Pilot study of the DART tool - an objective healthcare simulation debriefing assessment instrument.

BACKGROUND: Various rating tools aim to assess simulation debriefing quality, but their use may be limited by complexity and subjectivity. The Debriefing Assessment in Real Time (DART) tool represents an alternative debriefing aid that uses quantitative measures to estimate quality and requires minimal training to use. The DART is uses a cumulative tally of instructor questions (IQ), instructor statements (IS) and trainee responses (TR). Ratios for IQ:IS and TR:[IQ + IS] may estimate the level of debriefer inclusivity and participant engagement. METHODS: Experienced faculty from four geographically disparate university-affiliated simulation centers rated video-based debriefings and a transcript using the DART. The primary endpoint was an assessment of the estimated reliability of the tool. The small sample size confined analysis to descriptive statistics and coefficient of variations (CV%) as an estimate of reliability. RESULTS: Ratings for Video A (n = 7), Video B (n = 6), and Transcript A (n = 6) demonstrated mean CV% for IQ (27.8%), IS (39.5%), TR (34.8%), IQ:IS (40.8%), and TR:[IQ + IS] (28.0%). Higher CV% observed in IS and TR may be attributable to rater characterizations of longer contributions as either lumped or split. Lower variances in IQ and TR:[IQ + IS] suggest overall consistency regardless of scores being lumped or split. CONCLUSION: The DART tool appears to be reliable for the recording of data which may be useful for informing feedback to debriefers. Future studies should assess reliability in a wider pool of debriefings and examine potential uses in faculty development.

A multicenter evaluation of the accuracy of prehospital eFAST by a physician-staffed helicopter emergency medical service.

PURPOSE: The purpose of this study is to report the relative accuracy of prehospital extended focused assessment with sonography in trauma (eFAST) examinations performed by HEMS physicians. METHODS: Trauma patients who received prehospital eFAST by HEMS clinicians between January 2013 and December 2017 were reviewed. The clinician's interpretations of these ultrasounds were compared to gold standard references of CT imaging or operating room findings. The outcomes measured include the calculated accuracy of eFAST for detecting intraperitoneal free fluid (IPFF), pneumothorax, hemothorax, and pericardial fluid compared to available gold standard results. RESULTS: Of the 411 patients with adequate data for comparison, the median age was 39.5 years with 73% male and 98% sustaining blunt force trauma. For the detection of IPFF, eFAST had a sensitivity of 25% (95% CI 16-36%) and specificity of 96% (95% CI 93-98%). Sensitivities and specificities were calculated for pneumothorax (38% and 96% respectively), hemothorax (17% and 97% respectively), and pericardial effusion (17% and 100% respectively). These results did not change significantly when reassessed with several sensitivity analyses. CONCLUSION: Prehospital eFAST is reliable for detecting the presence of intraperitoneal free fluid. This finding should inform receiving trauma teams to prepare for early definitive care in these patients. The low sensitivities across all components of the eFAST highlight the importance of cautiously interpreting negative studies while prompting the need for further studies. TRIAL REGISTRATION: ACTRN12618001973202 (Registered on 06/12/2018).

Out of hospital cardiac arrest in Western Sydney-an analysis of outcomes and estimation of future eCPR eligibility.

BACKGROUND: Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres. METHODS: A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly. RESULTS: In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n = 58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within "office hours" and no case obtained a return of spontaneous circulation standard advanced life support. CONCLUSIONS: In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.

Twelve tips for facilitating and implementing clinical debriefing programmes.

Contemporary clinical practice places a high demand on healthcare workforces due to complexity and rapid evolution of guidelines. We need embedded workplace practices such as clinical debriefing (CD) to support everyday learning and patient care. Debriefing, defined as a 'guided reflective learning conversation', is most often undertaken in small groups following simulation-based experiences. However, emerging evidence suggests that debriefing may also enhance learning in clinical environments where facilitators need to simultaneously balance psychological safety, learning goals and emotional well-being. This twelve tips article summarises international experience collated at the recent Association for Medical Education in Europe (AMEE) debriefing symposium. These tips encompass the benefits of CD, as well as suggested approach to facilitation. Successful CD programmes are frequently team focussed, interdisciplinary, implemented in stages and use a clear structure.

Utility of venous blood gases for the assessment of traumatic shock: a prospective observational study.

BACKGROUND: ABG samples are often obtained in trauma patients to assess shock severity. Venous blood gas (VBG) sampling, which is less invasive, has been widely used to assess other forms of shock. The study aim was to determine the agreement between VBG and ABG measurements in trauma. METHODS: Patients were enrolled at an Australian trauma centre between October 2016 and October 2018. Bland-Altman limits of agreement (LOA) between paired blood gas samples taken <30 min apart were used to quantify the extent of agreement. The impact of using only VBG measurements was considered using an a priori plan. Cases where venous sampling failed to detect 'concerning levels' were flagged using evidence-based cut-offs: pH ≤7.2, base deficit (BD) ≤-6, bicarbonate <21 and lactate ≥4. Case summaries of these patients were assessed by independent trauma clinicians as to whether an ABG would change expected management. RESULTS: During the study period 176 major trauma patients had valid paired blood gas samples available for analysis. The median time difference between paired measurements was 11 min (IQR 6-17). There was a predominance of men (81.8%) and blunt trauma (92.0%). Median Injury Severity Score was 13 (range 1-75) and inpatient mortality was 6.3%. Mean difference (ABG-VBG) and LOA between paired arterial and venous measurements were 0.036 (LOA -0.048 to 0.120) for pH, -1.27 mmol/L (LOA -4.35 to 1.81) for BD, -0.64 mmol/L (LOA -1.86 to 0.57) for lactate and -1.97 mmol/L (LOA -5.49 to 1.55) for bicarbonate. Independent assessment of the VBG 'false negative' cases (n=20) suggested an ABG would change circulatory management in two cases. CONCLUSIONS: In trauma patients VBG and ABG parameters displayed suboptimal agreement. However, in cases flagged as VBG 'false negative' independent review indicated that the availability of an ABG was unlikely to change management.

Interdisciplinary clinical debriefing in the emergency department: an observational study of learning topics and outcomes.

BACKGROUND: Defined as a 'guided reflective learning conversation', 'debriefing' is most often undertaken in small groups following healthcare simulation training. Clinical debriefing (CD) following experiences in the working environment has the potential to enhance learning and improve performance. METHODS: Prior to the study, a literature review was completed resulting in a standardised approach to CD that was used for training faculty. A pilot study of CD (n = 10) was then performed to derive a list of discussion topics and optimise the faculty training. The resulting debriefing approach was based on the "S.T.O.P." structure (Summarise the case; Things that went well; Opportunities for improvement; Points of action). A debriefing aid, with suggested scripting, was provided. A subsequent observational study assessed CD within 1-h of clinical events. 'Significantly distressing' or 'violent' events were excluded. Data was collected on participant characteristics, discussion topics, and team recommendations. Study forms were non-identifiable. Subsequent analysis was performed by two investigators using content analysis of the debriefing forms (n = 71). Discussion topics (learning points) were coded using a modified version of the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework. One month after completion of the study, ED management staff were surveyed for reports of "harm" as the result of CD. RESULTS: During the study period, 71 CDs were recorded with a total of 506 participants. Mean debriefing length was 10.93 min (SD 5.6). Mean attendance was 7.13 (SD 3.3) participants. CD topics discussed were divided into 'plus' (well-done) and 'delta' (need to improve) groupings. 232 plus domains were recorded of which 195 (84.1%) aligned with the PEARLS debriefing framework, suggesting simulation debriefing skills may be translatable to a clinical setting. Topics discussed outside the PEARLS framework included family issues, patient outcome and environmental factors. CD reports led to preventative interventions for equipment problems and to changes in existing protocols. There were no recorded incidents of participant harm resulting from CD. CONCLUSIONS: Topics discussed in CD predominantly aligned to those commonly observed in simulation-based medical education. Collective recommendations from CD can be used as evidence for improving existing protocols and models of care.

Simulation-based medical education can be used to improve the mental health competency of emergency physicians.

OBJECTIVE: We explored the feasibility of developing, running and evaluating a simulation-based medical education (SBME) workshop to improve the knowledge, skills and attitudes of emergency department (ED) doctors when called on to assess patients in psychiatric crisis. METHOD: We designed a four-hour workshop incorporating SBME and a blend of pre-reading, short didactic elements and multiple-choice questions (MCQs). Emergency department nurses (operating as SBME faculty) used prepared scripts to portray patients presenting in psychiatric crisis. They were interviewed in front of, and by, ED doctors. We collected structured course evaluations, Debriefing Assessment for Simulation in Healthcare (DASH) scores, and pre- and post-course MCQs. RESULTS: The pilot workshop was delivered to 12 ED registrars using only existing resources of the Psychiatry and Emergency Departments. Participants highly valued both 'level of appropriateness' (Likert rating µ = 4.8/5.0) and 'overall usefulness' (µ = 4.7/5.0) of the programme. They reported an improved understanding of the mental state and of relevant legal issues and rated the debriefings highly (participant DASH rating: n = 193; score µ = 6.3/7.0). Median MCQ scores improved non-significantly pre- and post-course (7.5/12 vs 10/12, p = 0.261). CONCLUSION: An SBME workshop with these aims could be delivered and evaluated using the existing resources of the Psychiatry and Emergency Departments.

Randomised controlled trial of simulation-based education for mechanical cardiopulmonary resuscitation training.

INTRODUCTION: Mechanical cardiopulmonary resuscitation (M-CPR) is increasingly used in the management of cardiac arrest. There are no previously reported randomised studies investigating M-CPR training. This study of newly trained M-CPR providers hypothesised that a brief simulation-based intervention after 4 months would improve M-CPR performance at 6 months. METHODS: This study used a simulated 'in situ' cardiac arrest model. The M-CPR device used was a proprietary Lund University Cardiac Assist System 3 machine (Physio Control, Redmond, Washington, USA). Standardised baseline training was provided to all participants. Following training, baseline performance was assessed. The primary outcome measure was the time taken to initiate M-CPR and the secondary outcome was performance against a checklist of errors. Participants were then randomised to intervention group (simulation training) or control group (routine clinical use of M-CPR). After 6 months the outcome measures were reassessed. Comparative statistical tests used an intention-to-treat analysis. RESULTS: 112 participants were enrolled. The intervention group (n=60) and control group (n=52) had similar demographic characteristics. At the 6-month assessment, median time to M-CPR initiation was 27.0 s (IQR 22.0-31.0) in the intervention group and 31.0 s (IQR 25.6-46.0) in the control group (p=0.003). The intervention group demonstrated fewer errors compared with controls at 6 months (p<0.001) CONCLUSION: In this randomised study of approaches to M-CPR training, providers receiving additional simulation-based training had higher retention levels of M-CPR skills. Therefore, when resuscitation skills are newly learnt, provision follow-up training should be an important consideration.

Assessment of inhaled acute ammonia-induced lung injury in rats.

This study examined acute toxicity and lung injury following inhalation exposure to ammonia. Male Sprague-Dawley rats (300-350 g) were exposed to 9000, 20,000, 23,000, 26,000, 30,000 or 35,000 ppm of ammonia for 20 min in a custom head-out exposure system. The exposure atmosphere, which attained steady state within 3 min for all ammonia concentrations, was monitored and verified using a Fourier transform infrared spectroscopy (FTIR) gas analyzer. Animals exposed to ammonia resulted in dose-dependent increases in observed signs of intoxication, including increased chewing and licking, ocular irritation, salivation, lacrimation, oronasal secretion and labored breathing. The LCt50 of ammonia within this head-out inhalation exposure model was determined by probit analysis to be 23,672 ppm (16,489 mg/m(3)) for the 20 min exposure in male rats. Exposure to 20,000 or 23,000 ppm of ammonia resulted in significant body weight loss 24-h post-exposure. Lung edema increased in all ammonia-exposed animal groups and was significant following exposure to 9000 ppm. Bronchoalveolar fluid (BALF) protein concentrations significantly increased following exposure to 20,000 or 23,000 ppm of ammonia in comparison to controls. BAL cell (BALC) death and total cell counts increased in animals exposed to 20,000 or 23,000 ppm of ammonia in comparison to controls. Differential cell counts of white blood cells, neutrophils and platelets from blood and BALF were significantly increased following exposure to 23,000 ppm of ammonia. The following studies describe the validation of a head-out inhalation exposure model for the determination of acute ammonia-induced toxicity; this model will be used for the development and evaluation of potential therapies that provide protection against respiratory and systemic toxicological effects.

Management of critical illness with non-invasive ventilation by an Australian HEMS.

BACKGROUND: Non-invasive ventilation (NIV) therapy is widely used for the management of acute respiratory failure. The objective of this study was to investigate the current use of NIV during interhospital retrievals in an Australian physician-led aeromedical service. METHODS: We reviewed patients receiving NIV during interhospital retrieval at the Greater Sydney Area Helicopter Medical Services (GSA-HEMS) over a 14-month period. The main objectives were to describe the number of retrievals using NIV, the need for intubation in NIV patients and the effect of the therapy on mission duration. RESULTS: Over the study period, 3018 missions were reported; 106 cases (3.51%) involved administration of NIV therapy during the retrieval. The most common indication for NIV was pneumonia (34.0%). 86/106 patients received a successful trial of NIV therapy prior to interhospital transfer. 58 patients were transferred on NIV, while 28 patients had NIV removed during transport. None of these 86 patients required intubation or died, although 17/86 ultimately required intubation within 24 hours at the receiving centre. 20/106 patients required intubation at the referring hospital after a failed trial of NIV therapy. NIV was successfully used in all available transport platforms including rotary wing. Patients receiving NIV were found to have prolonged mission durations compared with other GSA-HEMS patients (222.5 vs 193 min). This increase in mission duration was largely attributable to NIV failure, resulting in a need for Rapid Sequence Intubation at the referring hospital. CONCLUSIONS: With careful patient selection, the use of interhospital NIV is feasible and appears to be safe in a retrieval system with care provided by a critical care physician.

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department.

Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims to provide perfusion to the patient whilst the underlying cause of arrest can be addressed. ECPR use has increased substantially, with varying survival rates to hospital discharge. The best outcomes for ECPR occur when the time from cardiac arrest to implementation of ECPR is minimised. To reduce this time, systems must be in place to identify the correct patient, expedite transfer to hospital, facilitate rapid cannulation and ECMO circuit flows. We describe the process of activation of ECPR, patient selection, and the steps that emergency department clinicians can utilise to facilitate timely cannulation to ensure the best outcomes for patients in refractory cardiac arrest. With these processes in place our survival to hospital discharge for OHCA patients is 35%, with most patients having a good neurological function.

Bystander cardiopulmonary resuscitation differences by sex - The role of arrest recognition.

PURPOSE: To assess whether bystander cardiopulmonary resuscitation (CPR) differed by patient sex among bystander-witnessed out-of-hospital cardiac arrests (OHCA). METHODS: This study is a retrospective analysis of paramedic-attended OHCA in New South Wales (NSW) between January 2017 to December 2019 (restricted to bystander-witnessed cases). Exclusions included OHCA in aged care, medical facilities, with advance care directives, from non-medical causes. Multivariate logistic regression examined the association of patient sex with bystander CPR. Secondary outcomes were OHCA recognition, bystander AED application, initial shockable rhythm, and survival outcomes. RESULTS: Of 4,491cases, females were less likely to receive bystander CPR in private residential (Adjusted Odds ratio [AOR]: 0.82, 95%CI: 0.70-0.95) and public locations (AOR: 0.58, 95%CI:0.39-0.88). OHCA recognition during the emergency call was lower for females arresting in public locations (84.6% vs 91.6%, p = 0.002) and this partially explained the association of sex with bystander CPR (∼44%). This difference in recognition was not observed in private residential locations (p = 0.2). Bystander AED use was lower for females (4.8% vs 9.6%, p < 0.001); however, after adjustment for location and other covariates, this relationship was no longer significant (AOR: 0.83, 95%CI: 0.60-1.12). Females were less likely to be in an initial shockable rhythm (AOR: 0.52, 95%CI: 0.44-0.61), but more likely to survive the event (AOR: 1.34, 95%CI: 1.15-1.56). There was no sex difference in survival to hospital discharge (AOR: 0.96, 95%CI: 0.77-1.19). CONCLUSION: OHCA recognition and bystander CPR differ by patient sex in NSW. Research is needed to understand why this difference occurs and to raise public awareness of this issue.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial.

INTRODUCTION: Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS: NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION: This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER: ACTRN12623001000695.

Chimeric antigen receptor T-cell therapy: Prospective observational study of unplanned emergency department presentations.

OBJECTIVE: Chimeric antigen receptor T-cell (CAR-T) therapy is an emerging treatment for refractory hematologic malignancy. Unplanned ED presentations following CAR-T present the increasing need for an integrated model of care that allows for the early recognition of its specific complications. METHODS: This is a prospective observational study at a tertiary centre. CAR-T patients (n = 17) were universally enrolled into a study registry by treating providers. These patients were flagged by investigators to trigger a pop-up notification CAR-T information warning at ED triage. Medical records were reviewed 90 days for unplanned presentations, complications and patient-oriented outcomes. RESULTS: Patients receiving CAR-T frequently encountered toxicity within 7 days of therapy. This was typically mild and occurred in an inpatient setting. Medical record review revealed five unplanned ED presentations (that were recognised as post CAR-T) and not directly attributable to specific toxicities. CONCLUSION: If CAR-T therapy is to be used more widely especially in an outpatient model of care, a standardised ED model of care for recognition of specific complications is needed.

Expedited transport versus continued on-scene resuscitation for refractory out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Background: The benefit of rapid transport from the scene to definitive in-hospital care versus extended on-scene resuscitation in out-of-Hospital Cardiac Arrest (OHCA) is uncertain. Aim: To assess the use of expedited transport from the scene of OHCA compared with more extended on-scene resuscitation of out-of-hospital cardiac arrest in adults. Methods: A systematic search of the literature was conducted using MEDLINE, Embase, and SCOPUS. Randomised control trials (RCTs) and observational studies were included. Studies reporting transport timing for OHCA patients with outcome data on survival were identified and reviewed. Two investigators assessed studies identified by screening for relevance and assessed bias using the ROBINS-I tool. Studies with non-dichotomous timing data or an absence of comparator group(s) were excluded. Outcomes of interest included survival and favourable neurological outcome. Survival to discharge and favourable neurological outcome were meta-analysed using a random-effects model. Results: Nine studies (eight cohort studies, one RCT) met eligibility criteria and were considered suitable for meta-analysis. On pooled analysis, expedited (or earlier) transfer was not predictive of survival to discharge (odds ratio [OR] 1.16, 95% confidence interval [CI] 0.53 to 2.53, I2 = 99%, p = 0. 65) or favorable neurological outcome (OR 1.06, 95% CI 0.48 to 2.37, I2 = 99%, p = 0.85). The certainty of evidence across studies was assessed as very low with a moderate risk of bias. Region of publication was noted to be a major contributor to the significant heterogeneity observed amongst included studies. Conclusions: There is inconclusive evidence to support or refute the use of expedited transport of refractory OHCA.

The Debriefing Assessment in Real Time (DART) tool for simulation-based medical education.

BACKGROUND: Debriefing is crucial for enhancing learning following healthcare simulation. Various validated tools have been shown to have contextual value for assessing debriefers. The Debriefing Assessment in Real Time (DART) tool may offer an alternative or additional assessment of conversational dynamics during debriefings. METHODS: This is a multi-method international study investigating reliability and validity. Enrolled raters (n = 12) were active simulation educators. Following tool training, the raters were asked to score a mixed sample of debriefings. Descriptive statistics are recorded, with coefficient of variation (CV%) and Cronbach's α used to estimate reliability. Raters returned a detailed reflective survey following their contribution. Kane's framework was used to construct validity arguments. RESULTS: The 8 debriefings (µ = 15.4 min (SD 2.7)) included 45 interdisciplinary learners at various levels of training. Reliability (mean CV%) for key components was as follows: instructor questions µ = 14.7%, instructor statements µ = 34.1%, and trainee responses µ = 29.0%. Cronbach α ranged from 0.852 to 0.978 across the debriefings. Post-experience responses suggested that DARTs can highlight suboptimal practices including unqualified lecturing by debriefers. CONCLUSION: The DART demonstrated acceptable reliability and may have a limited role in assessment of healthcare simulation debriefing. Inherent complexity and emergent properties of debriefing practice should be accounted for when using this tool.

Examining training and attitudes to basic life support in multi-ethnic communities residing in New South Wales, Australia: A mixed-methods investigation.

BACKGROUND: Bystander response, including cardiopulmonary resuscitation (CPR), is critical to out-of-hospital cardiac arrest (OHCA) survival. Nearly 30% of Australian residents were born overseas, and little is known about their preparedness to perform CPR. In this mixed-methods study, we examined rates of training and willingness and barriers to performing CPR among immigrants in Australia. METHODS: First, we surveyed residents in New South Wales, Australia, using purposeful sampling to enrich immigrant populations. Multivariate logistic regression was used to examine the association between place of birth and willingness to perform CPR. Next, we conducted focus-group discussions with members of the region's largest migrant groups to explore barriers and relevant societal or cultural factors. RESULTS: Of the 1267 survey participants (average age 49.6 years, 52% female), 60% were born outside Australia, most in Asia and 73% had lived in Australia for more than 10 years. Higher rates of previous CPR training were reported among Australian-born participants compared with South Asian-born and East Asian-born (77%, 35%, 48%, respectively, p <0.001). In adjusted models, the odds of willingness to perform CPR on a stranger were significantly lower among migrants than Australian-born (adjusted OR: 0.64; 95% CI 0.49 to 0.83); however, this association was mediated by history of training. Themes emerging from the focus-group discussions included concerns about causing harm, fear of liability, and birthplace-specific social and cultural barriers. CONCLUSIONS: Targeted awareness and training interventions, which address common and culture-specific barriers to response and improved access to training, may improve confidence and willingness to respond to OHCA in multi-ethnic communities.

Immediate faculty feedback using debriefing timing data and conversational diagrams.

BACKGROUND: Debriefing is an essential skill for simulation educators and feedback for debriefers is recognised as important in progression to mastery. Existing assessment tools, such as the Debriefing Assessment for Simulation in Healthcare (DASH), may assist in rating performance but their utility is limited by subjectivity and complexity. Use of quantitative data measurements for feedback has been shown to improve performance of clinicians but has not been studied as a focus for debriefer feedback. METHODS: A multi-centre sample of interdisciplinary debriefings was observed. Total debriefing time, length of individual contributions and demographics were recorded. DASH scores from simulation participants, debriefers and supervising faculty were collected after each event. Conversational diagrams were drawn in real-time by supervising faculty using an approach described by Dieckmann. For each debriefing, the data points listed above were compiled on a single page and then used as a focus for feedback to the debriefer. RESULTS: Twelve debriefings were included (µ = 6.5 simulation participants per event). Debriefers receiving feedback from supervising faculty were physicians or nurses with a range of experience (n = 7). In 9/12 cases the ratio of debriefer to simulation participant contribution length was ≧ 1:1. The diagrams for these debriefings typically resembled a fan-shape. Debriefings (n = 3) with a ratio < 1:1 received higher DASH ratings compared with the ≧ 1:1 group (p = 0.038). These debriefings generated star-shaped diagrams. Debriefer self-rated DASH scores (µ = 5.08/7.0) were lower than simulation participant scores (µ = 6.50/7.0). The differences reached statistical significance for all 6 DASH elements. Debriefers evaluated the 'usefulness' of feedback and rated it 'highly' (µ= 4.6/5). CONCLUSION: Basic quantitative data measures collected during debriefings may represent a useful focus for immediate debriefer feedback in a healthcare simulation setting.

How mindful self-care practices changed during the winter 2020 COVID-19 lockdown in Western Sydney.

BACKGROUND AND OBJECTIVES: Self-care strategies are important to maintain psychological wellbeing. The aim of this study was to explore how self-care changed during the first COVID-19 lockdown in winter 2020 and identify targets for interventions. METHOD: This was a cross-sectional study. Participants attending a COVID-19 testing clinic completed the Mindful Self-Care Scale (MSCS) and Hospital Anxiety and Depression Scale (HADS). RESULTS: A total of 332 participants completed questionnaires (mean age 38 years, 55% female). Self-care strategies used less frequently during lockdown when compared with pre-lockdown were in MSCS domains of Physical Care (P <0.001), Supportive Relationships (P <0.001), Supportive Structures (P <0.001) and Mindful Awareness (P <0.001). Mean anxiety and depression scores were 5.97 (standard deviation [SD] = 4.36) and 4.12 (SD = 3.594). DISCUSSION: Several pre-pandemic strategies were used less frequently, including individual activities not restricted during lockdown ('listening'; 'using images' to relax). This study provides insight into activities that are practised and reduced during a lockdown, which can guide wellbeing interventions to assist people in isolation.

Exploring the use of virtual reality to manage distress in adolescent patients in emergency departments: A feasibility study.

OBJECTIVE: The present study aimed to explore the feasibility and potential benefits of deploying virtual reality (VR) for adolescents in the ED. METHODS: This multi-centre study was undertaken in paediatric and adult EDs in two university teaching hospitals. Twenty-six participants who had voluntarily attended the ED received the VR intervention. Pre- and post-measures assessing changes in state anxiety, stress and affect, and physical biomarkers were obtained. RESULTS: The use of VR intervention was associated with significant reductions in distress (Short State Stress Questionnaire - Distress Subscale; t = 4.55, P < 0.001) and negative affect (the International Positive and Negative Affect Scale - Short Form version; t = 4.99, P < 0.001). Most participants chose 'Netflix' as their content of choice. The technology was well received by the participants with subjective reports indicating that receiving VR intervention was 'insanely cool', 'takes you away from what's actually happening' and some participants felt 'privileged to get this experience in a hospital'. CONCLUSIONS: VR technology can effectively be used in EDs to assist adolescents and young adults better manage their distress and take steps towards activating more self-control mechanisms that will in turn allow for more meaningful engagements to be established with health clinicians. This technology has broad implications for reducing distress in adolescents in a variety of clinical contexts.