate psychomotor learning outcomes (21 items, 6-point Likert scale). High values in all variables indicated a high level of each learning outcome. The Kolmogorov-Smirnov test was tested to test the variable distributions for normality. The paired t-test was used for data analysis, which was carried out using PASW 18.0.
Results: After the completion of simulation-based practice, all variables of cognitive, affective, and psychomotor learning outcomes were significantly increased posttest as compared to pretest (Table 1).
Conclusion: Simulation-based practice is an effective educational method that can be used to improve the cognitive, affective, and psychomotor learning outcomes of nursing students. Development of an instrument to assess student performance during simulated clinical experience is needed in the future. Even though this study had some limitations due to the testing effect and a small sample size, the results regarding simulation-based practice found in this study could be applied to improving current limited emergency care training for nursing students and enhancing students’ competency in clinical situations.
1. Gaberson KB, Oermann MH: Clinical teaching strategies in nursing, 3rd edition. NY, Springer Publishers, 2010, pp10-11.
2. Kang H, Hur HK: Development of a simulation scenario on emergency nursing care of dyspnea patients. Journal of Korean Critical Nursing 2010; 3: 59-74.
3. Scheider Sarver PA, Senczakowicz EA: Development of simulation scenarios for an adolescent patient with diabetic ketoacidosis. Journal of Nursing Education 2010; 49: 578-586.
4. Hur HK, Park SM: Effects of simulation based education for emergency care of patients with dyspnea on knowledge and performance confidence of nursing students. Journal of Korean Academy Society Nursing Education 2012; 18: 111-119.
5. Kim YH, Chang KS: Effects of a simulation-based education on cardio-pulmonary emergency care knowledge, clinical performance ability and problem solving process in new nurses. Journal of Korean Academy Nursing 2011; 41: 245-255.
6. Ko IS, Kim HS, Kim IS, Kim SS, Oh EG, Kim EJ, Lee JH, and Kang SW: Development of a scenario and evaluation for simulation learning of care for patients with asthma in emergency units. Journal of Korean Academy Fundamental Nursing 2011; 17: 371-381.
1203 Snapshots of the Road to Reflective Practice: What Advanced Simulation Instructors Think During a Master Class
Michaela Kolbe, PhD1, and Jenny Rudolph, PhD2
1MANAGEMENT, TECHNOLOGY, ECONOMICS, ETH ZURICH, ZURICH, CHE and 2CENTER FOR MEDICAL SIMULATION (CMS), HARVARD UNIVERSITY, CAMBRIDGE, MA, USA
Introduction/Background: While there is an increasing array of recommendations for what constitutes basic simulation instructor skills,1,2 not much is known about how they are learned and sustained effectively. The learning needs of intermediate and advanced simulation faculty trying to improve their debriefing skills are largely unexplored in the simulation education literature. Understanding what captivates or concerns them could help simulation faculty development programs target instructor candidates’ needs more accurately. Whereas formal evaluation of instructor curriculum by post hoc measures can be done in a rigorous way, such evaluation is often prohibitively resource-intensive. More importantly, these measures may not capture instructor candidates’ subjective experiences and the nuances of skill development evolution. This qualitative study reports on an effort to capture the preoccupations of instructor candidates as they moved through an advanced instructor skills development course.
Methods: Using a method called experience sampling,3 we longitudinally “biopsied” learners’ subjective experiences throughout the four-day Institute for Medical Simulation’s Graduate Course (www.harvardmedsim.org) using repeated, identical, two-minute free writing tasks for each learner (for a total of 512 measures). Brief, written reflections after each session (called “headlines”) were built into the course to systematically initiate thinking about learning. The specific query was: “What is the headline for what is on your mind right now?”. These headlines were analyzed for the purpose of this study applying an inductive process4 to identify evident constructs. Participants included 25 experienced instructor candidates and 10 course facilitators.
Results: We found that learners described their learning with seven processes among which we identified a variety of themes (). These themes included monitoring one’s learning process with respect to performance gaps and what one needs to have (e.g., “need help”) or do (e.g., “need to learn about research and assessment”) to close them and what helps for doing so (e.g., “practice and watching others practice helps me”). Another central group of themes involved reflections about the actual learning content: participants reported insights into the importance of concepts such as psychological safety, honesty, and frames for high-quality debriefings. Surprisingly, participants also formulated behavior rules around these themes (e.g., “don’t hesitate to make my point of view known”), some of which even included if-then relations (e.g., “when I don’t know: explore”). These insights, rules, and meta-evaluations occurred more often after experience-based learning sessions than after lectures or informal discussion rounds.
Conclusion: When engaged in experienced-based learning, simulation instructor candidates process the learning content and setting in many shades that go beyond mere opinions of whether or not they liked a particular exercise or tool. They actively think about how they learn and how they can learn better. Particularly after having personally practiced and reflected on a learning content, participants reported insights and developed action-rules for future performance. As such, brief written reflections during courses provide meaningful insights into what and how simulation instructors learn.
1. Rudolph JW, Simon FB, Raemer DB, Eppich WJ. Debriefing as formative assessment: Closing performance gaps in medical education. Acad Emerg Med 2008;15:1010-6.
2. McGaghie WC, Issenberg BS, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Medical Education 2010;44:50-63.
3. Larson R, Csikszentmihalyi M. The experience sampling method. New Directions for Methodology of Social & Behavioral Science 1983;15:41-56.
4. Miles MB, Huberman AM. Qualitative data analysis. Thousand Oaks, CA: Sage; 1994.
1220 Self-efficacy in an Interprofessional Postgraduate Education Programme: A Cross-sectional Study
Colm Watters, MB BCh BAO, MCEM3, Nicola Morgan, MBChB3, Libby Thomas, BMedSci, BMBS4, Rhodri Thomas, MB BS1, Alastair Ross, PhD2, Peter Jaye, BSc, MBBS, FCEM3, and Claire McHale, MB ChB3
1GENERAL INTERNAL MEDICINE, KING’S COLLEGE LONDON, KING’S HEALTH PARTNERS, LONDON, GBR and 2MANAGEMENT, KING’S COLLEGE LONDON, KING’S HEALTH PARTNERS, LONDON, GBR and 3SIMULATION AND INTERACTIVE LEARNING (SaIL) CENTRE, KING’S COLLEGE LONDON, KING’S HEALTH PARTNERS, LONDON, GBR and 4SIMULATION AND INTERACTIVE LEARNING (SAIL) CENTRE, SAINT THOMAS’ HOSPITAL, LONDON, UK, GBR
Introduction/Background: Interprofessionalism and collaborative practices have been climbing the healthcare agenda over the past fifty years and numerous organisations have heralded its coming, most notably WHO1 and CAIPE.2 In order to promote interprofessionalism within our current and future healthcare workforce, we should educate in a similar manner. 3–5 However robust evidence is lacking for Interprofessional Education (IPE) as highlighted by the Cochrane6 and BEME3 reviews. Recent reviews and publications have called for strengthening of the research agenda for IPE.7-9 Simulation is widely utilised to promote IPE in which learners from different professions are brought together to ‘learn with, from, and about each other’.2 To contribute to this agenda, differences between IPE and Uni-professional (UP) Education were examined to determine if there was something in the nature of the inter-professional interaction that enhances the learning for all involved.
Methods: We looked at an educational episode within the first and second years of doctors’ and nurses’ postgraduate experience. Each course was a high fidelity simulation day in which learners participated in five clinical scenarios and one communication scenario. 399 learners across 3 hospitals participated over 3 years. Cohorts consisted of either doctors only (n=94; foundation year (FY) one and two) and nurses only (n=177; first year postgraduate preceptorship nurses including midwives). The combined cohort (n=128) consisted of a mixture of these groups. After each simulation a facilitated debriefing took place in which the main focus of learning was on non-technical skills. Learners completed pre- and post- course questionnaires consisting of open and closed questions. Self-efficacy in the domains of management of emergency situations, leadership, inter-professional communication and team work were measured.
Results: Overall, IP training led to increased post-course self-efficacy when compared to UP. This difference was significant for one domain ‘communicate useful information effectively with colleagues,’ (82% vs 78%; t=2.7, p<0.01). A subset of 187 participants (70% Nursing and Midwifery, 30% FY doctors) were measured both before and after the course for evidence of improvements in self-efficacy. A significant positive shift (63%, SD 14.6 vs 77%, SD 12.3, p=<0.001) was revealed which was higher in the nursing/midwifery cohort (t=4.5, df 185, p<0.001). Overall self-efficacy was higher in the IP group (14% points) than UP group (12% points) but not significantly so (t=0.9, df 185,NS) following the course. An exploratory factor analysis of post course scores shows a two-factor solution (74% variance); namely leadership/management and communication/teamwork). There were significant improvements on both dimensions for both doctors and midwives, with the biggest shift being 21% for nurses on leadership/management. Thematic analysis of open responses aligned with three primary themes: communication, leadership and teamwork which triangulate with the quantitative findings.
Conclusion: Simulation training improved self-efficacy for all learners regardless of clinical background. IP education within a simulation setting provides a different focus of learning when compared to that delivered uniprofessionally, and suggests a richer experience for all learners involved. We conclude that IPE enhances the learning by providing a broader range of non-technical skills discussion, which we believe will foster greater interprofessionalism and collaborative practices and thus lead to improved patient safety and health outcomes. Based on our findings we suggest that if non-technical skills are to be the main focus of learning, then it should be delivered within an interprofessional setting.
1. World Health Organisation. Learning together to work together for health. Report of a WHO study group on Multiprofessional Education for health personnel: the Team Approach. Geneva: WHO; 1998 World Health Organisation Technical Report Series no 769.
2. Centre for Advancement of Interprofessional Education. The definition and principles of interprofessional education Internet. CAIPE UK; 2002 cited 10th April 2012. Available from http://www.caipe.org.uk/about-us/the-definition-and-principles-of-interprofessional-education/:
3. Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional education. Med Teach. 2007;29:735-51.
4. Bristol Royal Infirmary Inquiry. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. Bristol Royal Infirmary 2001. Available from: http://www.bristol-inquiry.org.uk
5. General Medical Council. Tomorrows Doctors: Outcomes and Standards for Undergraduate Medical Education Online. GMC 2009. Available: http://www.gmc-uk.org/static/documents/content/TomorrowsDoctors_2009.pdf Accessed 17th April 2012.
6. Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD002213. DOI: 10.1002/14651858.CD002213.pub2.
7. Thistlethwaite J. Interprofessional education: a review of context, learning and the research agenda. Med Educ. 2012; 46(1):58-70.
8. Begley CM. Developing interprofessional learning: Tactics, teamwork and talk. Nurse Educ Today. 2009 Apr;29(3):276-83.
9. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD000072. DOI: 10.1002/14651858.CD000072.pub2.
Disclosures: The Simulation and Interactive Learning (SaIL) receives grant support from Gaumard towards the support of research fellows and PhD students.
1230 Comparing No-Flow-Time During Endotracheal Intubation Versus Placement of a Laryngeal Mask Airway During a Simulated Cardiac Arrest Scenario
Vincent Miller, MD2, and Erin Flaherty, MD1
1UNIVERSITY OF VERMONT, BURLINGTON, VT, USA and 2ANESTHESIOLOGY, UNIVERSITY OF VERMONT, BURLINGTON, VT, USA
Introduction/Background: In 2010, the American Heart Association (AHA) released revisions of its Guidelines for Cardiopulmonary Resuscitation. The most notable AHA change is the basic life support sequence steps from “A-B-C” (Airway, Breathing, Chest Compressions) to “C-A-B” (Chest compressions, Airway, Breathing).1 Emphasis has been placed on adequate chest compressions and limiting the amount of no-flow-time (NFT) to 10 seconds or less. Regarding airway management, the guidelines stress that it is important that achievement of an advanced airway not significantly delay the administration of chest compressions or shocks. The guidelines endorse the use of supraglottic airway devices as an alternative to endotracheal intubation for advanced airway management during cardiopulmonary rescuscitation (CPR). Our study evaluates the efficacy of placing both laryngeal mask airways (LMA) and endotracheal tubes (ET) in the midst of ongoing, adequate chest compressions, to eliminate or minimize NFT, by respiratory therapists during a simulated cardiac arrest scenario.
Methods: Forty-one respiratory therapists at our academic hospital participated in this cross over trial. Following a standardized training and practice session covering endotracheal intubation via direct laryngoscopy and LMA placement, the airway managers were directed to place an advanced airway during a simulated cardiac arrest scenario. They were informed to attempt the airway management task during chest compressions and to ask for cessation of CPR only if absolutely necessary. Time to successful ventilation and no-flow times were measured.
Results: In the ET group, only one subject requested cessation of chest compressions during direct laryngoscopy for 2.3 seconds (p=0.175). There were no requested interruptions in chest compressions in the LMA group. The mean time for insertion of an ETT during adequate chest compressions was 49.2 seconds. The mean time for inserting an LMA during adequate chest compression was 31.6 seconds. Insertion of an LMA was significantly faster (p<0.001).
Conclusion: Respiratory therapists can successfully establish ventilation with an LMA and ETT without prolongng no-flow-times in a manikin during a simulated cardiopulmonary arrest. However, insertion of an LMA was significantly faster compared to endotracheal intubation.
1. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S640-S656.
1236 Simulation-based Training: Do Residents Think about Their Learning of Procedural Skills Using Simulation?
Ryan Brydges, PhD4, Maria Mylopoulos, PhD3, David Shanks, MD1, and Rose Hatala, MD, MSc2
1INTERNAL MEDICINE, UNIVERSITY OF BRITISH COLUMBIA, VANCOUVER, BC, CAN and 2MEDICINE, UNIVERSITY OF BRITISH COLUMBIA, VANCOUVER, BC, CAN and 3PEDIATRICS, UNIVERSITY OF TORONTO, TORONTO, ON, CAN and 4THE WILSON CENTRE, UNIVERSITY OF TORONTO, MICHENER INSTITUTE MEDICAL RADIATION SCIENCES, TORONTO, ON, CAN
Introduction/Background: Simulation-based training is ubiquitous in medical education, yet we do not fully understand how trainees conceptualize the learning process in this environment. Without evidence for how trainees think about their learning (i.e., employ metacognition), some training techniques may be working against rather than supporting trainees’ learning strategies. Here, we explored junior residents’ conceptions of self-regulated learning (SRL) during simulation-based training of lumbar puncture (LP) skills.
Methods: We randomly assigned 21 post-graduate year 1 internal medicine residents to self-regulate their learning using two versions of the same LP simulator (easy and difficult). We conducted two semi-structured interviews: (1) when participants transitioned from the easy to the difficult version of the simulator, and (2) when they decided to complete a final posttest. The interview questions focused participants on the processes and strategies they used to monitor their own learning, and how they made important learning decisions (e.g., when to transition between models, when to stop learning). Three researchers conducted a thematic analysis of the interview transcripts and came to consensus on emergent themes during several team meetings. One researcher applied the final thematic structure to the entire data set using NVivo qualitative software and two researchers ensured that the final coding was consistent with the agreed upon thematic structure.
Results: Three major themes emerged from our analysis. First, participants showed an astute awareness of the learning context by discussing both the limitations (e.g., simulator not representative of all patients) and affordances (e.g., ability to make mistakes) of simulation training. Second, participants identified connections they made between performance and confidence/comfort, including the feel of instruments, not forgetting the procedural steps, and getting the cerebrospinal fluid. Third, participants discussed conceptions of learning that were centered on task-specific strategies (e.g., repetitive practice), rather than metacognitive strategies (e.g., self-monitoring or self-questioning). Further, participants tended to focus on outcome goals (e.g. obtaining CSF fluid) rather than the processes that permit a successful outcome and when they did discuss process, they emphasized memorizing the steps.
Conclusion: From the lens of SRL theory, the relative absence of metacognitive strategies (a key component of SRL) and residents’ preferences for outcome goals (vs. process goals) suggests their conceptions of simulation-based learning may need refinement. Further, the focus on memorizing the steps rather than maintaining awareness of performance processes “in the moment” suggest trainees are applying strategies useful in other domains (e.g., MCQ exams) to their learning of procedures. According to SRL theory, educators may need to explicitly instruct trainees to avoid prioritizing outcome goals and to more closely monitor learning decisions during procedural training. The implications of such instructional practices should be evaluated before being incorporated into simulation training practices.
Disclosures: Ryan Brydges, PhD, receives a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.
1242 Intrauterine Fetal Resuscitation during the Second Stage of Labor Evaluated in a Physiological Simulation Model
Lauren Bullens, MD2, Beatrijs van der Hout, MSc1, Pieter van Runnard Heimel, MD, PhD2, and Guid Oei, MD, PhD2
1BIOMEDICAL ENGINEERING, EINDHOVEN UNIVERSITY OF TECHNOLOGY, EINDHOVEN, NLD and 2OBSTETRICS AND GYNECOLOGY, MAXIMA MEDICAL CENTER, VELDHOVEN, NLD
Introduction/Background: Fetal well-being is monitored during labor by the use of the cardiotocogram (CTG), which is the continuous registration of fetal heart rate (FHR) and uterine pressure. The CTG serves as the only continuous and noninvasive indication of fetal oxygenation. In case of nonreassuring FHR patterns, it is important to improve fetal condition and prevent fetal hypoxemia, acidosis and asphyxia. Variable decelerations are caused by impaired blood flow toward the fetus by compression of the uterine vessels and umbilical cord. Both pressure of the uterine wall and abdominal wall contribute to the intrauterine pressure. Studies have shown that intrauterine pressure increases from 25 to 55 mmHg during contractions. While bearing down, the pressure increases up to 160 mmHg by the use of abdominal muscles.1 Increase of intrauterine pressures causes an intermittent decrease in blood flow.2,3 If this reaches abnormal levels the fetus may become hypoxic and changes in FHR will occur. Several intrauterine resuscitation techniques may be applied in case of suspected fetal distress.4,5 We hypothesize that to interrupt pushing leads to intrauterine resuscitation of the fetus by improving placental blood flow.
Methods: We developed a mathematical model that simulates the CTG based on maternal cardiac output, maternal saturation and oxygen pressure, uterine pressure and blood flow, oxygen diffusion capacity in the placenta, fetal cerebral blood flow, fetal oxygen consumption, baroreceptor, chemoreceptor, vagal and sympathetic nerve response.6,7 In this model we simulated variable decelerations caused by compression of uterine and cord vessels. We simulated contractions with a maximum strength of 160 mmHg (when bearing down), and with 70 mmHg (without pushing). We focused on alterations in fetal heart rate and pO2 in the feto-placental circulation.
Results: When intrauterine pressure is reduced, the model shows a decrease in the duration of a deceleration from 55 to 30 seconds. The depth of a deceleration is decreased from 73 to 63 beats per minute. Fetal arterial pO2 is increased from 7 to 11 mmHg. The pO2 in the fetal microcirculation increases from 8 to 9 mmHg. In the placenta, oxygen pressures do not increase as much as during bearing down: in the intervillous space pO2 decreases from 66 to 54 mmHg (baseline is 43 mmHg), while in the villous capillaries pO2 decreases from 63 to 49 mmHg (baseline is 30 mmHg).
Conclusion: In our model, the depth and duration of decelerations decrease when intrauterine pressure is reduced. Also, fetal oxygen status improves when blood flow towards the fetus is increased. In conclusion, the model shows that stopping to push during the second stage of labor results in improvement of the fetal condition and may be a useful technique for intrauterine resuscitation. The model has added value as a clinical training tool. Moreover, the model may be useful to evaluate hypothesis arised from clinical practice.
1. Woodbury RA, Hamilton WF, Torpin R. The relationship between abdominal, uterine and arterial pressures during labor. AJP. 1938;121;640-49.
2. Janbu T, Nesheim BI. Uterine artery blood velocities during contractions in pregnancy and labour related to intrauterine pressure. Br J Obstet Gynaecol. 1987 Dec;94(12):1150-55.
3. Janbu T, Koss KS, Nesheim BI, Wesche J. Blood velocities in the uterine artery in humans during labour. Acta Physiol Scan. 1985 Jun;124(2):153-61.
4. Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstet Gynecol. 2005 Jun;105(6):1362-8.
5. Simpson KR, James DC. Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns. Am J Obstet Gynecol. 2008 Jul;199(1):34.e1-5.
6. van der Hout-van der Jagt MB, Oei SG, Bovendeerd PHM. A mathematical model for simulation of early decelerations in the cardiotocogram during labor. Med Eng Phys. 2012 Jun:34(5);579-89.
7. van der Hout-van der Jagt MB, Oei SG, Bovendeerd PHM. Simulation of reflex late decelerations in labor with a mathematical model. Early Human Dev. 2012 in press.
Guid Oei, MD, PhD is the Medical Director of Medical Education and Simulation Center at Maxima Medical Center, Veldhoven, Netherlands.
1243 Two Heads are Better Than One? Dyad Practice to Improve Simulation-based Procedural Skills Training
David Shanks, MD2, Ryan Brydges, PhD4, Wendie denBrok, MD2, Parvathy Nair, MD1, and Rose Hatala, MD, MSc3
1CARDIOLOGY, UNIVERSITY OF BRITISH COLUMBIA, VANCOUVER, BC, CAN and 2INTERNAL MEDICINE, UNIVERSITY OF BRITISH COLUMBIA, VANCOUVER, BC, CAN and 3MEDICINE, UNIVERSITY OF BRITISH COLUMBIA, VANCOUVER, BC, CAN and 4THE WILSON CENTRE, UNIVERSITY OF TORONTO, MICHENER INSTITUTE MEDICAL RADIATION SCIENCES, TORONTO, ON, CAN
Introduction/Background: Simulation has been widely adopted in the teaching of procedural skills to both medical and surgical trainees. Although it is resource intensive, simulation provides learners with the opportunity to develop and refine procedural skills without jeopardizing patient safety.1 While some features that enhance simulation-based learning of procedural skills have been established, one area that has received insufficient focus is the optimal group size. Research in motor learning with non-medical trainees suggests that dyad training, defined as observational training in pairs that is coupled with hands-on practice, may be as effective as individual training.2,3 Past research with non-medical trainees learning complex tasks has shown that dyad training results not only in greater immediate learning gains, but that these gains are maintained on retention testing a day later.4 Based on this body of research, we hypothesized that medical trainees will derive similar benefits from dyad training in a simulation-based procedural skills course. The objective of the present study is to compare the relative effectiveness and efficiency of dyad training versus individual learning of simulation-based lumbar puncture (LP) among first year internal medicine residents.
Methods: We conducted a two-group randomized equivalence trial. First year internal medicine residents (N=46) were randomly assigned to learn LP on a simulator as either dyad pairs or individual learners using a directed self-guided approach. Specifically, learners in both groups were given control over their practice time, including how they used two different versions of the simulator (i.e., an easy and difficult model), and an instructional video. Moreover, they could terminate the practice session whenever they saw fit. All participants were videotaped performing a simulated LP as a pre-test, an immediate post-test, and a 6-week delayed retention test. Two independent, blinded raters evaluated trainee performance using a 5-item global rating scale (GRS). We analyzed the average GRS score (mean of the 5 items) using a 2 group (dyad vs. individual) X 3 test (pre, post, retention) repeated measures analysis of variance.
Results: Our analyses showed no significant group differences (p=0.69) on pre-test, post-test, or retention test GRS scores between the dyad (2.39±0.57, 3.48±0.62, 3.12±0.85) and individual learners (2.67±0.57, 3.34±0.77, 3.21±0.79). A main effect of test showed that both groups improved significantly from pre-test to post-test (p<.001) and retained that performance following the 6-week delay. Notably, a significant interaction (p=0.02) revealed that the dyad learners experienced significantly greater pre-test to post-test gains than individual learners. Total practice time was 20.94 minutes for individuals, compared to 23.65 minutes for dyads (p=0.175).
Conclusion: The results indicate active learning in pairs, which combines both observational and hands-on practice, is as effective as individual self-regulated learning. Dyad training permits more efficient use of simulators with two learners using the same resources as an individual in solo practice. While this suggests dyad training does not create an efficiency/effectiveness trade-off, future work should test the limits of this trade-off with larger groups of learners (e.g., triads or quads).
1. Simulation-based medical education: an ethical imperative. Ziv A, Wolpe PR, Small SD, Glick S. Acad Med. 2003; 78(8): 783-8.
2. A dyadic protocol for training complex skills. Shebilske WL, Regian JW, Arthur W, Jordan JA. Hum Factors 1992;34:369–74.
3. Physical and observational practice afford unique learning opportunities. Shea CH, Wulf G, Whitacre C, Wright DL. J Mot Behav 2000;32:27–36.
4. Enhancing training efficiency and effectiveness through the use of dyad training. Shea CH, Wulf G, Whitacre C. J Mot Behav. 1999; 31:119-25.
Disclosures: Ryan Brydges, PhD, receives a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.
1259 Effectiveness of Simulation for Laparoscopic Surgery Training: A Systematic Review and Meta-analysis
Benjamin Zendejas, MD, MSc2, Ryan Brydges, PhD4, Stanley Hamstra, PhD3, and David Cook, MD, MHPE1
1GENERAL INTERNAL MEDICINE, MAYO CLINIC, ROCHESTER, MN, USA and 2SURGERY, MAYO CLINIC, ROCHESTER, MN, USA and 3ACADEMY FOR INNOVATION IN MEDICAL EDUCATION, UNIVERSITY OF OTTAWA, OTTAWA, ON, CAN and 4THE WILSON CENTRE, UNIVERSITY OF TORONTO, MICHENER INSTITUTE MEDICAL RADIATION SCIENCES, TORONTO, ON, CAN
Introduction/Background: The features that lead to effective simulation-based training of laparoscopic surgery have not been quantitatively synthesized in previous reviews. We sought to summarize the outcomes of simulation training for laparoscopic surgery among health professions learners.
Methods: We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011 for original research in any language evaluating simulation, in comparison with no intervention or an active simulation-based or non-simulation training activity, for training health professionals in laparoscopic surgery. Reviewers working in duplicate evaluated study quality and abstracted study data. Outcomes were classified as reactions (learner satisfaction), skills (in a test setting) of time, process (e.g. performance rating), and product (e.g. knot strength) measures, and behaviors (when caring for patients). We pooled effect sizes using random effects, and effect sizes (ES) 0.5 to 0.79 were considered moderate and >0.8 large, and educationally relevant.
Results: From a pool of 10,903 articles, we identified 218 eligible studies enrolling 7115 trainees, including 91 (42%) randomized trials. For comparisons with no intervention (n=149 studies), pooled ES favored simulation for outcomes of knowledge (1.18 [95% CI, 0.76 to 1.62]; N=9 studies), skills-time (1.12 [95% CI, 0.98 to 1.25]; N=87), skills-process (1.23 [95% CI, 1.09 to 1.36]; N=111), skills-product (1.10 [95% CI, 0.56 to 1.64]; N=6), behavior-time (1.15 [95% CI, 0.72 to 1.58]; N=7), behavior-process (1.4 [95% CI, 0.89 to 1.54]; N=14), and patient effects (1.28 [95% CI, 0.08 to 2.48]; N=1), all p<0.05. When compared to other non-simulation instruction (n=3 studies each), results significantly favored simulation for outcomes of skills-time (ES 0.75 [95% CI, 0.24 to 1.26]) and skills-process (ES 0.54 [95% CI, 0.21 to 0.86]). Comparisons between different simulation interventions (n=79 studies) showed that while box trainers (BT) are moderately more effective than virtual reality (VR) simulators for outcomes of skills-time and satisfaction, they are no different for the remainder outcomes. Overall, there was no significant difference for training with or without computer enhanced haptic feedback. Interventions that allowed for repeated practice, incorporated features that resemble the clinical environment, and focused on clinically relevant tasks were associated with improved outcomes (See ).
Conclusion: Simulation-based laparoscopic surgery training of health professionals is largely effective when compared to no intervention and moderately effective when compared to non-simulation instructional modalities. The lack of clear benefit from VR over BT simulators calls into question the role of expensive VR simulators.
Disclosures: Ryan Brydges, PhD, receives a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.
1263 Does High Fidelity Hemorrhage Simulation Improve Intern Knowledge and Confidence?
Heather Straub, MD3, Ian Grable, MD, MPH5, Peggy Ochoa, RNC-OB, BS, MS1, Ernest Wang, MD2, Morris Kharasch, MD2, and Beth Plunkett, MD, MPH4
1CENTER FOR SIMULATION AND INNOVATION, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 2EMERGENCY MEDICINE, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 3OBSTETRICS AND GYNECOLOGY, NORTHSHORE UNIVERSITY HEALTHSYSTEM, CHICAGO, IL, USA and 4OBSTETRICS AND GYNECOLOGY, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA and 5OBSTETRICS AND GYNECOLOGY, WOMEN’S HEALTH, NORTHSHORE UNIVERSITY HEALTHSYSTEM, EVANSTON, IL, USA
Introduction/Background: Obstetric hemorrhage is the leading cause of maternal mortality world-wide. It is a rare and deadly complication. As such,simulation of obstetric hemorrhage has been used increasingly as an educational tool in hopes of improving clinical performance and outcome.1,2 Obstetrical hemorrhage simulations have been shown to improve resident confidence,1 which is an essential component for improvement in clinical performance.3 However, this improvement in confidence has not been linked to improvement in clinical knowledge. The purpose of this study was to determine if a high-fidelity simulation program improves residents’ knowledge and competence in the recognition and management of postpartum obstetric hemorrhage.
Methods: All incoming obstetric and gynecologic (OB) and family practice residents in 2011 received a state-mandated educational program which focused on the recognition and management of obstetric hemorrhage. The intervention entailed a 1.5 hour standardized lecture developed by the Illinois Department of Public Health, a blood estimation lab and a high-fidelity s simulation using the Noelle Simulator (Gaumard Scientific, Miami FL). After the simulation, a short debriefing session was held. The residents completed pre- and post-test including a 25 multiple-choice question standardized exam created by the Illinois Department of Public Health4 and a confidence survey. Residents rated their level of confidence in their ability to successfully perform delineated tasks on a 1-5 Likert scale (1=not confident, 5= very confident). Student’s t-test and Spearman’s correlation were used for statistical comparisons. A P-value of <0.05 was considered to be significant.
Results: Ten obstetric and four family practice residents participated in the simulation exercise. There were significant increases in both knowledge and confidence scores before and after the simulation (Refer to ). The confidence and test score appeared to be highly correlated with a Spearman’s coefficient of 0.651 (P<0.001).
Conclusion: A high fidelity simulation program during intern orientation significantly improves both resident confidence and knowledge. There appears to be a clear correlation between level of confidence and level of knowledge. Further research in resident education through simulation is needed to better characterize the relationship between confidence and knowledge.
1. Deering SH, Chinn M, Hodor J, Benedetti T, Mandel LS, Goff B. Use of a postpartum hemorrhage simulator for instruction and evaluation of residents. J Grad Med Ed.2009 Dec;1(2):260-3. PMID:21975989.
2. Pliego JF, Wehbe-Janek H, Rajab MH, Browning JL, Fothergill RE. Ob/gyn boot camp using high-fidelity human simulators: enhancing residents’ perceived competency, confidence in taking a leadership role, and stress hardiness. Simul Healthc.2008 Summer;3(2):82-9. PMID:19088646.
3. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007 Jun; 109(6):1295-300. PMID: 175408004.
4. Obstetric hemorrhage education project workgroup. Maternal hemorrhage education project. Chicago, IL: Illinois Dept of Public Health; 2008. http://www.idph.state.il.us/.
1270 Impact of Instruction and Practice on Surgical Simulation Training
Angela Brunstein, PhD3, Joerg Brunstein, MSc1, David Sargsyan, MD, PhD2, Bakr Nour, MD, PhD,FACS4
1MANAMA, BHR and 2GENERAL SURGERY, HAMAD MEDICAL CORPORATION, DOHA, QAT and 3FACULTY OF HEALTH SCIENCES, ROYAL COLLEGE OF SURGEONS IN IRELAND, BAHRAIN, MUHARRAQ, BHR and 4SURGERY, WEILL CORNELL MEDICAL COLLEGE IN QATAR, DOHA, QAT
Introduction/Background: In surgical simulation training, time of mentor and trainees are the most scare resources. Time of the mentor impacts the availability of immediate feedback and guidance during training. Time of the trainee impacts the duration and timing of practice. Therefore, this research investigated the impact of immediate feedback and of sufficient practice on surgical skill acquisition for simulated laparoscopic cholecystectomy. For intelligent tutoring systems on algebra, we1 have found that self-directed learning and guiding instruction have different effects on skill acquisition. For laparoscopic surgical simulation training, research has demonstrated that trainees need expert assessment for at least some aspects of their performance,2 and that immediate feedback can reduce errors and smooth the learning curve.3 In addition, sufficient simulation training has been shown to result in automatization, expert-level performance, and transfer to the OR.4 Based on that research, we expected trainees with extensive practice to perform better during post-test and during transfer than trainees with minimum practice, improving especially in terms of speed. In addition, we expected mentored trainees with minimum practice to perform better during post-test and during transfer than participants with minimum practice, but without mentor, improving especially in terms of demonstrated skills.
Methods: In total, 26 third and fourth year medical students after surgical clerkship participated in this study for 5 individual sessions. During the first session, participants signed the consent form, performed case 1 on simulated laparoscopic cholecystectomy using a high fidelity laparoscopic simulator as a pre-test and were randomly assigned to 1 of 3 conditions: mentored, minimum practice, or extensive practice. During sessions 2 through 4, participants practiced the procedure for 30 minutes each (mentored and minimal practice) or for 60 minutes each (extensive practice). Mentored students were supervised by an experienced surgeon; all others relied on feedback of the simulation engine only. After mastering a case, participants continued with the next, more challenging case. During session 5, participants performed case 1 again as a post-test, and case 4 as a novel transfer task.
Results: Randomized and anonymized screen-recordings from pre/post and transfer tests were graded by 2 independent raters. Simulation engine protocols providing time on task, path length, proficiency, dexterity, and damage measures were analyzed for all completed cases. Both kinds of data were analyzed using MANOVAs with time of test as repeated measure for the three groups. Post-hoc analyses corresponding to Bonferroni were performed for identifying simple effects. All 3 groups improved performance significantly from pre-test to post-test. During post-test and transfer, mentored and extensive practice trainees received higher scores from faculty than minimum practice trainees. For the protocols, extensive practice trainees performed faster during post-test and transfer and received higher scores than minimal practice trainees. In contrast, mentored trainees did not perform faster during post-test than minimum practice trainees, but received higher scores. During transfer, mentored students received highest scores. When inspecting trainees’ protocols, we observed that extended practice trainees might receive perfect scores for a case in one trial and completely fail during the next trial.
Conclusion: Both, mentoring and sufficient practice were critical for surgical skill acquisition in this study. Mentoring seems to be essential for building safe practice and for preventing trainees from automatizing non-safe habits, like entering the cavity with widely open scissors. In contrast, sufficient practice is needed for automatizing skills and for speeding up performance. As a next step, we need to identify when exactly during training it is best to guide trainees’ learning by a mentor and when it is better for them to explore and practice on their own.
1. Brunstein A, Betts S, Anderson JR. Practice enables successful learning under minimal guidance.Journal of Education Psychology 2009 Nov; Vol. 101 (4), pp. 790-802.
2. Arora S, Miskovic D, Hull L, Moorthy K, Aggarwal R, Johannson H, Gautama S, Kneebone R, Sevdalis N. Self versus expert assessment of technical and non-technical skills in high fidelity simulation. American Journal of Surgery 2011 Oct; 202(4):500-6.
3. Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Optimising surgical training: Use of feedback to reduce errors during simulated surgical procedure. Postgraduate Medical Journal 2011 Aug; 87(1030): 524-8.
4. Stefanidis D, Scerbo MW, Montero PN, Acker CE, Smith WD. Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency-based training: A randomized controlled trial. Annals of Surgery 2012 Jan; 255(1):30-7.
Disclosures: Angela Brunstein, PhD, received grant support from Qatar Foundation’s Undergraduate Research Experience Program, UREP 07-056-5-012.
1276 Estimated Blood Loss Assessment Simulation
Jyothshna Bayya, MD2, Ahmed Ahmed, MD, MSc2, Peter Homel, PhD1, Nelli Fisher, MD2
1MEDICINE, ALBERT EINSTEIN COLLEGE OF MEDICINE, MONTEFIORE MEDICAL CENTER, BRONX, NY, USA and 2OBSTETRICS AND GYNECOLOGY, MAIMONIDES MEDICAL CENTER, BROOKLYN, NY, USA
Introduction/Background: Hemorrhage remains one of the leading causes of maternal mortality in the United States.1 Peripartum blood loss is notoriously underestimated; this can lead to delay in treatment and cause significant maternal morbidity and mortality. Health-care providers tend to underestimate the volume of postpartum blood loss by about 30%. Error in estimating blood loss is dependent on actual blood loss volume. Visual estimated blood loss (EBL) can be inaccurate, overestimating at low volumes and underestimating at high volumes. Training staff to accurately assess estimated blood loss during postpartum hemorrhage will help timely initiation of management, thus preventing associated maternal morbidity and mortality.2 Medical students and experienced faculty demonstrate similar errors, and both can be improved significantly with limited instruction.3 Our objective was to evaluate if simulation-based teaching of blood loss assessment can improve accuracy of blood loss estimation.
Methods: We conducted a prospective cohort study approved by Maimonides Medical Center IRB. Two hundred twenty three participants (OB residents, interns, attending physicians, L and D Nurses, Post partum nurses, and nurse orientees) were introduced to 5 stations with known measured quantities of blood: under buttocks drape, clots, sanitary pad, speculum and floor spill. The participants completed visual estimation of these amounts as a pre-test. Teaching consisted of demonstration of 5 stations with commonly used containers like medicine cup (30ml), Dixie cup (100ml), and orange juice carton (250ml), ice cream pint (500ml), water bottle (1000ml). They were taught about the standard volumes of these items and how to correlate to the common surgical materials soaked with blood such as laparotomy sponge, 4 × 4 gauze, sanitary pad, chux, kidney basin, and placenta tray. The participants were reassessed on the 5 testing stations for blood loss assessment as a post-test. Paired t-test was used to assess the pre-test and post-test absolute differences between estimated blood volume and actual blood volume. Kruskal-Wallis test was used for comparisons of difference scores between staff groups.
Results: Participants (N=223) demonstrated statistically significant improvement in accuracy of blood loss estimation after EBL training. The absolute difference between mean pre-test estimate volume and correct blood volume (D1) was compared to the absolute difference between mean post-test estimate and correct blood volume (D2). (). Mean post-test blood volume estimates were significantly closer to correct blood volumes for all stations. No significant difference was found between difference in scores between the staff groups for any station except for the sanitary pad station (P=0.022). See : Comparison of pre-test and post-test absolute differences between estimated blood volume and actual blood volume
Conclusion: We demonstrate that simulation training of blood loss assessment improves providers accuracy in blood loss estimation. Simulation training may positively affect providers’ abilities to timely and accurately recognize obstetrical blood loss during an actual obstetrical hemorrhage, which in turn may lead to early initiation of hemorrhage management.
1. Berg C, Atrash K, Koonin M, Tucker M: Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol 1996; 88:161-167.
2. Al Kadri H, Bedayah K, Al Anazi B, and Tamim H. Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet. 2011; 283:1207-1213.
3. Dildy G, Paine A, George N, and Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. 2004; 104:601-606.
1344 For Your Ego or to Learn the Task? Qualitative vs. Quantitative Feedback in Endotracheal Intubation Training
Julian Manzone2, Luc Tremblay, PhD2, Devdatta Desai, MD, DHA1, Eric You-Ten, MD, PhD, FRCPC1, and Ryan Brydges, PhD3
1ANESTHESIA, UNIVERSITY OF TORONTO, TORONTO, ON, CAN and 2KINESIOLOGY AND PHYSICAL EDUCATION, UNIVERSITY OF TORONTO, TORONTO, ON, CAN and 3THE WILSON CENTRE, UNIVERSITY OF TORONTO, MICHENER INSTITUTE MEDICAL RADIATION SCIENCES, TORONTO, ON, CAN
Introduction/Background: When learning a novel task, individuals can focus on mastering the task (e.g., task orientation) and/or on how they are learning relative to others (i.e., ego orientation). Educational psychology researchers have shown that a task orientation is more conducive to learning than an ego-orientation. This benefit has traditionally been demonstrated in studies using qualitative (e.g., comments) and quantitative (e.g., grades) feedback, which researchers describe as task and ego orienting feedback respectively. Previous research has not examined whether the major driver of the learning benefit is if feedback is task or ego oriented or if it is quantitative versus qualitative. We assessed how feedback that differed on those dimensions affected medical students’ short- and long-term learning of endotracheal intubation skills. Further, we assessed how students perceived the quality and credibility of the feedback.
Methods: Using a 2 feedback format (quantitative vs. qualitative) × 2 feedback orientation (task vs. ego-orientation) orthogonal study design, we randomly assigned junior medical students to four groups: quantitative task (numeric hand motion feedback), quantitative ego (norm-referenced hand motion feedback), qualitative task (task-oriented expert feedback), or qualitative ego (norm-referenced expert feedback). Using a simulator, all participants (n=40) independently performed 20 trials of four clinical variations of endotracheal intubation: table-top, supine, ice pick, and lateral. We videotaped participants’ performances on a pre-test, immediate post-test, and 2-week delayed retention test. We assessed intubation skills using two measures: participants computer measured hand motion efficiency, and a global rating scale (GRS). Two blinded, trained anesthetists independently rated the videotaped performances on all tests using the GRS. Immediately after training, participants recorded their perceptions of feedback quality and credibility using 5-pt Likert scales. Due to high variability on pretest, we analyzed the hand motion data using 2 feedback format × 2 feedback orientation × 2 test repeated measures analyses of covariance, with participants’ pretest scores as the covariate.
Results: The group’s hand motion efficiency did not differ on the post-test or the retention test for the easier (e.g., table-top) and more difficult task variations (i.e., ice pick and lateral). For the moderately difficult supine variation, there was a significant main effect for format (p=.02) suggesting the quantitative groups used significantly fewer hand movements than the qualitative groups. Moreover, we observed a format by test interaction (p=.05) whereby the quantitative groups maintained performance from post-test (39.93±11.17) to retention test (38.90±4.77), whereas qualitative groups showed significant improvement (79.25±11.49 to 47.90±4.90). For the student perception data, we found significant orientation by format interactions. Specifically, the quantitative ego group rated feedback quality (3.20±.30 vs.1.80±0.30, p=.003) and credibility (3.78±.40 vs. 2.30±.38, p=.01) higher than the quantitative task group, whereas the two qualitative groups did not differ from either quantitative group.
Conclusion: Our findings suggest superior overall performance by groups that received quantitative feedback. That finding, along with the lack of any effect of whether feedback was task or ego oriented, suggests that medical students learning procedural skills with simulation respond in ways that do not correspond with previous education research. Despite coming from a machine rather than an instructor, students in the quantitative-ego group judged their feedback as higher quality and more credible than the other conditions. These findings suggest that medical students perform better and respond more positively to quantitative feedback that is provided with an external, ego-orienting criterion (e.g., scores achieved by residents and experts on the task). These results are particularly relevant for a framework called directed self-assessment, to which we add evidence of how students react to feedback in the simulation training context.
Disclosures: Ryan Brydges, PhD, receives a Medical Education Research Grant from the Royal College of Physicians and Surgeons of Canada.
1359 Using Virtual Reality Simulation to Assess Performance in Endobronchial Ultrasound
Lars Konge, MD, PhD2, and Charlotte Ringsted, MD, PhD1
1CENTRE OF CLINICAL EDUCATION, RIGSHOSPITALET, COPENHAGEN UNIVERSITY HOSPITAL, COPENHAGEN, DNK and 2CENTRE FOR CLINICAL EDUCATION, UNIVERSITY OF COPENHAGEN AND THE CAPITAL REGION OF DENMARK, COPENHAGEN, DNK
Introduction/Background: Mediastinal tissue staging is essential when deciding treatment for patients with non-small-cell lung cancer and should preferentially start with endosonographic procedures.1 By endobronchial ultrasound guided fine-needle aspiration (EBUS), it is possible to sample mediastinal lymph nodes, but the diagnostic yield is very influenced by the experience of the operator.2 According to clinical guidelines the important decision of when a physician is deemed competent should be based on assessing performance instead of demanding an arbitrary number of performed procedures.3 Virtual-reality (VR) simulators can provide unbiased performance data from a highly controlled, standardized measurement environment,4 but the clinical relevance of these simulator metrics needs to be explored. Earlier studies about VR-bronchoscopy simulators have found that simulator metrics could not discriminate between experts and novices who had practiced briefly on the simulator.5,6 The aims of this study were to identify simulator metrics with discriminative ability, test the reliability of these, set pass/fail standards, and use these to test the effect of EBUS simulator training. Our hypothesis was that only two hours of training would enable novices to perform like experienced clinicians on a VR simulator.
Methods: Sixteen trainees in respiratory medicine in Denmark and the Netherlands were randomized to either a novice group or a training group. The 8 physicians in the novice group and a convenience sample of 5 very experienced EBUS operators each performed two, standardized EBUS procedures on a VR-simulator. Simulator metrics were analyzed using two-way mixed design ANOVAs, and the data with discriminatory ability were combined to a single, aggregated score – the quality score (QS). The reliability of the QS was tested using generalizability theory in a G-study, and the effect of changing the number of procedures in the test were explored in a D-study. A pass/fail standard was set using the contrasting groups method. The 8 physicians in the training group were each trained individually on the EBUS simulator in a standardized fashion by the same instructor in both countries. Immediately following training each physician performed the same two EBUS procedures as the other groups, and their QS’s were compared to the pass/fail standard.
Results: Procedure time and successfully sampled lymph nodes were the only simulator metrics that showed statistically significant differences between the novices and the experienced operators, p=0.003 and p=0.039 respectively. Percentage of time with ultrasound visualization, number of biopsies made with suboptimal positioning of the scope, number of blood vessels accidentally punctured, number of hemodynamic complications, and amount of damage to the scope were all similar in the two groups. The resulting quality score (sampled lymph nodes per minute) showed acceptable reliability, generalisability coefficient=0.67. Reliability of 0.8 and 0.9 required for higher stakes examinations could be obtained by testing in 4 and 9 procedures respectively. The median QS of the novices was 0.098, range 0.04-0.21, and the median QS of the experienced operators was 0.24, range 0.21-0.26. The resulting pass/fail-standard was set at 0.19. The mean, effective simulator practice time of the physicians in the training group was 1 hour and 46 minutes, SD 17 minutes. Their median post-training QS was 0.11, range 0-0.17, meaning that none of them made the pass/fail-standard.
Conclusion: Great caution has to be applied when using simulator metrics to assess procedural competence. We only found two metrics with discriminative ability. However these data allowed for the setting of a credible pass/fail standard ensuring that a brief training session was not enough to pass the test. With proper and careful design of standardized tests, we believe that VR-simulators could be an important first line in credentialing procedural skills before proceeding to supervised performance on patients.
1. Tournoy KG, Keller SM, Annema JT. Mediastinal staging of lung cancer: novel concepts. Lancet Oncol 2012 May;13(5):e221-e229.
2. Kemp SV, El Batrawy SH, Harrison RN, Skwarski K, Munavvar M, Rosell A, Cusworth K, Shah PL. Learning curves for endobronchial ultrasound using cusum analysis. Thorax 2010 June;65(6):534-8.
3. Du Rand IA, Barber PV, Goldring J, Lewis RA, Mandal S, Munavvar M, Rintoul RC, Shah PL, Singh S, Slade MG, Woolley A. Summary of the British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011 November;66(11):1014-5.
4. McGaghie WC, Issenberg SB. Simulations in Assessment. In: Downing SM, Yudkowsky R, editors. Assessment in Health Professions Education. 1 ed. New York: Routledge; 2009. p. 245-68.
5. Moorthy K, Smith S, Brown T, Bann S, Darzi A. Evaluation of virtual reality bronchoscopy as a learning and assessment tool. Respiration 2003 March;70(2):195-9.
6. Konge L, Arendrup H, von BC, Ringsted C. Using Performance in Multiple Simulated Scenarios to Assess Bronchoscopy Skills. Respiration 2012 March;81(6):483-90.
Disclosures: Charlotte Ringsted, MD, PhD receives grant support from Laerdal Foundation and TrygFonden. Dr. Ringsted is a consultant for Covidience.
1362 TeamSTEPPS Interprofessional Simulation Training of Pre-hospital and Hospital STEMI Teams
Susan Cristante, MSN, BSN, RN3, Shari Brand, MD5, Kim Ezrre, MBA, MSN, BSN, RN3, F David Fortuin, MD1, Bhavesh Patel, MD4, Steve Sabyan, RT (R) (CV)8, Kristen Slee, MSN, RN9, Jan Stepanek, MD7, Rebecca Wilson, RN, PhD2, and Richard Zimmerman, MD6
1MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 2ADMINISTRATIVE SERVICES EDUCATION, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 3CARDIOLOGY, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 4CRITICAL CARE, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 5EMERGENCY MEDICINE, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 6NEUROSURGERY, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 7PREVENTIVE, OCCUPATIONAL AND AEROSPACE MEDICINE, MAYO CLINIC ARIZONA, PHOENIX, AZ, USA and 8CARDIAC CATH LAB, MAYO CLINIC HOSPITAL, PHOENIX, AZ, USA and 9EMERGENCY DEPARTMENT, MAYO CLINIC HOSPITAL, PHOENIX, AZ, USA
Introduction/Background: Acute myocardial infarction clinical guidelines recommend multidisciplinary meetings among pre-hospital (Emergency Medical Services) and hospital providers (Emergency Department (ED), Cardiology)1 in order to achieve rapid reperfusion by primary percutaneous coronary intervention (PCI) in patients presenting with ST elevation myocardial infarction (STEMI). This has become a top priority for hospitals in part, secondary to the Centers for Medicare and Medicaid ServicesHospital Quality Initiative. Processes for decreasing time to primary PCI have been effective, however quicker triage, transport, and balloon/device delivery may have the unintended consequences of creating potential threats to patient safety. For example, abbreviated communication between providers may compromise patient handoffs. These latent behavioral and environmental systems risks may not be captured by currently monitored processes and outcomes. Simulation-based team training facilitates exposure of latent risks as well as promotes the development of teamwork, which has been shown to reduce errors and improve outcomes in other settings.2,3 Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was designed by the Health and Human Services Agency for Healthcare Research and Quality and the Department of Defense Health Care Team Coordination Program.4 Emphasis is placed on defining team skills, identifying tools and strategies that can be used to overcome common barriers to achieve desired outcomes, and demonstrating proficiency in the skills.5 We hypothesized that interprofessional simulation training of STEMI contingency teams (pre-hospital and hospital-based) using the TeamSTEPPS® framework will provide improvements in teamwork and identify latent risks to patient safety.
Methods: This intervention study used a pre-training/post-training design. The participants included: Emergency Medical Technicians, Paramedics; Emergency Department physicians, registered nurses and technicians; and Cardiac Catheterization Lab (CCL) physicians, registered nurses and radiologic technologists. There were two educational interventions; a TeamSTEPPS® Fundamentals Course followed nine months later by simulation-based teamwork education. The simulation-based education consisted of two high fidelity STEMI scenarios. Patient care was initiated in a mock home setting, followed by patient transported to a mock ED and subsequently to a mock CCL, all within a dedicated simulation center. Scenarios incorporated planned errors and patient complications to meet the learning objectives of eliciting clear, concise communication with attention to detail and focusing on patient handoffs. The TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) is a useful, reliable, and validated tool for assessing individual attitudes related to the role of teamwork.6 The T-TAQ was administered prior to education, and then after simulation-based education. Unpaired student’s t-test was used to compare questionnaire results post training to pre-training, statistical significance defined as p < 0.05.
Results: T-TAQ was analyzed from 122 participants prior to training and 105 participants after training. Prior to training, mean (± standard deviation) T-TAQ responses for team structure, leadership, situation monitoring, mutual support, and communication were 4.5±0.63, 4.7±0.43, 4.5±0.57, 4.4±0.42, and 4.4±0.43, respectively (5 point Likert scale). There were no significant differences between disciplines or specialties. There were no changes in T-TAQ responses following training. The training was well received based on post training surveys. Other consequences of the training included the development of immediate feedback mechanisms to report patient findings and outcomes to pre-hospital providers. Also, latent risks were identified and to address some of these a STEMI checklist and worksheet have been implemented.
Conclusion: Interprofessional simulation training of contingency STEMI pre-hospital and hospital teams using the TeamSTEPPS framework was well received by attendees, resulted in tangible actionable items, fostered improved working relationships among disciplines and departments, and identified latent risks to patient safety. However this did not translate into improved T-TAQ scores which may be, at least in part, secondary to preexisting favorable attitudes toward teamwork.
1. Kushner, F. G., M. Hand, et al. (2009). “2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.” Circulation 120(22): 2271-2306.
2. Mann, S., R. Marcus, and B. Sachs. Lessons from the Cockpit: How Team Training Can Reduce Errors on L&D. Contemporary OB/GYN. January, 2006, pp. 34-45.
3. Pronovost, P., S. Berenholtz, T. Dorman, et. al. Improving Communication in the ICU Using Daily Goals. Journal of Critical Care, 18:2, pgs. 71-75, (2003).
4. http://teamstepps.ahrq.gov/. Accessed January 28, 2011.
5. King, H., J. Battles, et al. (2008). TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety Performance and Tools). Advances in Patient Safety: New Directions and Alternative Approaches. Rockville (MD), Agency for Healthcare Research and Quality (US). 3: Performance and Tools.
6. TeamSTEPPS™ Teamwork Attitudes Questionnaire Manual Prepared for: U.S. Department of Defense, Tricare Management Activity, Subcontract agreement # SK-443-07-AIR-HCTCP, Prime Contract # W81XWH-06-F-0526Prepared by: David P. Baker, Ph.D., Kelley J. Krokos, Ph.D., Andrea M. Amodeo, M.S., American Institutes for Research, 1000 Thomas Jefferson Street, NW, Washington, DC 20007.
1383 How Do Participants of Multi-professional Obstetric Teams Evaluate Deliberate Practice?
Annemarie Fransen, MD1, and Guid Oei, MD, PhD1
1OBSTETRICS AND GYNECOLOGY, MAXIMA MEDICAL CENTER, VELDHOVEN, NLD
Introduction/Background: Expert performance is the end result of individuals’ prolonged efforts to improve their performance. The theoretical framework, which explains how different levels of performance are attained as a function of deliberate practice, was developed by Ericsson.1 Recently it was proven that simulation based medical education with deliberate practice is superior to traditional clinical medical education.2 However introducing deliberate practice into simulation training is not simple due to motivational and external constraints.3 In this study we investigate the opinion of trainees from different professions about simulation based medical team training courses, based on the principles of deliberate practice.
Methods: In a cluster randomized multi-center controlled trial, 24 obstetric departments were allocated to a one-day team training in a medical simulation center versus a similar training, but based on the principles of deliberate practice. The first “standard” group performed six different obstetric emergency situations, with emphasis on both medical skills and crew resource management. The second “deliberate practice” group trained only three of the six scenarios, which were repeated with intermittent feedback. Afterwards, the trainees had to fill in an evaluation form and rate the training on a scale of 1 to 10.
Results: The standard group, consisting of 440 trainees, rated the one-day training course significantly higher than the second group of 562 trainees(8.75 SD 0.629 versus 8.61 SD 0.651; unpaired t-test: p 0.001). Comparison between the two groups for the separate professions showed a significantly higher score among gynecologists and nurses in the standard group (8.75 SD 0.603 and 8.81 SD 0.647, respectively) compared to the deliberate practice group (8.49 SD 0.080 and 8.63 SD 0.653; p 0.016 and p 0.001 respectively). Within the standard group, there was a significantly lower rating among the midwives (8.58 SD 0.575) in comparison to the other professions (8.75, 8.66 and 8.81; ANOVA p 0.047). In the deliberate practice group there were no significant differences between the professions (Refer to ).
Conclusion: This report demonstrates that a training based on deliberate practice is lower rated by trainees compared to a standard training. An explanation could be that trainees consider repetition of a scenario less interesting than participating in a new scenario, which can lead to a decrease in interest and motivation. As motivation of trainees is a fundamental part of deliberate practice, it is important to keep in mind that simulation courses based on deliberate practice should be challenging enough for all participants. However, looking at the separate score of the deliberate practice course, it is still a high score.
1. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008 Nov; 15(11): 988-94. Pubmed PMID: 18778378.
2. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011 June; 86(6):706-11. Pubmed PMID: 21512370.
3. Ericsson KA, Nandagopal K, Roring RW. Toward a science of exceptional achievement: attaining superior performance through deliberate practice. Longevity, Regeneration, and Optimal Health: Ann N Y Acad Sci. 2009 Aug; 1172:199-217. Pubmed PMID: 19743555.
Disclosures: Guid Oei, MD, PhD is the Medical Director of Medical Education and Simulation Center at Maxima Medical Center, Veldhoven, Netherlands.
1396 Simulation Training Improves Fundoscopic Examination Skills in Third Year Medical Students
Russell Levine, BA1, Arash Mozayan, MD5, Poulsen David, BA1, Monique Tanna, MD4, Manuela Calvo, MD4, Sharon Silberger2, Lewis Eisein, MD3, and Jamie Rosenberg, MD5
1OPHTHALMOLOGY, ALBERT EINSTEIN COLLEGE OF MEDICINE, MONTEFIORE MEDICAL CENTER, BRONX, NY, USA and 2MONTEFIORE MEDICAL CENTER, BRONX, NY, USA and 3INTERNAL MEDICINE, MONTEFIORE MEDICAL CENTER, BRONX, NY, USA and 4MEDICINE, MONTEFIORE MEDICAL CENTER, BRONX, NY, USA and 5OPHTHALMOLOGY, MONTEFIORE MEDICAL CENTER, BRONX, NY, USA
Introduction/Background: Direct ophthalmoscopy is an important skill for physicians, as it screens for numerous systemic and ocular problems. This project was designed to determine whether simulation training, followed immediately by clinical practice, would improve competency in direct ophthalmoscopy in third year medical students.
Methods: We administered a half-day course in direct ophthalmoscopy consisting of a didactic session, simulation training, and clinical practice on dilated patients. We conducted a pre-session survey and objective assessment, followed by a post-session survey and objective assessment. The survey measured students’ comfort and confidence in using the ophthalmoscope to visualize key structures. Students were tested with a mannequin head containing a fundoscopic simulator (Eye Examination Simulator 2, Kyoto Kagaku Co., Kyoto, Japan). As a novel method of objective assessment, we superimposed small-type letters behind the optic nerves of the simulators and prompted students to record the letter they saw. Each eye of the four simulators had a different letter on the optic nerve. Students used one simulator for the pre-session assessment and practice and another simulator for the post-session assessment. Statistical analysis of pre- and post-session survey and assessment results was conducted using the Wilcoxon signed rank-sum test, with p<0.05 considered statistically significant.
Results: The interventional group consisted of 9 third year medical students. Before the session, students’ median self-rated scores on a 5-point Likert scale where 1 is “strongly disagree” and 5 is “strongly agree” were 3.0 for comfort in using the direct ophthalmoscope; 2.0 and 4.0 for confidence in visualizing the optic nerve and retinal blood vessels; and 3.0 for likelihood that they would use a direct ophthalmoscope to examine patients in the future. Survey data showed an increase in student comfort to 4.0 (p=0.011); an increase in confidence in visualizing the optic nerve to 4.0 (p=0.011) and visualizing retinal blood vessels to 5.0 (p=0.012); and an increase in the likelihood they would use an ophthalmoscope to examine patients in the future to 4.0 (p=0.017). The students strongly agreed (median value 5.0) that ophthalmoscopy should be included in the curriculum during the clinical years. They felt that the didactic session (median value 4.0) and clinical session (median value 4.0) helped them gain proficiency with this skill. In addition, the assessment showed a statistically significant increase in students’ abilities to visualize the optic nerve. Before the session, 4 students were able to correctly identify the letter on the nerve; after the session, 8 students were successful (p=0.046).
Conclusion: Introduction of a half-day curriculum of direct ophthalmoscopy skills consisting of simulation training, followed by immediate clinical practice, is an effective way to increase student competency in this skill. Adoption of the curriculum will increase students’ confidence in the skill, as well as the likelihood they will use an ophthalmoscope when examining their patients.
1405 The Effect of Physical Stress on Simulated Operating Room Crisis Management
Vivian Lee, MD1, Niyati Mehta, DDS3, Richard Fidler, CRNA, CRNP, MSN, MBA2, and Jan Hirsch, MD, PhD1
1ANESTHESIOLOGY, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA and 2HEALTHCARE SIMULATION PROGRAMS, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA and 3DENTAL SERVICE, VETERANS AFFAIRS MEDICAL CENTER SAN FRANCISCO, SAN FRANCISCO, CA, USA
Introduction/Background: Anesthesia providers are required to manage emergency situations all over the hospital. Clinicians are generally notified of a crisis without prior warning and expected to arrive within minutes, to rapidly assess the situation and to act immediately and appropriately while still under physical stress from running to the site of the emergency. The necessary measures to respond to the emergency typically require short and long term memory, executive function and technical manual skills. There are conflicting reports in the literature if physical stress affects these skills, and if it does so in a positive or negative way.1-8 We therefore designed a study to test the hypothesis that physical stress alters the response of providers to an emergency.
Methods: Anesthesia providers were prospectively randomized to undergo either physical stress (PS) or no physical stress (NPS) prior to managing one of two randomly assigned simulated operating room crisis events. Both simulated crises incorporated measures of cognitive challenges (short and long term memory), executive function and technical tasks (intubation). At least two weeks later, the same clinicians were subjected to the other scenario (either physical stress or no physical stress) prior to managing the other simulated crisis event. Salivary cortisol levels were measured prior to and after each simulation as an objective and quantifiable measure of stress.
Results: Data analysis showed average heart rate / systolic blood pressure increases by 12% / 5% after the procedure without physical stress and by 52% / 24% after physical stress (n=8). Moreover, after physical stress the providers required 8% more time to perform the tasks and remembered 16% less diagnosis items from the patient’s history.
Conclusion: Our results indicate that both technical and cognitive performances are markedly reduced by physical stress. This could have significant implications for hospital planning and call schedules. We anticipate that further analysis will elucidate which technical skills and cognitive functions are most affected by physical stress.
1. Gothe N, Pontifex MB, Hillman C, McAuley E. J Phys Act Health. 2012. PMID: 22820158 [PubMed - as supplied by publisher.
2. Huertas F, Zahonero J, Sanabria D, Lupianez J. J Sport Exerc Psychol. 2011;33(5):649-65. PMID: 21984640 [PubMed - indexed for MEDLINE].
3. Lambourne K, Audiffren M, Tomporowski PD. Med Sci Sports Exerc. 2010;42(7):1396-402. PMID: 20019631 [PubMed - indexed for MEDLINE].
4. Audiffren M, Tomporowski PD, Zagrodnik J. Acta Psychol (Amst). 2009;132(1):85-95.
5. Audiffren M, Tomporowski PD, Zagrodnik J. Acta Psychol (Amst). 2008;129(3):410-9. PMID: 19632661 [PubMed - indexed for MEDLINE].
6. Coles K, Tomporowski PD. J Sports Sci. 2008;26(3):333-44. PMID: 18074301 [PubMed - indexed for MEDLINE].
7. Harvey A, Bandiera G, Nathens AB, Leblanc VR. J Trauma. 2011. PMID: 21808212 [PubMed - as supplied by publisher].
8. Lieberman HR, Tharion WJ, Shukitt-Hale B, Speckman KL, Tulley R. Sea-Air-Land. Psychopharmacology (Berl). 2002;164(3):250-61. PMID: 12424548 [PubMed - indexed for MEDLINE].
1418 Evaluating the Role of Medical Student Bias for Unintended Pregnancy Counseling Encounters in an OSCE
Shimena Li, BS1, Yurhee Lee1, Nikita Patel1, Shelby Marx, BS1, Brian Loveland, MPH1, Alice Chuang, MD2, and Donald Woodyard, BS1
1CLINICAL SKILLS AND PATIENT SIMULATION CENTER, UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, CHAPEL HILL, NC, USA and 2OBSTETRICS AND GYNECOLOGY, UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, CHAPEL HILL, NC, USA
Introduction/Background: The prevention and reduction of unintended pregnancy in the United States has been a national public health goal on the Healthy People agenda for over thirty years.1 Despite the urgency of this issue and the economic, social and health implications it ensues, it continues to be a problem for the US. Unintended pregnancies impose a significant financial strain on the nation, with an estimated $11.3 billion in U.S. taxpayer dollars being allocated to provide medical services for women with unintended pregnancies.2 The interaction between a healthcare provider and a patient provides a strong basis for the healthcare decisions that a patient makes. Those interactions can be affected by socioeconomic factors, domestic support systems and lifestyle choices of the patient, which in turn can influence the quality of care they receive. The purpose of this study is to analyze the influence that a patient’s lifestyle and household stability have on a student’s agenda during prenatal counseling for an unintended pregnancy.
Methods: Two versions of an unintended pregnancy Standardized Patient (SP) case were presented in the Clinical Performance Examination (CPX), a 14-station OSCE required of fourth year medical students. Half the students were randomly assigned to see an SP with higher socioeconomic status (SES) who is married with a stable job. The other half interacted with an SP who is of lower SES, unwed, unable to identify the father, is unemployed and relies on food stamps and Medicaid. All other factors were held constant between the two versions. Students were evaluated on a checklist to identify any differences in the overall tone of the consultation and the additional healthcare resources offered to the patient. A Chi Square analysis was performed on all dichotomous standardized patient checklist items. Checklist items that involved more than 2 choices were analyzed using independent sample t-tests.
Results: A total of 72 students saw the high SES case and 63 saw the low SES case (Total N=135). The number of students who discussed the patients’ employment status during the encounter was statistically higher (p = 0.001) for the SP with lower socioeconomic status. Students did focus more discussion on the option for terminating the pregnancy for the high SES vs low SES patient (p=.002), and students documented the SES into the progress note for low SES patients significantly more often (p<.001) than for high SES. However, the SPs did not report any greater emphasis by the students on other pregnancy options (keeping the pregnancy, or adoption) as there were no statically significant differences (p>.1), nor did the SP report any increased emphasis or pressure on their decision for any of the three options (p> .1).
Conclusion: While the students did recognize and tend to give more attention to the financial situation of the low SES patient, this did not significantly affect the students’ medical counseling during the pregnancy counseling encounters. Each patient left with an understanding of all the options available to her treatment plan. While some students did push a particular option, this was not statistically significant. We plan to investigate further to see if additional healthcare resources were more readily offered to one or the other.
1. Healthy people: the surgeon general’s report on health promotion and disease prevention. Department of Health, Education and Welfare. 1979: 8-2.
2. Wise investment: reducing the steep cost to medicaid of unintended pregnancy in the united states. Gold RB. Guttmacher Policy Review. 2011 Summer;14(3): 1.
1419 Human Simulators in Trauma Resuscitation Education for Junior Medical Staff
Geng-shiau Lin, MD, MBA, MPH, LLB1, and Shyr-Chyr Chen, MD1
1EMERGENCY MEDICINE, NATIONAL TAIWAN UNIVERSITY HOSPITAL, TAIPEI, TAIWAN, TWN
Introduction/Background: The objective was to design and implement a demonstration project to teach junior medical staff how to engage and participate in trauma resuscitation.
Methods: Scenarios with a human simulator were constructed to assess the performance of the junior medical staff for trauma patients in the emergency department. The emergency physicians gave the medical students, junior emergency residents, and student nurses general trauma resuscitation lectures based on advance trauma life support (ATLS). The junior medical staffs participated in trauma resuscitation scenarios with human simulators. A debriefing was given after every scenario by emergency physicians.
Results: All participants evaluated the medical simulation positively and a majority demonstrated improved knowledge and skills. The course modulators also learned lessons that will help better design future trauma education programs, including an emphasis on simulations over didactic lectures and the importance of group debriefing on trauma resuscitation. Drawbacks included the major time commitment for standard simulation scenarios design and implementation, sustainability, and the lack of resources to apply this curriculum for all the health care staff. The simulation-based trauma resuscitation program offers a positively evaluated possibility to enhance junior medical staffs’ performances in handling trauma patients.
Conclusion: Although it is difficult to teach the junior medical staff diagnosis and management of the trauma patient, specifically those who require resuscitation from different experts, simulation is an effective and safe model for them to learn how to engage and participate in trauma resuscitations with the concerns for patient safety. Human simulators play an important role in modern medical education, but their efficacy remains unclear. The correlation between simulator-based trauma resuscitation and real-world performance deserves objective evaluations in the future.
1. Simulation in resuscitation teaching and training, anevidence based practicereview. Sahu S, Lata I. J Emerg Trauma Shock. 2010 Oct;3(4):378-84. PMID: 21063561 [PubMed] PMCID: PMC296657.
2. Simulation-based learning: Just like the real thing. Lateef F. J Emerg Trauma Shock. 2010 Oct;3(4):348-52. PMID:21063557 [PubMed] PMCID:PMC2966567.
3. The development of a comprehensive school-wide simulation-based procedural skills curriculum for medical students. Sullivan M, Nyquist J, Etcheverry J, Nally M, Schaff P, Abbott A, Elliott D, Taylor C. J Surg Educ. 2010 Sep-Oct;67(5):309-15. PMID: 21035771 [PubMed - indexed for MEDLINE].
4. Use of simulator-based medical procedural curriculum: the learner’s perspectives. Shanks D, Wong RY, Roberts JM, Nair P, Ma IW. BMC Med Educ.2010 Nov 8;10:77. PMID: 21059253 [PubMed - indexed for MEDLINE] PMCID: PMC2988805.
5. Assessing medical decision making using human patient simulation. Fox BA. Fam Med.2010 Oct;42(9):661-3. PMID: 20927680 [PubMed - indexed for MEDLINE].
6. Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns. Gordon JA, Alexander EK, Lockley SW, Flynn-Evans E, Venkatan SK, Landrigan CP, Czeisler CA; Harvard Work Hours, Health, and Safety Group (Boston, Massachusetts). Acad Med. 2010 Oct;85(10):1583-8. PMID: 20881679 [PubMed - indexed for MEDLINE].
7. How to measure the quality of the OSCE: A review of metrics-AMEE guide no. 49. Pell G, Fuller R, Homer M, Roberts T; International Association for Medical Education. Med Teach. 2010;32(10):802-11. PMID:20854155 [PubMed - indexed for MEDLINE].
1435 Computerized Standardized Preoperative Patient Interview Simulator
Jason Epstein, MD1, Samuel DeMaria, Jr, MD1, and Adam Levine, MD1ANESTHESIOLOGY, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: Performing a preoperative evaluation is a critical skill for anesthesiologists.1 Training and assessing the performance of preoperative evaluations with standardized patients is expensive, time consuming, resource intensive. In certain cases, virtual humans may provide more fidelity than standardized patients for certain kinds of pathophysiology.2 Residents are increasingly familiar and comfortable with virtual reality and this technology has the potential to offer a scalable, portable solution to such a problem. We created a virtual human preoperative patient interview simulator (Avatar) as a joint project with LogicJunction, Inc. (Cleveland, Ohio). The Avatar presents an immersive environment to match the sensory experience of interviewing a patient in the holding area of our hospital. Users may ask free text questions of the patient, as well as perform physical examination and order relevant laboratory studies. The AI model for the Avatar was created through an iterative test-build process. At the conclusion of the interview, the participant entered his/her assessment and anesthetic plan and was given performance based feedback based on a 23-item checklist generated by a panel of anesthesia experts via a modified Delphi process.
Methods: All 24 CA-1 residents in our program were recruited to participate in this study at four months into their training. As part of a standard performance assessment, residents were asked to perform a preoperative interview on an ASA 2 female patient presenting for emergent appendectomy. The residents were randomly assigned to interview the Avatar or a standardized patient. Interviews with a standardized patient were observed and adherence to feedback criteria was recorded. Performance of residents interviewing the Avatar was assessed by reviewing system logs.
Results: Group makeup as determined by characteristics and self-reported confidence in performing resident duties was comparable. Residents interviewing the Avatar spent 1.75 minutes longer asking questions (7.33 +/- 0.9 min vs 4.48 +/- 0.5 min; p=0.002); however, the total number of questions asked was comparable (26.92 +/- 2.3 vs 29.00 +/- 1.5; p=0.09). Residents interviewing the Avatar were more likely to perform a physical examination (83% vs 33%) and check vital signs (83% vs 8%). Overall performance as measured by total scores on feedback criteria were similar (16.25 +/- 0.6 vs 16.58 +/- 0.5; p=0.26).
Conclusion: Resident performance of preoperative interview on a virtual reality simulated patient and a standardized patient was comparable. While average interview time was increased, total number of questions, and performance on objective feedback criteria was similar between the two groups.
1. Pasternak LR. ASA practice guidelines for preanesthetic assessment. Int. Anesthesiol Clin. 2002 Spring;40(2):31-46. Review. PubMed PMID: 11897934.
2. Wendling AL, Halan S, Tighe P, Le L, Euliano T, Lok B. Virtual humans versus standardized patients: which lead residents to more correct diagnoses? Acad Med. 2011 Mar;86(3):384-8.
1464 Simulated Arterial Blood Pressure Feedback Improves Chest Compression Quality in a Single Rescuer Model
Samkon Gado, BS1, Martin Rieke, Dipl-Phys3, Paul Nietert, PhD2, Carlee Clark, MD1, Larry Field, MD1, Cory Furse, MD, MPH1, Matt McEvoy, MD1, and Horst Rieke, MD, PhD1
1ANESTHESIA AND PERIOPERATIVE MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 2MEDICINE (BIOSTATISTICS), MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 3PHYSICS, RUHR-UNIVERSITY BOCHUM, BOCHUM, NRW, DEU
Introduction/Background: High quality chest compressions (CC) are vital to success of cardio-pulmonary resuscitation (CPR), but have room for improvement.1 ACLS guidelines, designed as “one-size-fits-all” for lay rescuers, may fail to regard the variance of individual hemodynamic responses to CC. Individually adjusted CC may increase perfusion pressures, but would require real-time hemodynamic feedback, which is known to be effective.2 Such feedback could be established in the perioperative setting with an invasive arterial blood pressure (BP) display, which would enable the compressor to adjust CC. Thus, single specialized rescuers, going beyond ACLS guidelines, could possibly improve CPR results.3 Accordingly, this study tested the hypothesis that single-rescuer CC quality can be improved with real-time BP-display.
Methods: After IRB approval and informed consent, twenty 2nd year medical students in above average physical condition were enrolled. An endotracheally intubated, high-fidelity mannequin was equipped with additional hardware and software, comprised of a linear potientiometer/ microprocessor unit and a mathematical hemodynamic model. It allowed quantitative analysis of CC to calculate and display in real-time the achieved BP. The mathematical hemodynamic model represented a dampened harmonic oscillator coupled to a decaying reservoir. Compression rates of 100/min, depth of 5 cm, a 50% duty-cycle allowing for full recoil, and a delayed response requiring 5 effective CC for an optimized BP result were used as baseline parameters for computation of the BP-display, which ranged from 0 to 100 mmHg. The target parameter for data analysis was the area under the BP curve over time (AUC). Two CPR sessions were scheduled for each student over 2 days, one with and one without BP-display. During each session, students performed CC in five 2-minute-cycles with 10 second interruptions for simulated pulse checks. The study sessions were arranged such that possible improvements of CC due to learning effects would be taken into account. Data was analyzed and presented statistically as mean ± standard deviation for non-compared data and as mean with 95% confidence interval for comparisons. Significance was defined with p<0.05, and paired t-test was used.
Results: Five females and 15 males, who endorsed regular physical exercise of 5 hours/week were enrolled (age 25±2.7 years, weight 76.9±13.4 kg, and height 178±11.6 cm). Twenty CPR sessions with an average mean arterial pressure (MAP) of 43.3±8.7 mmHg for CC without BP-display and twenty CPR sessions with an anverage MAP of 50.9±6.1 mmHg for CC with BP-display were analyzed. The average AUC for CC without BP-display was 5201 units (95% CI of 4804-5597), and 6110 units (95% CI 5715-6507) (p<0.0001, see ) for CC with BP-display. The averaged increase of AUC from CC without to CC with BP-display for each student was 20.2%±17.4. showing the average AUC with 95% confidence bar for CC without and CC with BP-display.
Conclusion: Our study confirms the hypothesis that a real-time BP-display during CPR allows for continuous adjustment of CC, thereby improving and maintaining the achieved BP quality of CC. Our data also confirms the legitimacy of employing measures beyond current ACLS guidelines for CPR in the high-tech environment of perioperative medicine. Regarding the learning effect due to BP-display, the common practice of rotating the compressors every two minutes could be reconsidered. Single, physically fit compressors could optimize CC over time, although being at risk of fatigue. Further simulation studies employing hemodynamic modeling and BP-display could disclose advantages of modified guidelines for high-tech environments.
1. Cardiocerebral Resuscitation: The New Cardiopulmonary Resuscitation. Ewy GA. Circulation. 2005; 111:2134-2142 PMID: 15851620 [PubMed - indexed for MEDLINE].
2. A counterbalance cross over study of the effects of visual, auditory and no feedback on performance measures in a simulated cardiopulmonary resuscitation. Cason CL, Trowbridge C, Baxley SM, Ricard MD. BMC Nursing, 2011. 10(1):15 PMID: 21810239 [PubMed].
3. Anesthesia Advanced Circulatory Life Support. Moitra VK, Gabrielli A, Maccioli GA, O’Conner MF. Can J Anesth/J Can Anesth. 2012. 59:586-603 PMID: 22528163 [PubMed - in process].
1469 Simulation-based Assessment and Retraining for the Anesthesiologist: A Case Series of Twenty Participants
Stefan Samuelson, MD1, Samuel DeMaria, Jr, MD1, Andrew Schwartz, MD1, Alan Sim, MD1, and Adam Levine, MD1ANESTHESIOLOGY, MOUNT SINAI SCHOOL OF MEDICINE, NEW YORK, NY, USA
Introduction/Background: Anesthesiologists are a heterogeneous group, and current models of determining and maintaining competency in physicians may be inadequate for those with greater needs. We present a case series of 20 participants in which the simulated OR environment provides an effective means by which to assess baseline competency in this specialized population, as well as a way to retrain physicians prior to return to clinical practice. Competency in anesthesia is a moving target throughout one’s career.1,2 The current model for assessment and maintenance, namely the ABA examination and MOCA programs, may not be adequate for all anesthesiologists; specifically, those whose needs are greater due to limited scope of practice, hiatuses from clinical duty, or medico-legal issues. While the use of simulation in anesthesia education has received increasing attention in recent years,3 at present few programs exist to address the needs of this specialized sub-population.4,5,6 Herein we describe a program developed in our institution using combined written and simulator-based education to help determine competency in licensed and previously-licensed anesthesiologists prior to return to clinical practice.
Methods: We have been using simulation as a tool for assessment and retraining at our institution since 2002. Physicians are referred or self-refer to our center with various needs: assessment, retraining, OR observation, or a combination of these. An initial needs assessment is followed by a feasibility assessment and finally an offer back to the participant or referring body regarding pricing, length, and a course of action specific to the participant’s needs. The participant then undergoes a four-hour simulator orientation, followed by an adaptable two-day formal simulation-based assessment conducted with two board-certified anesthesiologists observing the cases in real time and two other support staff who portray other OR personnel as indicated. A minimum of three cases are presented on each day with specific ACGME core competencies assessed. The assessment process is adjusted on an ongoing basis at the observer’s discretion to fully characterize areas of competency which need improvement. In addition, participants complete a standard CA-3 level Anesthesia Knowledge Test (AKT). After written and simulation-based assessment is completed, participants are debriefed extensively on their results. When indicated, a retraining regimen is designed, which is specific to their needs, but usually consists of a combination of simulation and observership with 3-4 simulated cases per day followed by 4 hours of OR time.
Results: Twenty anesthesiologists were referred to our institution between 2002-2012 for assessment. Thirteen of the 20 participants were available within one year of their program’s completion for a follow up survey. Eleven of these (55%) had successfully returned to practice. Five (25%), per our recommendations, were in supervised positions (i.e. residency, fellowship, or supervised clinical practice) and 8 (40%) were able to resume their old positions or took new positions without delay or need for supervision. Four of the 20 participants (20%) were not in practice as of one year after our program. The reasons were personal (1 participant) and medicolegal (3 participants). Two of the 14 physicians who were formally assessed in our program were deemed unlikely to improve adequately even with retraining or supervision. These physicians were unavailable for contact one year after assessment and their current employment statuses are unknown.
Conclusion: Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.
1. Gallagher CJ, Tan JM. The current status of simulation in the maintenance of certification in anesthesia. Int Anesthesiol Clin. 2010;48(3):83-99.
2. American Medical Association: Report 6 of the Council on Medical Education (A-08). Physician reentry Chicago; 2008 [http://www.ama-assn.org/ama1/pub/upload/mm/377/cmerpt_6a-08.pdf], accessed 7 April 2012.
3. Steadman RH. The American Society of Anesthesiologists’ national endorsement program for simulation centers. J Crit Care. 2008;23(2):203-6.
4. Varjavand N, Greco M, Novack DH, Schindler BA. Assessment of an innovative instructional program to return non-practicing physicians to the workforce. Med Teach. 2012; 34(4):285-291.
5. Larson CP, Steadman RH. An advanced specialty training program in anesthesiology: a special educational fellowship designed to return community anesthesiologists to clinical practice. Anesth Analg. 2006;103(1):126-30.
6. DeMaria S Jr, Levine AI, Bryson EO. The use of multi-modality simulation in the retraining of the physician for medical licensure. J Clin Anesth. 2010;22(4):294-9.
1471 Can 5 Minutes Really Make a Difference?
Patricia Ouellette, MSN4, Angelic Sorrell, MSN-ED2, Kristine Jose, ADN, PCCN1, and Patricia Denton, ADN, RN3
1INTERANL MEDICINE, VIDANT MEDICAL CENTER, GREENVILLE, NC, USA and 2CLINICAL SIMULATION CENTER, EAST CAROLINA UNIVERSITY BRODY SCHOOL OF MEDICINE, GREENVILLE, NC, USA and 3EMERGENCY RESPONSE TEAM, VIDANT MEDICAL CENTER, GREENVILLE, NC, USA and 4STAFF DEVELOPMENT, VIDANT MEDICAL CENTER, GREENVILLE, NC, USA
Introduction/Background: The nursing leadership at Vidant Medical Center, an academic medical center in eastern North Carolina, identified a staff development need related to quality outcomes and patient safety. With increases in cardiac monitored patient beds and patient acuity levels, a need for staff to respond quickly to changing patient status was apparent. Literature reviews support the need for the use of simulation training scenarios before these events occur in actual clinical care to assess resuscitation quality based on the performance of the team.1 A team of nursing educators, leadership and staff decided that the varying levels of staff experience, time and space constraints did not lend itself to a realistic goal for all nursing staff caring for cardiac monitored patients to be certified in Advanced Cardiac Life support. An American Heart Association (AHA) approved program, The First 5 Minutes® 2 (FFM), quickly became the topic of discussion as a viable option. The purpose of this research was to explore the impact of the FFM educational program on staff’s perception of competency and confidence and the factors that potentially impact patient care management during an emergent situation.
Methods: A descriptive design was utilized to evaluate the staff perception of competency and confidence in patient care management during a patient crisis situation. All of the unit’s Registered Nurses and Certified Nurse Assistants from the selected medical surgical pilot unit participated in the FFM education. Each participant was asked to complete a pre and post quiz. Unit staff was also asked to complete a Post Crisis Survey for each event that required Emergency Response Team (ERT) calls within the six month post education timeframe. Retrospective data from patient safety rounds, ERT quality data and calls was reviewed prior to and post implementation of the standardized educational offering of the FFM curriculum which served as the basis of comparison for analysis of the impact of program.
Results: Gold Standards help hospital teams save lives threatened by cardiopulmonary emergencies through consistent application of the most up-to-date scientific guidelines for in-hospital resuscitation.3 The ERT quality data revealed zero failures in deviations in the Gold Standards as measured by the AHA as compared to two failures in the prior twelve month timeframe. Quiz data indicate a trend-line in improvement of correct responses in all areas however the most significant improvement was in the areas of airway management and Automatic External Defibrillator (AED) utilization. The post crisis survey indicated that the staff “strongly agreed” with the ability to recognize a patient in crisis and active the ERT.
Conclusion: Despite the importance of teamwork and the delivery of quality care these skills are not typically included in healthcare profession curriculum.4 Findings of this pilot study support that providing education to Registered Nurses and Certified Nurses Assistants with the FFM curriculum improved preparedness of the patient care environment and increases staff perception of comfortable level with the crisis. Despite limitations to this research project such as: patient condition, staff mix, and lack of medical staff participation in the FFM curriculum, the data supports a positive impact on staff’s perception of competency and confidence with patient care management during an emergent situation.5 Data supports utilization of the FFM curriculum as a standard educational course within the organization and is currently being implemented with interprofessional teams that include RNs, CNAs and Respiratory Therapists (RTs). FFM is also offered to medical residents and attending physicians during residency conference sessions.
1. Wayne DB, Didwaina A, Fudala M, et. Al. Simulation –based education improves quality of care during advanced cardiac life support events: a case control study. Chest 2008;133:56-61.
2. Hunt Ea, Walker AR, Shaffner DH, Miller MR, Pronvost PJ. Simulation-of in-hospital pediatric medical emergencies and cardiopulmonary arrest: highlighting the importance of the fist 5 minutes. Pediatrics2008;121(1)e34-43.
3. American Heart Association. Get with the Guidelines Resuscitation. Site reviewed: June 10,2012. http://www.heart.org/HEARTORG/.
4. Institute of Medicine. Health Professions Education: A bridge to Quality. Washington, DC: National Academy Press; 2003.
5. Thomas EJ, Taggart B, Crandell S, et. al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. J Perinatal 2007;27:409-414.
Oral Presentation 1472 Non-parametric Resampling in Evaluating Reductions in Pneumothorax Rates and Hospital Charges of a Simulation-based Educational Intervention
Zachary Klein, PhD student3, Jesus Seda, BS1, Joshua Lenchus, DO, FACP, SFHM2
1ANESTHESIOLOGY, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA and 2MEDICINE, UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, MIAMI, FL, USA and 3ANESTHESIOLOGY (ECONOMICS), UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE, STATE UNIVERSITY OF NEW YORK, ALBANY, ALBANY, NY, USA
Introduction/Background: Patient safety has received considerable attention in recent years, particularly with respect to the ensuing costs of error.1,2 This literature makes clear the room for improvement, both in outcomes and the financial burden associated with current inefficiencies. To strengthen our institution’s alignment with these concerns we have implemented a simulation-based training program, teaching invasive bedside procedures to groups of medical residents. Our Procedure Team has demonstrated significant improvement over control-group performance regarding pneumothorax occurrence during thoracentesis. Our aim was to standardize sample demographics within the Team and control-group data, facilitating comparison and the incorporation of published figures on excess charges after pneumothorax.
Methods: Control data is obtained from 308 thoracenteses performed hospital-wide (excluding Procedure Team participants) between July 2007 and June 2008. The Procedure Team performed 95 thoracenteses during that period, and another 323 from July 2008 through June 2011. The one-year Team pneumothorax rate of 3/95 (3.16%) depicts an improvement in delivery of this procedure over the control rate of 17/308 (5.52%). The four-year Team rate of 8/418 (1.91%) showed statistically significant improvement over the control. However, these samples are not uniform in demographic composition, and speak little of the economic gains. Two studies, Shreve et al.3 and Zhan & Miller,4 convincingly assessed the costs of treating pneumothorax. Each calculated statistically significant excess charges of a large, control-matched group after pneumothorax. Further, they described specifically the gender-age distribution for their samples, allowing us to construct similarly-composed subsamples of our data (subsamples are of size 82, drawn with replacement). This effectively created standardized samples, facilitating comparison and incorporation of reported excess charges. Four pools of subsamples are required: both Team and hospital-wide samples each conforming to the demographic distribution of the two comparative studies. We attempted to mimic our single service-provider delivering roughly one thoracentesis per day for a year. Thus, we randomly drew 5 subsamples (410 procedures) from each data set, matched to each study (four sets of 410). The pneumothorax rate was recorded for each set of 410 procedures. This process was performed 100,000 times, producing a distribution of sample means; the pneumothorax rates we might encounter, insofar as our sample is representative. Finally, once our sample demographics agreed, excess hospital-charge estimates were applied to the analysis. The two studies reported figures of $27,570 (Shreve, et al.) and $17,312 (Zhan & Miller).
Results: Baseline comparisons (four-year Team rates to 2007-2008 hospital-wide) showed a 65% reduction in pneumothorax occurrence. However, the analysis indicated this reduction was closer to 73%, a consistent across demographic structures. Using the published excess charge rates, some $867-$1,188 in charges were avoided for every thoracentesis performed by our Team. In the four-year period under question, this amounted to between $362,544 and $496,695. If the Procedure Team performed all thoracenteses in our hospital during those four years, the reduction could have been between $1,431,096 and $1,960,640 (assuming 308*4 + 418 procedures).
Conclusion: Pneumothorax-rate estimates declined for the Procedure Team once our samples conformed to the demographic distributions of published studies. Conversely, rate estimates increased when the same procedure was applied to hospital-wide data (excluding Procedure Team participants). Such a process should be standard in reporting complication rates. Further, the calculation of unnecessary charge avoidance is staggering, both in magnitude and when considering that thoracentesis is one of five procedures performed by the Team.
1. Thomas EJ, Studdert DM, Newhouse JP, Zbar BI, Hoawrd KM, Williams EJ, et al. Costs of Medical Injuries in Utah and Colorado. Inquiry. 1999; 36:255–264.
2. Johnson WG, Brennan TA, Newhouse JP, Leape LL, Lawthers AG, Hiatt HH, et al. The Economic Consequences of Medical Injuries. JAMA. 1992 May 13;267(18):2487-2492.
3. Shreve J, Van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. The Economic Measurement of Medical Errors. Schaumburg, IL: The Society of Actuaries, The Society of Actuaries Health Section; 2010 Jun.
4. Zhan C, Miller MR. Excess Length of Stay, Charges, and mortality Attributable to Medical Injuries During Hospitalization. N Engl J Med. 2003; 290:1868–1874.
1484 Are Movements of the Team Members in Obstetric Scenarios Related to Crew Resource Management Training in a Medical Simulation Center?
Annemarie Fransen, MD,2, Bas Oei,1 and Guid Oei, MD, PhD2
1AMSTERDAM, NLD and 2OBSTETRICS AND GYNECOLOGY, MAXIMA MEDICAL CENTER, VELDHOVEN, NLD
Introduction/Background: Crew resource management (CRM) courses teach healthcare teams about clear communication and leadership. The leader of the team should gather the available information, summarize, take decisions, and give instructions to the other team members. In this study the hypothesis is tested that the team leader moves less than other members of a medical team after they have received CRM training in a simulation center.
Methods: Twenty multi-professional obstetric teams who underwent a one-day course in a medical simulation center about CRM participated in this study that was part of a cluster randomized controlled trial. Before and after providing instructions about CRM ten different teams were videotaped during two different scenarios. The obstetric scenario before instruction was about shoulder dystocia and the scenario after instruction was about post partum hemorrhage. The video recordings were evaluated by an independent team of four observers who measured the time that different members moved during the scenario. Main outcome was the relative time: the absolute time the participant was moving divided by the absolute time the participant was in the room during the scenario.
Results: Eighteen gynecologists, 17 midwives, 3 residents, and 50 nurses participated in this trial. The average relative time that the gynecologist, midwife, and principal nurse moved during the scenario before the CRM course was given was resp. 9.34% (SD 3.49), 3.09% (SD 3.1), and 8.1% (SD 4.0) and after the CRM course resp. 6.27% (SD 3.43), 8.66% (SD 5.62), and 15.05% (SD 8.39). Eighteen scenarios could be used for analyses. In nine scenarios before and nine scenarios after the CRM course the relative time of the leading obstetrician could be compared to the other team members. In one of the scenarios before and in five of the scenarios after the CRM course the obstetrician moved less than the other team members (Fisher’s exact test p=0.06).
Conclusion: In an obstetric emergency the gynecologist should take the lead, followed by the resident, midwife, first nurse, second nurse, and third nurse. In this study the gynecologist did not move less than the other team members during an obstetric simulation scenario, but after an oral presentation and simulation training with focus on CRM the gynecologist moved less (not significant) than the other team members. There seemed to be a hierarchical order in which team members move. This is consistent with the principles of good leadership where one expects that the leader moves less than the other team members. Measurement of movement during obstetric emergency scenarios might therefore be an objective instrument to provide the team of feedback.
Disclosures: Guid Oei, MD, PhD is the Medical Director of Medical Education and Simulation Center at Maxima Medical Center, Veldhoven, Netherlands.
1492 Differences between Knowledge and Skills in ALS Among 1st Year Anesthesiology Residents in France
Grigoresco Benedicte, Resident1, Alexandre Mignon, MD3, and Antoine Tesniere, MD, PhD2
1ANESTHESIOLOGY AND INTENSIVE CARE, ASSISTANCE PUBLIQUE HOPITAUX DE PARIS, PARIS, FRC and 2INTENSIVE CARE, ILUMENS, APHP, PARIS, FRA and 3ANESTHESIOLOGY, UNIVERSITY PARIS DESCARTES, PARIS, FRA
Introduction/Background: The level of both knowledge and skills in performing ALS in anesthesia residents in France is poorly evaluated. During a regular simulation training for anesthesia residents, we tried to evaluate the knowledge and skills of 1st and 2nd year (respectively n=80 and n=65 students)) anesthesiology residents for performing CPR when facing an unexpected cardiac arrest situation. Among mandatory simulation training, we included a simulated CPR evaluation to adress this important question.
Methods: The assesment of theoritical knowledge and skills on ALS was first performed with a self evaluation form, that was given right before the simulated scenario, and that was sent after 5 months to test the retention of the knowledge. This form was based on the lastet ILCOR recommandations (2010), validated by two independent experts, and also included training informations concerning the residents. The residents were then asked to undergo a simulated scenario of CPR where they are required to take care of a 55 year old patient in pre hospital situation, first alone, and then with the hel p of a witness. The test was performed on a RescuciAnn Skill Station. Recorded parameters included the frequency of chest compressions, as well as depth of chest compression, and hands on time. After informed consent, all residents were video recorded during the scenario. The gold standard of clinical response in this scenario was defined by two experts and five anesthesiology professors, and was used to establish an objective criteria evaluation form. All recordings were reviewed off line by a work psychologist to assist the clinical evaluation performed by the examinator.) Statistical analysis was performed to compare the answers to the initial evaluation form with the observed clinical skills at day 0 and at 5 months. A p value < 0.05 was considered to be statistically significant.
Results: 145 residents were enrolled in the study. All responded to the initial evaluation form, but only 38% did fill the 5 months evaluation form. All 1st and 2nd year residents performed an acceptable level of theoritical knowledge on BLS and ALS, with no difference between the 1st and 2nd year residents. Most of the residents (94%) described appropriately the diagnosis signs of CPR, as well as the different steps for performing CPR (92%), the main features of chest compressions (95%), the use of epinephrine (83%), and the different algorithms for asystolia (92%) or venticular fibrillation (94%) in advanced life support. However, when asked to perform CPR in a specifically designed simulation scenario, skills were not correlated with theoritical knowledge. The diagnosis of asystolia, when present, was only performed in 62 % of the residents. Similarly, the main progonostic factors, and the benefits of hypothermia after CPR were poorly achieved (25% and 40 % respectively). Also, an insufficient number of residents performed an appropriate call for help (35%), or asked for an AED (50%). The data recored and analysed from the mannikin showed that the overall hands on time is only 45% +/_ 9%, and that the average chest compression rythm is 92+/_8 bpm. This acceptable knowledge was probably due to the recent participation of 78% of the residents to an ALS situation (either in anesthesia, intensive care, pre hospital teams or operating room rotations), observed on the initial evaluation form.
Conclusion: The knowledge of BLS and ALS in 1st and 2nd year anesthesiolgy and intensive care residents in France is rather good, but is in contrast with poor performance in skills for performing CPR. From the analysis of the data, we will identify the potential gaps in training and will propose appropriate simulation training to reduce the difference between knowledge and skills when performing CPR.
1528 An Application of a Clinical Map to E-mail Tutorials with a Quantitative Evaluation of Two-dimensional Knowledge Structure in an Emergency Department
Yasuhiko Ajimi, MD, PhD2, Tetsuya Sakamoto, MD, PhD2, Takehiro Nakamura, MD, PhD1, Benjamin Berg, MD3, and Hiroshi Okudera, PhD, MD4
1NEUROLOGICAL SURGERY, KAGWA UNIVERSITY, MIKI, KAGAWA, JPN and 2EMERGENCY MEDICINE, TEIKYO UNIVERSITY, SCHOOL OF MEDICINE, ITABASHI, TOKYO, JPN and 3SIMTIKI SIMULATION CENTER, UNIVERSITY OF HAWAII, JOHN A BURNS SCHOOL OF MEDICINE, HONOLULU, HI, USA and 4CRISIS MEDICINE, UNIVERSITY OF TOYAMA, TOYAMA, JPN
Introduction/Background: To know the true meaning of a medical word is to put the word into practice adequately in a medical situation. We must know the timing and the category to use the word more precisely when we put the word into practice in emergency. Both of the timing and the categories of the medical words form two-dimensional knowledge structure. We reported a new method to evaluate medical knowledge structure in emergency department using a clinical map (CM) on Research Abstract in the last IMSH. This time, we utilized a CM as a material of e-mail tutorials of emergency medicine for medical students.
Methods: Fifty four medical students in fifth-year participated in this study. A CM has a tabular structure like a clinical pathway and consists of a frame and elements. The horizontal axis of the frame means steps of an algorithm and vertical axis means the categories of medical practice consisting of physical and physiological examinations, blood/urinary examinations, imaging tests and treatments. The elements mean specific examinations, its results or treatments such as anisocoria, 12-lead ECG, atrial fibrillation, oxygen mask 6L/min, or extracellular fluid. We removed twenty four elements from a CM which expressed an initial management for a patient with severe ischemic stroke and designed a training to return those 24 elements to the exact places in the CM frame represented in a Excel file. We called this training a CM puzzle. Each student performed the CM puzzle before bed side learning. After the each puzzle game, we counted the number of erroneous, unused and correct elements. Erroneous elements were classified into three categories: step errors, practice errors and both errors.
Results: (1) Step errors: mean (SD), maximal and minimal numbers of 54 students were 6.9 (2.8), 14 and 2. (2) Practice errors: 0.7 (0.7), 3 and 0. (3) Both errors: 0.4 (0.7), 3 and 0. (4) Unused elements: 0.6 (1.5), 6 and 0. (5) Correct elements: 15.4 (3.0), 21 and 9.
Conclusion: The results showed their structure mistakes of an initial management for a patient with sever ischemic stroke. Step and practice errors mean lack of understanding timing to perform the practices and lack of understanding the meaning of the practices themselves, respectively. We could implement e-mail tutorials about true meaning of each medical word in the initial management for a stroke patient in the ED. E-mail tutorials for medical students using a CM puzzle game enable us to evaluate their two-dimensional medical structures in emergency medicine.
1. Ajimi Y, Okudera H et al. Knowledge management in ISLS course Introduction of a group work training using clinical maps for an initial treatment of stroke. Journal of Japanese Congress on Neurological Emergencies (2010) 22: 1-5.
2. Ajimi Y et al. Group Work with Clinical Maps: A new training method for constructing a medical knowledge structure of stroke in ER. WIP, 10th IMSH, 2010.
3. Ajimi Y et al. Utility of puzzle type of clinical maps as a training material for an initial treatment of stroke. WIP, 11th IMSH, 2011.
4. Ajimi Y et al. A new method for quantitative evaluation of medical knowledge structures in emergency room by a clinical map. Research Abstract, 12th IMSH, Jan. 30, 2012.
5. Ajimi Y et al. Handout of ISLS course. module D: Tabletop Exercise using Clinical Map Puzzles, Pre-course WS. 12th IMSH, Jan. 28, 2012.
Disclosures: Benjamin Berg, MD is on the CME/CNE Speaker’s Bureau for Laerdal Medical.
1540 Beyond the ADA: Standardized Patients with Physical Disabilities
Donald Woodyard, BS1, Brian Loveland, MPH1, and Pranay Prabhakar, BS1
1CLINICAL SKILLS AND PATIENT SIMULATION CENTER, UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, CHAPEL HILL, NC, USA
Introduction/Background: In 2005, the US Surgeon General issued a call to action to “improve the health and wellness of persons with disabilities.” The report cited a failure of medical education programs to teach health professional students concepts of disability and how to treat the whole patient with a disability appropriately. While didactic lectures can provide an important framework for understanding ADA requirements and assessing, treating and managing patients with disabilities, learners must be afforded the opportunity to both practice and be assessed on their clinical skills with persons with disabilities.
Methods: We introduced an Observed Structured Clinical Examination (OSCE) case for a patient presenting with fatigue secondary to new onset diabetes. Two very similar versions of the case were presented. Both patients experienced a severe car accident seven years earlier that resulted in chronic pain and reduced physical activity; however, one patient suffered a Spinal Cord Injury (SCI) while the other had not. While the SCI patient did require slight modifications to the medical history, such as using a catheter, most relevant social and medical history items were kept constant between the two cases. Both patients presented with fatigue worsening over 6-weeks, increased thirst and urination, and recent weight loss. The SCI patient used a wheelchair. Fourth year medical students were randomly assigned to see only one version of the case during their Clinical Performance Examination (CPX). Students were instructed to take a focused history and provide a routine focused physical examination and were not informed of the disability status of the patient prior to the encounter. For the SCI patient, students were permitted to complete the physical examination in the wheelchair or to assist the patient to the exam table to complete the physical examination. Each encounter was allotted a maximum of fifteen minutes for the history and physical exam with the patient followed by ten minutes for ordering labs and completing a 20-item questionnaire using a 4-point Likert Scale (0-3). The SP completed a 28-item checklist on history questions asked and physical exam techniques performed and a 10-item relationship and communication instrument.
Results: Seventy-eight students saw the SCI case, while 89 saw the non-disability case (N=167). From the student post-encounter questionnaire, all students reported feeling comfortable around persons in wheelchairs with a mean of 2.91 following the SCI encounter compared to 2.84 from the non-disability case. Students reported feeling “sorry for” persons with disabilities significantly less following the SCI encounter with a mean of 1.76 compared to 2.27 on the second case. Students also reported feeling awkward having to examine patients during the CPX 32.5% of the time following the SCI compared to 25.9% in the other case. For a fatigue case with a significant history of increased urination, students elicited the information significantly more often (100% compared to 79.8%) during the SCI encounters. Students varied significantly on appropriate completion of all physical examination techniques most notably by doing physical examination techniques over the gown for the SCI patient.
Conclusion: The SCI case ran successfully, demonstrating that SP encounters with patients with physical disabilities is reasonable. This can be used as both a teaching and assessment tool. Students report feeling comfortable around persons in a wheelchair regardless of whether they had recently encountered one. However, students reported feeling sorry for patients with disabilities significantly less often when they had just seen the patient with a disability. Students approached the history and physical examination differently between the two patients. While that may be expected, students focused on more obvious external observations (emptying the catheter bag) and did not attempt to examine on bare skin for the patient with SCI. More opportunities to work with patients with disabilities should be provided to medical students.
1543 Comparative Human Factors Evaluation of Three Hospital Defibrillator User Interfaces
Richard Fidler, CRNA, CRNP, MSN, MBA1, and Meshell Johnson, MD2
1HEALTHCARE SIMULATION PROGRAMS, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA and 2PULMONARY CRITICAL CARE, SAN FRANCISCO VETERANS AFFAIRS MEDICAL CENTER, SAN FRANCISCO, CA, USA
Introduction/Background: In-hospital cardiac arrest continues to be a major public health problem with much room for improvement in survival. Equipment-related issues have recently been cited as a significant contributor to the suboptimal outcomes of resuscitation management. A systematic evaluation of the human-device interface was undertaken to evaluate the intuitive nature of each competing defibrillator that met minimum equipment specifications.
Methods: A convenience sample of 74 multidisciplinary nurses, physicians, and biomedical engineers participated in this IRB-approved study at 5 different hospitals. All subjects’ performances were evaluated without any training or orientation to the devices being evaluated to assess the intuitive nature of the user interface. Head cameras and direct timed observations of performance were obtained by 2 raters in a structured, simulation-based usability evaluation, with follow up interviews on attitudes and recommendations that were conducted in private in clinical units. Each manufacturer supplied devices that met minimum specifications of AED and manual defibrillation modes, synchronized cardioversion, transcutaneous pacing, noninvasive blood pressure measurement, pulse oximetry, and waveform capnography. Devices tested were the Physio-Control LifePak 15, the Zoll R Series Plus, and the Philips MRx.
Results: There were significant differences in the usability of the devices: timed performance of critical steps for use of AED for ventricular fibrillation, manual defibrillation of VT, synchronized cardioversion of rapid atrial flutter, and transcutaneous pacing of complete heart block are shown in the . In this study, the Zoll was the fastest for AED shock, Philips for manual defibrillation, and Physio-Control for transcutaneous pacing. Participants also shared that the Philips was lightest and most portable; the Physio-Control was heaviest but most durable, and the Zoll was the simplest looking device.
Conclusion: Each device tested has positive and negative attributes for consideration in the context of cost, the amount of staff training, and size/weight for storage and transport when selecting new critical equipment. The characteristics of the end-user are often overlooked in selecting new equipment. Usability evaluations should also include determining the predominant uses of the devices: for example, if the most common use is defibrillation, then data regarding the top-performing device in defibrillation should be weighted more heavily than the best performing pacing function. Furthermore, usability evaluations can produce recommendations for equipment manufacturers to improve the user interface, such as adding color and flashing light to Philips sync button and differentiating energy settings from heart rate on the Zoll display by using different fonts or colors. This study was deliberately conducted without user training to test intuitiveness of usability, so it is expected the performance would improve with any education. Systematic comparison of defibrillator user interfaces allows contextually sensitive evaluation of the device usability prior to purchase demonstrating the utility of human factors evaluations prior to making expensive purchases.
1554 Simulation as an Assessment Tool for Chest Tube Placement by Junior Residents: Is There Need for Additional Training?
Raaj Ruparel, MD3, Shahzad Ali, MD1, David Farley, MD3, and William Dunn, MD2
1GENERAL SURGERY, MAYO CLINIC, ROCHESTER, MN, USA and 2MULTIDISCIPLINARY SIMULATION CENTER, MAYO CLINIC, ROCHESTER, MN, USA and 3SURGERY, MAYO CLINIC, ROCHESTER, MN, USA
Introduction/Background: Our 32 general surgery interns rotate though services that routinely insert chest tubes during their first year. Complication rates associated with tube thoracostomy are nearly 30% for all operators and higher among physicians in training.1 We sought to assess baseline proficiency of chest tube placement within a simulation environment.
Methods: Our 32 general surgery interns participated in a simulated scenario involving a clinical vignette and a model thorax with representations for skin, subcutaneous fat, intercostal muscle, ribs, parietal and visceral pleura. Participants were evaluated for prior training or experience and were assessed using a 7-point checklist based on the ATLS criteria for chest tube placement. A passing score was designated as 7/7.
Results: Of the 32 participants, 11 had received prior training in the form of an ATLS course. All 11 had done so within 4 weeks prior to the simulation. The mean score of the ATLS group was 5.5 (range 4-7, SD = 1.02) with 2/11 receiving a passing score. Of the 21 trainees without prior training, 0/21 achieved a passing score with a lower mean score of 3.6 (range 1-6, SD = 1.66, p= 0.0002). Common errors included failing to digitally examine the incision (n = 24), neglecting to site-prep (n = 17), and inserting the chest tube backwards (n = 5).
Conclusion: While participation in the ATLS course correlates positively with a higher score for chest tube placement, 81% of those with previous exposure did not achieve a passing score. This study exposes a very real need for chest tube training among residents with no prior experience and for recent ATLS course graduates. We are embarking on just such a dedicated, standardized experiential training and evaluation regimen.
1. Bailey RC. Complications of tube thoracostomy in trauma. J Accid Emerg Med. 2000 Mar;17(2):111-4. Pub Med PMID: 10718232.
1588 Implicit Theories to Analyze an Instructor Training Program for Undergraduate Clinical Simulation
Soledad Armijo, MD1, Matilde Pulgar Garcia, MD1, and Karen Vergara, EU1
1CENTRO DE SIMULACION CLINICA, UNIVERSIDAD DIEGO PORTALES, SANTIAGO, CHL
Introduction/Background: The insertion of clinical simulation in undergraduate curriculum not only involves training activities for students, but there is also a need for teachers to be prepared for simulation-based instruction. Clinical simulation assumes adherence to non-traditional teaching models, moving away from models spread among basic science and clinical teachers.1 In the context of developing curriculums, teachers usually come from the clinical setting, and already have multiple parallel academic tasks.2 To build a group of instructors who accept the methodology, and incorporate the principles of positive environment for learning could be a difficult road. The use of elements that can help to select the best instructors could be a valuable tool for simulation-based curriculum innovations. From the psychological perspective, the study of implicit theories is necessary to know the frameworks through the teachers perspective and process information and analyze information from their teaching.3 We thought that the knowledge of teachers’ implicits theories seems likely to contribute to the process of recruitment and the development of instructors in the context of undergraduate simulation. The objective of the study was to describe the results of a Clinical Simulation instructor training program applied to the second phase of curricular insertion at Facultad de Medicina, Universidad Diego Portales, and to analyze the association between the third level of Kirkpatrick and implicit theories of teachers at the time of initial instruction.
Methods: In the process of incorporating simulation into medical and nursing curriculum at Universidad Diego Portales, the teacher training program begins in parallel with the leaders formation as clinical simulation instructors. The contents of the internal teacher training program arose from the professor needs analysis between 2007 and 2010. The courses were implemented on January and July of 2011. At the first day of basic instructor training course, all participants completed an inventory of implicit theories of Javier Marrero. Data from this instrument were analyzed in the traditional way (average of questions associated with each theory and definition of the dominant theories using the highest average). The evaluation of teacher training program was based on the Kirkpatrick model. The tests to evaluate the program were used a Likert survey to assess program satisfaction (validated in 2008), semi-structured qualitative assessment survey and monitoring of curriculum integration projects, to evaluate the transference.
Results: There were 40 participants in the basic training program. On the third level of Kirkpatrick, there was a high transfer to the undergraduate programs (80% of all participants, 100% of teachers of nursing, 87% of teachers of medicine). 52% of the teachers involved in projects to be implemented during 2012; 20% of the teachers had been working only with low-fidelity simulation; 12% only with high fidelity simulation; and 68% with both. Those teachers who did not show a clearly dominant implicit theory formed the group that completed the transfer of basic education to its undergraduate and not working on integration projects in the short term. On the other hand, among those who established the transfer, there was a clear dominance of the profiles associated with interpretive theories among those involved in teaching novice learners, and coincidence of emancipatory theories and activity between developers teaching with students more advanced levels.
Conclusion: The success or failure of educational innovations depends largely on how the professors interpret, redefine, filter and shape changes proposed. The way these mediators operate processes depends on what the teachers think, feel and do and their views about different dimensions of education. A future task is to clarify whether implicit theories can be modified through the years of experience, and if they offer a tool for prediction of stability of the faculty.
1. The Conceptions of In-service and Prospective Primary School Teachers About the Teaching and Learning of Science. Raphael Porlánand Rosa Martín del Pozo. Journal of Science Teacher EducationVolume 15, Number 1(2004), 39-62.
2. Halting the revolving door of faculty turnover: recruiting and retaining clinician educators in an academic medical simulation center. Kim S, Ross B, Wright A, Wu M, Benedetti T, Leland F, Pellegrini C. Simul Healthc. 2011 Jun;6(3):168-75.
3. Marcelo García, C. (1987). El pensamiento del profesor. Barcelona: Ediciones GREAC.
1595 Effect of a Designated Reader and Cognitive Aid on the Resident Performance During Simulation of Perioperative Emergencies
Richard Sedlak2, Jeremy Smalley, MD4, Michael McEvoy1, Jonathan Smalley2, Carlee Clark, MD2, Larry Field, MD2, Cory Furse, MD, MPH2, Horst Rieke, MD, PhD2, Paul Nietert, PhD3, and Matt McEvoy, MD2
1ANESTHESIA, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 2ANESTHESIA AND PERIOPERATIVE MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 3MEDICINE (BIOSTATISTICS), MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 4ORTHOPAEDICS, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA
Introduction/Background: Use of cognitive aids by a team leader has improved performance during high-fidelity simulations of in-hospital cardiac arrest.1 One previous study reported that the use of a designated reader of patient management protocols may increase guideline adherence during perioperative emergencies.2 Accordingly, we conducted a randomized, controlled trial to test whether the addition of a Reader plus electronic cognitive aid (App) was superior for managing multiple perioperative emergencies when compared to management from memory alone.
Methods: After IRB approval and informed consent, 27 anesthesiology residents ranging from PGY1 to PGY4 were enrolled and randomized into two groups: Reader+App (N=14) and Control (N=13). Each resident managed four high-fidelity simulations of perioperative emergencies, which were video recorded for later scoring. The scenarios were Anaphylaxis, ST Elevation Myocardial Infarction (STEMI), Malignant Hyperthermia (MH), and Hyperkalemia (HYPERK). In all cases SimMan3G® and trained confederates were used to simulate the patient and clinical staff, respectively. At a standardized point in the scenarios, the Reader prompted the participant for a diagnosis, and the Reader offered to read protocol steps of that diagnosis for those in the Reader+App group. For the Control group, this person made themselves available to assist in any way needed. In the Reader+App Group, an anesthesia technician was trained and equipped with a novel iOS-based App containing management protocols for numerous perioperative emergencies. The Control group had an equivalent number of confederates available to assist with any task. Performance was assessed using a grading checklist that was developed through a modified Delphi technique and based upon published best-practice guidelines, with certain items deemed to be critical actions (e.g. beta-blockers in STEMI scenario). Performance was recorded as the percentage of overall and of critical items performed during the scenarios. Data is reported as Mean±SD and was analyzed via an ANOVA for all individual scenario comparisons and via a general linear mixed model to account for the effects of the scenario and the presence of the APP when comparing overall results.
Results: The Reader+App group scored significantly better in all four scenarios in overall performance (% of steps correctly done) and in 3 of the scenarios in percentage of critical steps performed (see ). The percentage of overall correct steps in Anaphylaxis increased from 62±15% in the Control group to 75±17% in the Reader+App group [p<0.04], in STEMI this increased from 50±8% in the Control group to 81±11% [p<0.0001], in MH this increased from 43±12% in the Control group to 61%±10% [p=0.0006], and in HYPERK this increased from 66±8% in the Control group to 79±8% [p=.0008].
Conclusion: Our results demonstrate that the implementation of a Reader with a novel decision support tool markedly improves adherence to published guidelines for patient management during a variety of simulated perioperative emergencies. Although participants in the Reader+App group performed remarkably better than the control group, the critical averages still fell below 100% compliance. Future studies are needed to elucidate: a) how to improve adherence to 100% of published guidelines, b) whether these findings are reproducible during in-situ simulation using real clinical teams, and c) who is the most appropriate personnel for the Reader role.
1. Low D, Clark N, Soar J, Padkin A, Stoneham A, Perkins GD, Nolan J. A randomised control trial to determine if use of the iResus© application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency. Anaesthesia 2011;66:255-62.
2. Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC: Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simul Healthc 2012;7:1-9.
1616 Effect of a Novel Cognitive Aid on Adherence to Guidelines in the Management of Medically Unstable Patients
Louise Alexander, Jonathan Smalley2, Richard Sedlak2, Michael McEvoy1, Deborah DeWaay, MD4, Jeffrey Cluver, MD6, James Horne, NREMT-P3, Paul Nietert, PhD5, and Matt McEvoy, MD2
1ANESTHESIA, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 2ANESTHESIA AND PERIOPERATIVE MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 3CLINICAL EFFECTIVENESS AND PATIENT SAFETY CENTER, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 4INTERNAL MEDICINE, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 5MEDICINE (BIOSTATISTICS), MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA and 6PSYCHIATRY AND BEHAVIORAL SCIENCES, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC, USA
Introduction/Background: Each year in the United States, 500,000 people have a myocardial infarction (MI), 634,000 people are hospitalized for a Chronic Obstructive Pulmonary Disease (COPD) exacerbation, and 11-42% of medical in-patients have delirium.1,2,5 Each of these unstable conditions have best-practice guidelines that are published for proper patient assessment and management. Interns are frequently the first-line of assessment and care in these situations. However, little training is given for the assessment and management of unstable patients in most medical school curricula.3 One study has shown that cognitive aids can improve adherence to guidelines in simulations of cardiac arrest.4 However, this has not been evaluated in medically-unstable patients. As such, we performed a pilot study to test the hypothesis that the use of an iOS-based cognitive aid application (APP) will improve adherence to published guidelines for the management of a variety of unstable patient conditions by 4th year medical students and interns.
Methods: After IRB approval and informed consent, four interns and twelve 4th year medical students were enrolled and randomized into two groups: No APP (N=8) and APP (N=8). All participants had been given an orientation to the simulation setting prior to involvement with this study. Each participant managed 3 unstable patient scenarios: ST-Elevation MI (STEMI), COPD Exacerbation, and Delirium. Two actors trained as standardized patients portrayed a patient and nurse in each station. The APP group was given a brief orientation to the iOS-based APP containing management protocols. Performance was assessed through a grading checklist that was based upon published management guidelines and finalized through a modified Delphi technique. Overall scores and critical item scores were recorded as a percent (%) of total items completed. To compare the effect of APP v. No APP, data were analyzed via a general linear mixed model with random participant effects to account for multiple measurements recorded on individual participants. Data are reported as Mean±95%CI in the text and figure.
Results: Compared to no APP use, APP use was associated with significantly higher scores for each individual scenario and overall for both overall correct (%) and critical actions correct (%) (p<0.001 for all comparisons, see ). On average, the APP group performed 30.2 percentage points higher on the overall % correct than the No APP group, and 26.9 percentage points higher on the critical items % correct (p<0.0001 for both). Interaction terms involving scenario and APP use were also assessed, and they were not significant, meaning that the APP did not differentially help in one scenario versus another. This is true for overall scores and for critical scores.
Conclusion: This pilot study tested the effects of a novel electronic cognitive aid (APP) on the assessment and management of medically-unstable patients. Three important findings emerged. First, the APP significantly improved performance across scenarios involving cardiac, pulmonary, and neurologic/psychiatric instability. Second, senior medical students and interns managing these conditions from memory alone had a very poor adherence to published guidelines, adherence to which is associated with improved patient outcomes. Third, even with the APP, students failed to reach a score of 100%. Thus, future research needs to address the following: a) investigate the best pedagogical approach for training medical students and interns to manage medically-unstable patients and b) perform human factors analysis on the cognitive aid in order to determine the barriers to 100% adherence to published best-practice management guidelines for residents and practicing physicians.
1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004 Aug 31;110(9).
2. Cole MG, Ciampi A, Belzile E, Zhong L. Persistent Delirium in Older Hospital Patients: a systematic review of frequency and prognosis. Age Ageing. 2009 Jan;38(1):19-26.
3. Hannon, FB. A national medical education needs’ assessment of interns and the development of an intern education and training programme. Med Educ.2000 Apr;34(4):275-84.
4. Low D, Clark N, Soar J, Padkin A, Stoneham A, Perkins GD, Nolan, J. A randomised control trial to determine if use of the iResus© application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency.Anaesthesia 2011;66:255-62.
5. Stein BD, Charbeneau JT, Lee TA, Schumock GT, Lindenauer PK, Bautista A, Lauderdale DS, Naureckas ET, Krishnan JA. Hospitalizations for Acute Exacerbations of Chronic Obstructive Pulmonary Disease: how you count matters. COPD. 2010 Jun;7(3):164-71.
1618 Medical Students Prefer Unguided Over Guided Communication for History-taking Rehearsal in a Virtual Patient Environment
Teresa Johnson, PhD2, Rebecca Lyons1, Regis Kopper, PhD5, Kyle Johnsen, PhD6, Benjamin Lok, PhD4, and Juan Cendan, MD3
1INSTITUTE FOR SIMULATION AND TRAINING, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA and 2MEDICAL EDUCATION, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA and 3MEDICAL EDUCATION AND SURGERY, UNIVERSITY OF CENTRAL FLORIDA, COLLEGE OF MEDICINE, ORLANDO, FL, USA and 4COMPUTER AND INFORMATION SCIENCE AND ENGINEERING, UNIVERSITY OF FLORIDA, GAINESVILLE, FL, USA and 5COMPUTER AND INFORMATION SCIENCES AND ENGINEERING, UNIVERSITY OF FLORIDA, GAINESVILLE, FL, USA and 6COLLEGE OF ENGINERING, UNIVERSITY OF GEORGIA, ATHENS, GA, USA
Introduction/Background: We created a communicative avatar platform (Neurologic Exam Rehearsal Virtual Environment: NERVE) which allows students to engage virtual patients (VPs) in a wide-ranging and unscripted dialogue for the development of history-taking skills and physical examination of select abnormal findings, including high-fidelity presentation of cranial nerve (CN) palsies rarely encountered through other educational opportunities. Two communication modes are available in NERVE: Chat mode allows users to type to VPs in a text window. VPs respond both verbally and with visual display of text (image). If VPs do not recognize text, a message informs users, “Try rephrasing the question.” Speech clarification (SC) mode functions similarly, except when VPs do not recognize text, NERVE presents up to three alternatives to guide the conversation. The purpose of this study was to compare students’ perceptions of history-taking experiences in NERVE by communication mode.
Methods: Seventy-eight of 80 first-year medical students (97.5%) consented to participate in this IRB-approved study. Participants ranged in age from 20-32 years (mean=24.6), and included 39 females (50.0%). Students were randomly assigned to communication mode treatments (chat=38; SC=40), wherein they practiced history-taking skills with VPs in four diplopia scenarios. Student perceptions were assessed by a 17-item survey. Independent samples t-tests were conducted to compare ratings by communication mode.
Results: Mean ratings of history-taking experience with VPs differed significantly by communication mode on two survey items (; in bold). In chat mode, students agreed that they asked VPs the same questions that they would ask of real patients to a greater extent than in SC mode (p=0.03). Additionally, frequency of errors encountered with VPs was rated lower by students in chat mode as compared to SC mode (p=0.02).
Conclusion: Prior student feedback prompted us to explore alternative methods for communicating in NERVE. Initial reports suggested frustration with chat mode when faced with a question-to-answer mismatch. We, therefore, developed a sub-routine which guides students by presenting SCs. Current findings suggest that chat mode is preferable. Specifically, students in chat mode reported engaging with VPs in an authentic manner to a greater degree, and reported fewer errors. As educators, we value the open-ended, exploratory nature of chat mode without system-generated cues. This exchange mimics unscripted dialogue between physicians and patients, which may enhance skills transfer, and allows for development of critical thinking skills. We are compelled to improve the chat mode algorithm, rather than replace it with selection-based scaffolding.
Disclosures: Benjamin Lok, PhD is a stockholder/owner/partner in Shadow Health, Inc.
1621 How Much Force? A Possible Gap in Surgical Training
Timothy Kowalewski, PhD1, Lee White, PhC2, Thomas Lendvay, MD4, and Blake Hannaford, PhD3
1MECHANICAL ENGINEERING, UNIVERSITY OF MINNESOTA, MINNEAPOLIS, MN, USA and 2BIOENGINEERING, UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, SEATTLE, WA, USA and 3ELECTRICAL ENGINEERING, UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, SEATTLE, WA, USA and 4UROLOGY, UNIVERSITY OF WASHINGTON, SEATTLE CHILDREN’S HOSPITAL, SEATTLE, WA, USA
Introduction/Background: Simulation has become a valuable adjuvant to training laparoscopic technical skills, particularly in the widely-adopted and validated Fundamentals of Laparoscopic Skills (FLS) curriculum, which is used both for training and high-stakes evaluation.1,2 FLS scoring is based on task time and an error penalty intended to reward precision. However, these errors may not adequately address the levels of force exerted on the tissues by the tool, and thereby allow laparoscopic trainees to acquire poor habits of tissue handling. De et al.3 point out that excessive grasper-induced tissue stress injury, like crush injury, may cause “pathological scar tissue formation, bleeding, adhesions, and loss of bowel motility” and other groups report that laparoscopically manipulated organs “are susceptible to severe grasping injuries including perforation or hemorrhage.4,5 Even less severe immediate injury from grasping or manipulation may still result in clinically relevant consequences such as ileus (paralysis of the bowel), increased infection due to local breach of the bowel’s protective barrier and increased adhesion formation.”5,6 We hypothesize that the FLS scoring system does not adequately address the force levels trainees exert on tissues either in training or high-stakes evaluation.
Methods: We conducted an IRB-approved (ref), multi-institutional, cross-sectional study at three laparoscopic teaching hospitals (Seattle, Minneapolis, New Orleans) with surgical faculty, fellows, and residents as subjects. We employed the Electronic Data Generation and Evaluation (EDGE) platform (Simulab Corp, Seattle, WA) to measure tool motion and grasping force. Subjects were requested to perform the Block Transfer, Cutting, and Intracorporeal Suturing FLS tasks multiple times (3x, 2x, 2x respectively, in that order). FLS scores were computed for each task iteration along with peak grasping force and tool path distance.
Results: A total of 98 subjects participated, completing 447 FLS task iterations (193 Block Transfer, 165 Cutting, 89 Suturing). The correlations from FLS score to path length and peak force were measured via Pearson’s R for linearity and Spearman’s r for monotonicity. FLS score and path length correlated favorably for Block Transfer, Cutting, and Suturing with Pearson’s R = -0.92, -0.87, -0.95 (each p<0.0001 or less), respectively and Spearman’s rho=-0.89, -0.88, -0.93 (each p<0.001 or less), respectively. FLS score and Peak Grasp Force did not correlate, with Pearson’s R = -0.18(p<.01), -0.27 (p<.001), -0.16 (p <.13), Spearman’s rho =-0.08(p<.30), -0.27(p<.001), -0.26 (p <.01), again respectively. The attached scatter plots () indicate a somewhat uniform dispersion of FLS scores vs. Peak Force, showing multiple instances where extremes of high peak forces occur in both the best and worst FLS score categories.
Conclusion: If two clinically-relevant metrics correlate perfectly, they are redundant; one provides no added information over the other. We observed a strong correlation, and therefore possible redundancy, between FLS score and path length but not for grasping force. This suggests grasp forces provide additional information not present in the FLS scores. If minimal forces or respect for tissue were training objectives, we would expect to see less spread in peak force among higher (better) FLS scores. Such phenomena are not present in our data, particularly for the Block Transfer and Suturing tasks. To be clinically relevant, tissue-specific levels of safe peak force must be established as errors and training targets. Since FLS instructions do not specify a target tissue to establish this level, we cannot conclude that any of our high-force subjects exhibited clinically deleterious tissue handling. Should such levels be established, the FLS scoring system would not provide a means to discriminate such errors. We conclude the FLS scoring system may not adequately address the force levels trainees exert on tissues either in its training or evaluation.
1. Peters J, Fried G, Swanstrom L, Soper N, Sillin L, Schirmer B, Hoffman K and the SAGES FLS Committee. Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surg 2004; 135: 21-27.
2. Fraser S, Klassen D, Feldman L, Ghitulescu G, Stanbridge D, Fried G. Evaluating laparoscopic skills; setting the pass/fail score for the MISTELS system. Surg Endosc 2003; 17(6): 964-967.
3. De S. The Grasper-Tissue Interface in Minimally Invasive Surgery: Stress and Acute Indicators of Injury [dissertation]. [Washington]: University of Washington 2008.
4. Heijnsdijk E, Dankelman J, Gouma D. Effectiveness of Grasping and Duration of Clamping Using Laparoscopic Graspers. Surg Endosc 2002;16: 1329-1331.
5. Marucci D, Shakeshaft A, Cartmill J, Cox M, Adams S, Martin C. Grasper Trauma During Laparoscopic Cholecystectomy. ANZ J Surg 2000;70:578-581.
6. Anup R, Balasubramanian K. Surgical Stress and the Gastrointestinal Tract. J Surg Res 2000; 92:291-300.
Disclosures: Timothy Kowalewski, PhD, is a consultant for Simulab Corporation. Thomas Lendvay, MD, is a co-founder in SPI Surgical, Inc. Blake Hannaford, PhD discloses that the Edge technology (described in this abstract) has been licensed from my laboratory at the University of Washington.
1656 Assessing High-fidelity Mannequin Facial Expressivity: A Preliminary Gap Analysis
Aaron Huus, B.Eng Biomedical Engineering, PhD Candidate1, and Laurel Riek, PhD1
1COMPUTER SCIENCE AND ENGINEERING, UNIVERSITY OF NOTRE DAME, NOTRE DAME, IN, USA
Introduction/Background: High-fidelity mannequin based medical simulators (HFMs) are limited by their lack of facial expressivity. Our preliminary work suggests that this lack of expressivity may negatively affect the realism of medical simulations, learner immersion, and patient safety.1,2,3 The objective of this study is to characterize how educators and clinicians perceive current HFM expressivity, and identify gaps. This gap analysis identifies the areas where HFM technology is unsatisfactory, and our preliminary work allows us to begin the initial stages toward technology improvement.
Methods: We created an online pilot survey to characterize this gap in HFM expressivity, and understand which limitations were most critical to learner education. To create the survey questions, we conducted three contextual inquiries with simulation center directors, each from a representative medical school, nursing school, and hospital educational setting. Based on these responses, we drafted and distributed a 70 question survey. The survey asked participants demographic questions to characterize their role within the simulation center, current HFM technology questions to characterize their existing HFM usage, and future HFM technology questions to characterize how they would envision the technological attributes of a new, facially expressive HFM. The current and future HFM technology questions were 5-point, discrete visual analogue scale questions (strong agree – strongly disagree), which addressed key technological issues and themes that emerged from the contextual inquiries. We randomly selected 65 members from the Society for Simulation in Healthcare (SSH) LinkedIn group who are employed in the fields of hospital and health care, higher education, and/or medical practice, and emailed them a link to our Survey Monkey instrument.
Results: The survey response rate was 33%, with 15 respondents finishing (23%). Survey participants consisted of mainly academic professionals, simulation program directors, and education specialists. Of the 15 respondents who completed the survey, 13 (87%) reported that they perform simulations on a high fidelity mannequin, 11 (73%) reported that they have worked with HFM technology for longer than six years, and 11 (73%) reported that over half of their simulations involve the HFM being awake and responsive. 11 respondents (73%) reported that when they perform simulations they required either themselves or someone else to verbally provide symptoms from a cue card for the HFM. 13 respondents (87%) reported that if an HFM could make eye contact with learners, as well as track a learner’s finger, it would result in greater learner immersion. 14 respondents (93%) reported that having a mannequin that had a more expressive face would improve the realism of simulations. Similarly, all 15 respondents (100%) reported that having a mannequin that could express pain or drowsiness would improve realism.
Conclusion: The results of this pilot study illustrate some limitations in existing HFM technology, such as the inability to synthesize facial expressions and requiring a cue card to express certain HFM symptoms. Our survey respondents desire HFMs to have more overall facial expressivity, and in particular be able to express pain and drowsiness, make eye contact, and track a learner’s finger. This work compliments our previous work that suggests expressive HFM technology may increase learner engagement, and create a more realistic training scenario. We will soon conduct this study on a much larger pool of SSH members to further define the HFM expressivity gap.
1. Huus, A. and Riek, L.D. 2012. An Expressive Robotic Patient to Improve Clinical Communication. In Proceedings of the HRI Pioneers Workshop at the 7th annual ACM/IEEE International Conference on Human-Robot Interaction (HRI), p. 52–54.
2. Martin, T.J., Rzepczynski, A.P. and Riek, L.D. 2012. Ask, inform, or act: communication with a robotic patient before haptic action. Proceedings of the 7th annual ACM/IEEE International Conference on Human-Robot Interaction (HRI), p. 221-222.
3. Rzepcynski, A.P., Martin, T.J. and Riek, L.D. 2012. Informed consent and haptic actions in interdisciplinary simulation training. Proceedings of the 140th annual meeting of the American Public Health Association (APHA). To appear.
1658 Innovations in Perfusion Education: The Use of Extracorporeal Circulation Simulator to Qualitative Measures as the Skills
Asako Tokumine, PhD1, and Yasuko Tomizawa, MD, PhD2
1BIOMEDICAL ENGINEERING, KINKI UNIVERSITY, KINOKAWA, WAKAYAMA, JPN and 2CARDIOVASCULAR SURGERY, TOKYO WOMEN’S MEDICAL UNIVERSITY, JPN
Introduction/Background: Application of the simulator for medical education is increasing. Recent years have seen the widespread introduction of simulation training involving extracorporeal circulation. Perfusionists need to be well-trained in both standard and emergency procedures, as complications during extracorporeal circulation can be potentially fatal.1 In light of increasing sophistication of medical simulators, the establishment of validated evaluation methods are likely to be a valuable addition to the educational program of perfusionists.2,3 This study was to explore whether a simulator system could evaluate extracorporeal circulation performances within a teaching environment. Furthermore, we performed quantitative evaluation of the basic skill and clinical skill training incorporating the simulation training procedure, which centered on changes in task accomplishment over repeated trials for perfusion education.
Methods: The perfusion simulator, CPB-Workshop (Senko, Tokyo, Japan) was used. The CPB-Workshop is controlled by the ECCSIM software, and simulated the condition of the patient at the time of an extracorporeal circulation. This software was used to record performances.2 A heart-lung machine, HAS-II (Senko, Tokyo, Japan) was used for the open circuit that incorporated venous reservoir, an oxygenator RX-25 and an arterial filter (Terumo, Tokyo, Japan). The circuit was primed with water, and gravity venous drainage was used. To evaluate performance in basic skills, a training session involving a simple training scenario was presented to several beginners. At the first session for the basic task training, the trainee was instructed to first reach arterial flow of 3.5 l/min within 30 seconds, maintain flow for 30 seconds, and to reduce flow within 30 seconds. And during all periods, he/she was instructed to maintain a reservoir level of 500 /- 50ml. And the second session for clinical skills, the trainee was required manipulation of the heart-lung machine to maintain simulated BP 80-89 mmHg. Each trainee was instructed on how to operate the simulator system from an instructor with experience in cardiopulmonary bypass procedures. After practicing freely for a period of 30 minutes, trainees completed a second trial. One hour later, a third trial was completed. One week later, all trainees performed the clinical skill training to maintain arterial pressure three times continuously. To fully compare accomplishment levels across training sessions, scores were recorded.
Results: On the 1st trial of the first training session, this participant (n=12) showed difficulty in controlling the arterial/venous flow and a sudden rise in the reservoir volume were observed. The reservoir level maintenance score became 75% (+8%) in the flow-up phase, 67% (+17%) in the flow-down phase at 3rd trial. On the second session held 1 week later, this skill level was maintained. However, the mission to maintain BP, at 1st trial, only one student achieved the mission. In the 3rd trial of this session, three persons (that include the former) achieved the mission (ex. mean BP 84.0 +/- 3.2 mmHg).
Conclusion: The evaluation of perfusion performances and/or techniques might be able can be behavioral and procedural scoring systems. Repetitive practice of protocols which develop key skills is effective in the training of new trainees.4 Effective training of perfusionists would benefit from the establishment of a standardized training regime, similar to the system adopted in clinical training. A fully trained perfusionist must be able to maintain a patient’s hemodynamic conditions adequately to accomplish the given surgical objective; and therefore, students have to perform evaluations of the basic skill and clinical skill training incorporating the simulation training procedure.
1. Palanzo D: Perfusion safety: past, present, and future. J Cardiothorac Vasc Anesth. 1997; 11: 383-390.
2. Ninomiya S, Tokumine A, Yasuda T and Tomizawa Y: Development of an educational simulator system, ECCSIM-Lite, for the acquisition of basic perfusion techniques and evaluation. J Artif Organs. 2007; 10: 201-205.
3. Morris R and Pybus D: “Orpheus” cardiopulmonary bypass simulation system. J Extra Corpor Technol. 2007; 39: 228-233.
4. Tokumine A, Ninomiya S, Tokaji M, Kurosaki T and Tomizawa Y: Evaluation of basic perfusion techniques, ECCSIM-Lite simulator. J Extra Corpor Technol. 2010; 42: 139-144.
1669 A Novel Mixed Reality Human Simulator Improves Medical Student Comfort and Competence in Digital Rectal Exam
David Lind, MD1
1SURGERY, DREXEL UNIVERSITY COLLEGE OF MEDICINE, PHILADELPHIA, PA, USA
Introduction/Background: While mannequins are used to teach intimate examinations, they lack the fidelity and feedback of a real patient. We have created a mixed reality human (MRH) simulator (interactive virtual patient (VP) and mannequin rectal/prostate exam simulator) designed to teach and assess students’ communication and digital rectal examination (DRE) skills. In this study, we piloted the MRH simulator with medical students at Drexel University College of Medicine.
Methods: Following IRB approval and informed consent, 26 third year medical students were randomized to two groups. Initially, both groups performed a baseline DRE on a mannequin simulator. Group 1 then performed another DRE without interacting with a VP, while group 2 conducted a medical interview with an interactive VP and then performed a DRE (). Both groups received real time, color-coded feedback regarding their examination following their second DRE ( inset). Following feedback, they performed one final DRE exam. During the simulation, students communicated with the VP on a LCD TV screen and performed DRE on a mannequin equipped with 12 pressure sensors covering the surface of the prostate. Students were surveyed pre and post MRH interaction regarding their confidence and anxiety in communication and DRE skills. DRE score calculated using pressure sensor data compared to an experienced clinician. YouTube video of a MRH simulator interaction at: http://www.youtube.com/watch?v=83IbtWZMCdE.
Results: As shown in , student self-reported confidence (p=0.007) and comfort level (p<0.001) increased post-interaction. In addition, DRE improved post-MRH interaction as measured by pressure data compared to an experienced clinician (p=0.028). See (Student Comfort and Competence with DRE):
Conclusion: We have created and successfully demonstrated that an MRH prostate simulator improves students’ comfort and competence in performing DRE. MRH simulators can enhance existing curricula to teach history-taking and examination skills, particularly for intimate exams, such as those for the breast, pelvis and prostate, as they more accurately simulate a real life interaction with a patient.
1676 Do PGY-1 Emergency Medicine Residents Appropriately Triage a High-Risk Chest Pain Patient? A Pilot Study
Steven Warrington, MD, BS2, Michael Beeson, MD, MBA2, and Gregory Griffin1
1EMERGENCY DEPARTMENT RESEARCH, AKRON GENERAL MEDICAL CENTER, AKRON, OH, USA and 2EMERGENCY MEDICINE, AKRON GENERAL MEDICAL CENTER, AKRON, OH, USA
Introduction/Background: Chest pain is one of the most common presentations of a patient to the emergency department (ED) representing 5% of ED visits.1 These patients have a wide range of possible diagnoses including many potentially critical disease processes such as myocardial infarction/acute coronary syndrome, pulmonary emboli, aortic dissection, and many others. As with any critical life-threatening disease process time becomes a crucial factor. A difference of 10 minutes from onset until intervention significantly increases the morbidity and mortality for patients experiencing a myocardial infarction.2-4 Due to this time sensitive nature there have been numerous studies on various aspects affecting the timing of care for patients with an acute myocardial infarction. Many factors including pre-hospital care, communication, and involvement of multi-departmental staff have been shown to have a significant impact on reducing time to treatment for these patients.5 At our institution PGY-1 emergency medicine (EM) residents begin internship seeing all levels of acuity and presentations in the ED with the expected responsibility to begin appropriate triage, work-up, and treatment as applicable. While these novice physicians are expected to discuss all cases early in their course in the ED, we believe that a PGY-1 should be able to appropriately begin the evaluation of a patient presenting with chest pain.
Methods: This was an IRRB approved study using 11 PGY-1 EM residents at Akron General Medical Center. This was a single-site pilot observational study to determine the ability of a PGY-1 EM resident to triage a patient presenting with chest pain at high risk of an acute coronary syndrome. This was done through the use of a standardized patient in a simulated ED environment. Each resident was evaluated through the use of a pre-developed scoring anchor, which was derived from national guideline recommendations.6 There were 23 actions which were based on communication skills, medical knowledge, evaluation skills, and treatment skills. Residents were scored 0 if they did not attempt/perform an action, 1 if they attempted an action but did not perform it appropriately (such as an incomplete or delayed action), and a 2 for standard/appropriate therapy.
Results: Overall resident performance was poor in that an action was performed correctly only 53% of the time, performed but not appropriately 17% of the time, and a required action was not attempted/performed 30% of the time.
Conclusion: We recognize this pilot study has multiple limitations such as a small sample size from a single site, as well as a non-validated anchor for scoring individuals. We did take multiple measures in recognition of these limitations including having all PGY-1 EM residents from our institution participate, using items derived from national guideline recommendations, as well as maintaining the same standardized patient and individual responsible for grading each case. Despite the limitations present, we believe this pilot represents an important study suggesting further research needs to be done on evaluation of beginning PGY-1 skills, as well as methods of improvement prior to, or early on, in their residency training.
1. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007 Jun 29;386:1-32. PubMed PMID: 17703794.
2. Boersma E, Maas AC, Deckers JW, et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996 Sep 21;348(9030):771-5. PubMed PMID: 8813982.
3. Nallamothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol. 2003 Oct 1;92(7):824-6. PubMed PMID: 14516884.
4. Berger PB, Ellis SG, Holmes Jr DR, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999 Jul 6;100(1):14-20. PubMed PMID: 10393675.
5. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006 Nov 30;355(22):2308-20. PubMed PMID: 17101617.
6. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007 Aug 14;50(7);e1-e157. PubMed PMID: 17692738.
Disclosures: Steven Warrington, MD, BS, creates self guided case-based iPad applications for training purposes in emergency medicine.
1693 Self-confidence and Communication Skills Addressing Vaccine Hesitancy Improve Among Pediatric Residents Exposed to a Combination of Standardized Patient Scenarios and a Systematic Interview Approach (C.A.S.E.)
Grace Arteaga, MD1, and Robert M Jacobson, MD1
1PEDIATRIC AND ADOLESCENT MEDICINE, MAYO CLINIC, ROCHESTER, MN, USA
Introduction/Background: A generalized decrease in vaccination coverage in the pediatric population has lead to new measles and pertussis outbreaks, along with increased influenza cases. Pediatric residents are required to learn immunization practices and health promotion during their training. Addressing vaccine hesitancy with parents who have strong beliefs can be challenging. We hypothesized an improvement in self-confidence addressing vaccine refusal with parents by exposing pediatric residents to a simulation-based vaccine hesitancy module.
Methods: We developed an educational module including two elements: three different scenarios with standarized parents enacting common reasons for vaccine reluctance: measles and autism in a one-year-old; multiple vaccines at once in a two-month-old infant, and flu-vaccine reluctance in a 10-year-old. The residents were exposed to a scenario twice with a debriefing session between them where a structured approach to vaccine refusal (second element) was discussed. This approach was developed by Alison Singer, Autism Science Foundation President, including: Corroboration of the parents feelings and beliefs, About me, Science behind vaccines and Explain and Advise (C.A.S.E). This approach served as a template for the second interaction.
Results: General confidence and comfort along with specific skill development were measured using the following Likert scale (1=strongly agree; 2=agree; 3=neutral; 4=disagree; 5=strongly disagree). A total of 28 pediatric residents (PGY I 10, PGY II 10, PGY III 8) were included. Overall, an improvement was noted in comfort addressing vaccine hesitance (pre-post exposure: 2.68±0.16 and 2.07± 0.14, p<0.05). Specific areas included: becoming familiar with common reasons for hesitancy (2.32±0.12 and 1.83±0.12, p<0.05) and developing confidence in attempting to change the parent’s decision making (2.89±0.17 and 1.50±0.12, p<0.05).
Conclusion: The development of educational modules involving not only a simulated based educational target, but a specific structural approach to develop new communication skills, allow for improvement in self-confidence and communication skills among residents.
Disclosures: Robert Jacobson, MD receives grant support from Novartis and Pfizer. Dr. Jacobson is a member of the Safety Review Committee and Data Monitoring Committee for Merck.
1713 Changes in Confidence, Knowledge and Teamwork in Facing Medical Emergencies in Dental Professionals
Pedro Verdugo, MD1, Soledad Armijo, MD1, Ruben Nissin, MD1, and Ricardo Flores, MD1
1CENTRO DE SIMULACION CLINICA, UNIVERSIDAD DIEGO PORTALES, SANTIAGO, CHL
Introduction/Background: Medical emergencies are rare and mostly mild in the dental context; however, each dentist will face one or two life threatening situations in their professional practice.1 In Chile dental training related to managing medical emergencies is low and mainly theoretical.2 The training programs for dentists recommend to strengthen teamwork, so that each of the participants know their roles during an emergency.3 This lack of theoretical and practical knowledge by the dental practitioner creates the necessity to develop a training program to cover these aspects. Our objective is to evaluate the sense of security and capability of teamwork before and after a clinical simulation-based training, oriented to manage medical emergencies within the dental office.
Methods: Based on recent epidemiological data, we structured a course of 20 hours, spread over two working days, with 6.3 hours devoted to the development of procedural skills and 6.25 hours of dynamic simulation, incorporating feedback with debriefing techniques supported by audio-visual records. The eight simulation scenarios covered major medical emergencies in dentistry in Chile; they involved 16 individuals (15 dentists and a nurse), and participants had previously received a manual and a complementary DVD developed to assist them with the course objectives. To assess the impact of the course we designed a cross-sectional observational study, with pre and post intervention questionnaire, without a control group. The measuring instruments were a non validated questionnaire developed by the facilitators and direct observation of performance in the first and last scenario of the course, tested by a checklist. We analyzed the frequency distributions and magnitudes of change, pre and post intervention.
Results: In the pre-test questionnaire none of the participants felt prepared to face a medical-dental emergency. All felt that the preparation for these events should be included in the undergraduate syllabus, as this is an important element for their profession. After the intervention, the participants felt a positive change in personal safety about confronting a medical emergency and the performance of CPR, as well as in leadership skills and teamwork. In the pre-intervention assessment, none of the participants considered the secretary or recepcionist as part of the emergency response team. A major change was seen on the post-intervention results, indicating the importance of incorporating the secretary or receptionist into emergency health care into the context of dental practice. In terms of results in simulation scenarios, in the pre-intervention assessment the percentage of achievement of competence was 46.67% (DS3, 33) and in the final stage, there was a positive change with success rate of 77.01% (DS 7.61).
Conclusion: In Chile dentists usually work in small practices with a dental assistant and a secretary. Vocational training of the dental team is uneven, and the recognition of the importance of the whole team by the dentists is an essential component of this program. Additionally, this study shows the need for training of professionals, technical staff, and administrative staff in order to better manage a medical emergency. The simulation also allows for the development of non-technical skills like teamwork, leadership, effective communication and self-confidence, which are essential in clinical practices, especially in emergencies. It highlights the emphasis placed on the dental staff, which included at least 3 participants: the leading dentist, the dental assistant and the administrative assistant / receptionist. To evaluate the long-term impact of this intervention, there is ongoing prospective evaluation of the cohort, and comparison of the intervention with a control group.
1. Theisen, F.C., Feil, P.H., and Schultz, R. Self perceptions of skill in office medical emergencies. J Dent Educ. 1990 Oct;54(10):623-5. No abstract available.
2. Requena R, Torres E, Tirreau V. Emergencias médicas en la consulta odontológica (Análisis de la realidad chilena). Rev. Odontología chilena. 2004; 29-34.
3. Haas DA. Preparing dental office staff members for emergencies. Developing a basic action plan. J Am Dent Assoc. 2010;141:8S-13S
1738 Training Anesthesia Team Members to Speak Up: A Simulation-based Study
Bastian Grande, MD2, Mona Weiss1, Micha Dambach, MD2, Adrian Marty, MD2, Carl Schick2, Donat Spahn, MD2, Gudela Grote, PhD1, and Michaela Kolbe, PhD1
1MANAGEMENT, TECHNOLOGY, ECONOMICS, ETH ZURICH, ZURICH, CHE and 2ANESTHESIOLOGY, UNIVERSITY HOSPITAL ZURICH, ZURICH, CHE
Introduction/Background: The potential risks of not speaking up (with concerns, questions, and opinions) when necessary are increasingly acknowledged in healthcare.1 Speaking up is more and more acknowledged as essential for error prevention2 and has indeed been found to be positively related to team performance.3 However, speaking up is difficult due to normative and informational social influence processes: people fear repercussion, social rejection, they fear to be wrong or think that the team’s climate does not allow for voicing successfully.4-6 Therefore, training healthcare team members to speak up seems crucial to enable and support them to challenge colleagues or authorities when needed.7 Building on an existing training concept of speaking up,7 we implemented and evaluated a simulation-based speaking up training for anesthesia team members; and in addition, we explored the role of team members’ self-perceptions during training.
Methods: We applied a pre-post randomized control group design. Participants in the control group (n=28) received a traditional, simulation-based, day-long ACRM training. Participants in the intervention group (n=32) received the ACRM training as well, including additional speaking up training. Building on recent trainings,7 this speaking up training included repeated cycles of simulated cases with situations requiring speaking up; detailed, facilitated debriefings on the nature and barriers of speaking up; and instructions and demonstrations of how to speak up using the two-challenge rule and advocacy-inquiry.7 The debriefings were led using guided team self-correction,8 advocacy-inquiry,9 as well as systemic-constructivist techniques.10 To evaluate the speaking up training, at the beginning and end of each training day we measured the following variables: participants’ self-perceived expressiveness and instrumentality,11 self-perceived confidence,12 self-reported speaking up behavior,13 actual speaking up behavior (via behavior coding),14 as well as psychological safety.15 We expected an increase in self-reported, as well as observed, speaking up behavior in the intervention group and moderating effects of self-perceived expressiveness and instrumentality, as well as psychological safety.
Results: Overall, 28 registered nurses, 26 anesthesia resident physicians, and 6 attending physicians participated. Data analysis revealed that, as expected, self-reported speaking up behavior significantly increased in the intervention group but not in the control group. Similar results were found for observed, actual speaking up behavior. No changes with respect to self-perceived confidence were found in either group. We found an interaction effect for psychological safety on the relationship between self-perceived instrumentality (i.e., assertiveness) and self-reported speaking up behavior: if participants regarded themselves as less instrumental, they needed high levels of psychological safety in order to say that they would speak up.
Conclusion: Speaking up training can improve self-reported, as well as observable, speaking up performance in the simulated setting. More research is needed to investigate whether and how these improvements transfer to the clinical setting.
1. Dwyer J. Primum non tacere. An ethics of speaking up. Hastings Cent Rep 1994;24:13-8.
2. Henriksen K, Dayton E. Organizational silence and hidden threats to patient safety. Health Serv Res 2006;41:1539-54.
3. Kolbe M, Burtscher MJ, Wacker J, Grande B, Nohynkova R, Manser T, Spahn D, Grote G. Speaking-up is related to better team performance in simulated anesthesia inductions: An observational study. Anesth Analg in press.
4. Kobayashi H, Pian-Smith M, Sato M, Sawa R, Takeshita T, Raemer D. A cross-cultural survey of residents’ perceived barriers in questioning/challenging authority. Qual Saf Health Care 2006;15:277-83.
5. Raemer DB. The clinician’s response to challenging cases. In: Yano E, Kawachi I, Nakao M, eds. The healthy hospital Maximizing the satisfaction of patients, health workers, and community. Tokyo: Shinohara Shinsha; 2010:27-32.
6. Detert JR, Edmondson A. Implicit voice theories: Taken-for-granted rules of self-censorship at work. Acad Manage J 2011;54:461-88.
7. Pian-Smith MCM, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching residents the Two-Challenge Rule: A simulation-based approach to improve education and patient safety. Simul Healthc 2009;4:84-91.
8. Smith-Jentsch KA, Cannon-Bowers JA, Tannenbaum S, Salas E. Guided team self-correction: Impacts on team mental models, processes, and effectiveness. Small Group Research 2008;39:303-29.
9. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as “nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simul Healthc 2006;1:49-55.
10. Kriz WC. A systemic-constructivist approach to the facilitation and debriefing of simulations and games. Simul Gaming 2010;41:663-80.
11. Runge TE, Frey D, Gollwitzer PM, Helmreich RL, Spence JT. Masculine (instrumental) and feminine (expressive) traits. A comparison between students in the United States and West Germany. J Cross-Cult Psychol 1981;12:142-62.
12. Flin R, Fletcher G, McGeorge P, Sutherland A, Patey R. Anaesthetists’ attitudes to teamwork and safety. Anaesthesia 2003;58:233-42.
13. Liang J, Farh CIC, Farh J-L. Psychological antecedents of promotive and prohibitive voice: A two-wave examinination. The Academy of Management Journal 2012;55:71-92.
14. Kolbe M, Künzle B, Zala-Mezö E, Wacker J, Grote G. Measuring coordination behaviour in anaesthesia teams during induction of general anaesthetics. In: Flin R, Mitchell L, eds. Safer surgery Analysing behaviour in the operating theatre. Aldershot: Ashgate; 2009:203-21.
15. Baer M, Frese M. Innovation is not enough: Climates for initiative and psychological safety, process innovations, and firm performance. J Organ Behav 2003;24:45-68.
Disclosures: Donat Spahn, MD’s academic department is receiving grant support from the Swiss National Science Foundation, Berne, Switzerland (grant numbers: 33CM30_124117 and 406440-131268), the Swiss Society of Anesthesiology and Reanimation (SGAR), Berne, Switzerland. Dr. Spahn was the chairman of the ABC Faculty and is a member of the ABC Trauma Faculty which both are managed by Thomson Physicians World GmbH, Mannheim, Germany and sponsored by an unrestricted educational grant from Novo Nordisk A/S.
1763 A Mixed Methods Observational Simulation-based Study of Interprofessional Team Communication
Charlotte Paltved, MD3, Peter Musaeus, PhD1, and Kurt Nielsen, MD2
1MEDICAL EDUCATION, AARHUS UNIVERSITY HOSPITAL, AARHUS, DNK and 2SKEJSIM, AARHUS UNIVERSITY HOSPITAL, AARHUS, DNK and 3SKEJSIM CENTRE FOR MEDICAL SIMULATION AND TRAINING, AARHUS, DNK
Introduction/Background: The quality and content of interprofessional team communication has consequences for patient safety.1;2 Breakdowns in team communication are likely to lead to inadequate care due to the risk of errors and adverse events. However, in-depth insight into the complexity and quality of team communication in critical situations is limited. In particular mixed methods3 video observational studies might fill a gap in terms of understanding the meaning of specific communication interactions and link team performance to patient outcome. This study has two aims: first, to develop a theory-based evaluation instrument that measures and qualifies team communication by documenting communication failures, and second, to investigate the quality and content of summaries and re-evaluations when assessing, re-assessing, and treating the critically ill patient. It is hypothesized that a core aspect of team communication, which determines effective team performance, is the significance of shared and qualifying summaries and re-evaluations.
Methods: In this study, team communications were video-observed in a simulated environment. Communication events and failures were recorded and classified into categories inspired by rhetoric theory4 as shown in Table 1. Twenty-eight scenarios were reviewed by three researchers. NVivo® was used for coding and thematic analyses. Using grounded theory,5 data supported the building of another model that captures and conceptualizes the quality, content and accuracy of summaries and re-evaluations throughout simulations. Thirty-two doctors and nurses participated in a Simulator Instructor Course lasting 2-3 days. Participants were divided into 5 interprofessional teams.
Results: In the 28 simulations, 581 communication events and 49 communication failures were recorded as shown in Table 1. The derived observed effects are shown in Table 2. Teams were found to differ in diagnostic acuity and adjustment of treatment plans. These differences could be explained using a five-level model describing the development of high-quality summaries and re-evaluations. This model might provide a significant framework for understanding the construct of efficient team performance.
Conclusion: The conceptual and theoretical base of this classification model of communication failures combined with the interpretative qualification of summaries and re-evaluations is promising from the perspective of describing the overall quality of team communication in a simulated environment. This research points to clear suggestions for simulation-based training interventions to improve interprofessional team communication. The study found that complex team communication does not readily reduce to mere observation and recording of events. It is concluded that a mixed methods approach, combining quantitative data with an interpretative approach, is required to meaningfully account for communication exchanges in context.
1. Kohn LT, Corrigan JM, Donaldson MS. To error is human: Building a safer health system. Washington DC: National Academy Press, 1999.
2. Redfern E, Brown R, Vincent CA. Identifying vulnerabilities in communication in the emergency department. Emerg Med J 2009;26:653-657.
3. Cresswell JW, Plano Clark VL. Designing and conducting mixed methods research. 2nd ed. Sage, 2011.
4. Lingard L, Espin S, Whyte S et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330-334.
5. Straus S, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory. 2nd ed. London: Sage Publications, Inc., 1998.
Disclosures: Charlotte Paltved, MD receives grant support from The Laerdal Foundation for Acute Medicine.© 2012 Society for Simulation in Healthcare