Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery.

BACKGROUND: The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. METHODS: This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. RESULTS: Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). CONCLUSIONS: Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room.

BACKGROUND: Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands. METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period. RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness. CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Does Adherence to World Health Organization Hand Hygiene Protocols in the Operating Room Have the Potential to Produce Irritant Contact Dermatitis in Anesthesia Providers?

Anesthesia providers have the burden of constant hand hygiene during task dense periods. The requirement for hand hygiene often demands frequent application of alcohol-based hand rub. To assess whether frequent alcohol-based hand rub use leads to skin changes or irritant contact dermatitis, volunteers cleaned their hands with alcohol-based hand rub every 15 minutes for 8 hours for 5 sequential days. They were examined by a dermatologist before and after and asked about subjective skin changes. Results suggest an increase in irritant contact dermatitis scores and subjective complaints.

Zika Virus: Obstetric and Pediatric Anesthesia Considerations.

As of November 2016, the Florida Department of Health (FDH) and the Centers for Disease Control and Prevention have confirmed more than 4000 travel-related Zika virus (ZIKV) infections in the United States with >700 of those in Florida. There have been 139 cases of locally acquired infection, all occurring in Miami, Florida. Within the US territories (eg, Puerto Rico, US Virgin Islands), >30,000 cases of ZIKV infection have been reported. The projected number of individuals at risk for ZIKV infection in the Caribbean and Latin America approximates 5 million. Similar to Dengue and Chikungunya viruses, ZIKV is spread to humans by infected Aedes aegypti mosquitoes, through travel-associated local transmission, via sexual contact, and through blood transfusions. South Florida is an epicenter for ZIKV infection in the United States and the year-round warm climate along with an abundance of mosquito vectors that can harbor the flavivirus raise health care concerns. ZIKV infection is generally mild with clinical manifestations of fever, rash, conjunctivitis, and arthralgia. Of greatest concern, however, is growing evidence for the relationship between ZIKV infection of pregnant women and increased incidence of abnormal pregnancies and congenital abnormalities in the newborn, now medically termed ZIKA Congenital Syndrome. Federal health officials are observing 899 confirmed Zika-positive pregnancies and the FDH is currently monitoring 110 pregnant women with evidence of Zika infection. The University of Miami/Jackson Memorial Hospital is uniquely positioned just north of downtown Miami and within the vicinity of Liberty City, Little Haiti, and Miami Beach, which are currently "hot spots" for Zika virus exposure and transmissions. As the FDH works fervently to prevent a Zika epidemic in the region, health care providers at the University of Miami and Jackson Memorial Hospital prepare for the clinical spectrum of ZIKV effects as well as the safe perioperative care of the parturients and their affected newborns. In an effort to meet anesthetic preparedness for the care of potential Zika-positive patients and perinatal management of babies born with ZIKA Congenital Syndrome, this review highlights the interim guidelines from the Centers for Disease Control and Prevention and also suggest anesthetic implications and recommendations. In addition, this article reviews guidance for the evaluation and anesthetic management of infants with congenital ZIKV infection. To better manage the perioperative care of affected newborns, this article also reviews the comparative anesthetic implications of babies born with related congenital malformations.

Introductions During Time-outs: Do Surgical Team Members Know One Another's Names?

BACKGROUND: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues' names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. METHODS: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used. They were asked (1) to name each OR participant, and (2) if they believed it is important to know the names of their team members and (3) for their team members to know their name. RESULTS: Of the 150 OR personnel interviewed, 147 (98%) named the surgery attending correctly. The surgery attending named only 44% of other OR staff (p <0.001). Only 62% of the OR staff correctly named the anesthesiology attending. The anesthesiology resident was the least well known but was able to name 82% of the others. The anesthesiology attending named his or her resident 100% of the time; the surgery attending correctly named his or her resident only 68% of the time (p = 0.002). CONCLUSION: This study suggests that OR personnel may consider introductions to be another bureaucratic hurdle instead of the safety check they were designed to be. It appears that this first step of the time-out is often being performed perfunctorily.

Significance of Objective Structured Clinical Examinations to Plastic Surgery Residency Training.

INTRODUCTION: Objective structured clinical examinations (OSCEs) have proven to be a powerful tool. They possess more than a 30-year track record in assessing the competency of medical students, residents, and fellows. Objective structured clinical examinations have been used successfully in a variety of medical specialties, including surgery. They have recently found their way into the subspecialty of plastic surgery. METHODS: This article uses a systematic review of the available literature on OSCEs and their recent use in plastic surgery. It incorporates survey results assessing program directors' views on the use of OSCEs. RESULTS: Approximately 40% of programs surveyed use OSCEs to assess the Accreditation Council for Graduate Medical Education core competencies. We found that 40% use OSCEs to evaluate specific plastic surgery milestones. Objective structured clinical examinations are usually performed annually. They cost anywhere between $100 and more than $1000 per resident. Four milestones giving residents the most difficulties on OSCEs were congenital anomalies, noncancer breast surgery, breast reconstruction, and practice-based learning and improvement. It was determined that challenges with milestones were due to lack of adequate general knowledge and surgical ward patient care, as well as deficits in professionalism and system-based problems. Programs were able to remediate weakness found by OSCEs using a variety of methods. CONCLUSIONS: Objective structured clinical examinations offer a unique tool to objectively assess the proficiency of residents in key areas of the Accreditation Council for Graduate Medical Education core competencies. In addition, they can be used to assess the specific milestones that plastic surgery residents must meet. This allows programs to identify and improve identified areas of weakness.

The influence of high fidelity simulation on first responders retention of CPR knowledge.

INTRODUCTION: The purpose of this study was to identify the impact of high-fidelity simulation on the retention of basic life support cardiopulmonary resuscitation (CPR) knowledge among a group of healthcare providers (HCPs). METHODS: A twenty-five question exam was completed by nurses and nurse technicians over a two-year period before and after mandatory CPR training with high-fidelity simulation. RESULTS: Most HCPs scored near 50% or below the passing score (80%) with a mean range of scores between 28% and 84%. HCPs missed questions on the exam that requested specific details related to technique or human physiology during CPR. CONCLUSION: The current teaching method for basic life support may be enhanced by using high-fidelity simulation, but this modality alone is not enough to support HCPs retention of CPR knowledge. Additional studies are needed to identify strategies that will help HCPs remember specific and detailed information in the CPR algorithm.

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.

OBJECTIVE: To establish the efficacy of simulation-based training for improving residents' management of postoperative complications on a surgical ward. BACKGROUND: Effective postoperative care is a crucial determinant of patient outcome, yet trainees learn this through the Halstedian approach. Little evidence exists on the efficacy of simulation in this safety-critical environment. METHODS: A pre-/postintervention design was employed with 185 residents from 5 hospitals. Residents participated in 2 simulated ward-based scenarios consisting of a deteriorating postoperative patient. A debriefing intervention was implemented between scenarios. Resident performance was evaluated by calibrated, blinded assessors using the validated Global Assessment Toolkit for Ward Care. This included an assessment of clinical skills (checklist of 35 tasks), team-working skills (score range 1-6 per skill), and physician-patient interaction skills. RESULTS: Excellent interrater reliability was achieved in all assessments (reliability 0.89-0.99, P < 0.001). Clinically, improvements were obtained posttraining in residents' ability to recognize/respond to falling saturations (pre = 73.7% vs post = 94.8%, P < 0.01), check circulatory status (pre = 21.1% vs post = 84.2% P < 0.001), continuously reassess patient (pre = 42.1% vs post = 100%, P < 0.001), and call for help (pre = 36.8% vs post = 89.8%, P < 0.001). Regarding teamwork, there was a significant improvement in residents' communication (pre = 1.75 vs post = 3.43), leadership (pre = 2.43 vs post = 4.20), and decision-making skills (pre = 2.20 vs post = 3.81, P < 0.001). Finally, residents improved in all elements of interaction with patients: empathy, organization, and verbal and nonverbal expression (Ps < 0.001). CONCLUSIONS: The study provides evidence for the efficacy of ward-based team training using simulation. Such exercises should be formally incorporated into training curricula to enhance patient safety in the high-risk surgical ward environment.

The dynamics and implications of bacterial transmission events arising from the anesthesia work area.

Health care-associated infections are a hospital-wide concern associated with a significant increase in patient morbidity, mortality, and health care costs. Bacterial transmission in the anesthesia work area of the operating room environment is a root cause of 30-day postoperative infections affecting as many as 16% of patients undergoing surgery. A better understanding of anesthesia-related bacterial transmission dynamics may help to generate improvements in intraoperative infection control and improve patient safety.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

BACKGROUND: Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. METHODS: Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. RESULTS: The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). CONCLUSIONS: The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

The use of a novel technology to study dynamics of pathogen transmission in the operating room.

Pathogenic organisms have been found in the intraoperative environment, potentially posing a risk of infection that could cause morbidity and mortality. In an effort to understand how a patient's bacteria can be spread throughout the operating room with the anesthesia provider as a vector, we conducted a study using recently developed experimental technology in a simulated operating room environment with a high-fidelity human patient simulator.

Using simulation technology to identify gaps between education and practice among new graduate nurses.

Applied knowledge was observed among nurse groups from a medical-surgical residency program to measure clinical performance during simulation training. Twenty groups of new graduate nurses were observed during five simulated clinical scenarios, and their performances were scored on a 24-item checklist. Nurse groups showed significant improvement (p < 0.001) in applied knowledge in four clinical domains from week 1 to week 5, and the results provided valuable information of the groups' overall performances. In two of the five scenarios, poor decisions and prioritization of competing tasks were factors associated with lower performance group scores. Complex patient conditions may pose a challenge for new graduate nurses, and standardized training during the residency program may help instructors recognize specific factors to address during the transition from education to practice.

Twitter as a tool to enhance student engagement during an interprofessional patient safety course.

Twitter and other social media forums are gaining popularity in both the academic and conference arenas as tools to increase participant engagement, attention and interaction. While Twitter has been used successfully to engage college students, it has not been explored for use in an interprofessional curriculum. We sought to explore it as a method to foster student engagement. During a weeklong interprofessional patient safety course we invited students and faculty to participate in a Twitter conversation. It was found that this form of social media successfully captured a "behind the scenes" conversation and the experiences of the students which would have not been otherwise captured. This information is guiding future interprofessional educational programming in both the medical and nursing schools.

Fetal assessment for anesthesiologists: are you evaluating the other patient?

Suboptimal communication between anesthesiologists and obstetricians can be associated with unintended poor maternal and neonatal outcomes, especially for emergency cesarean deliveries. Obstetricians use the results of antepartum and intrapartum fetal assessments to assess fetal well-being and to make decisions about the timing and method of delivery. Because abnormal results may lead to the need for urgent or emergency cesarean deliveries, these decisions may directly impact anesthetic care. Lack of familiarity with fetal assessments and the significance of the results may thus hinder the communication necessary for optimal patient care. In this review article, we discuss the current antepartum and intrapartum fetal assessment modalities, including the nonstress test, biophysical profile, Doppler velocimetry, electronic fetal heart rate monitoring, fetal electrocardiogram (STAN-ST waveform analysis), and fetal pulse oximetry. The physiologic basis behind these modalities and the available evidence regarding their utility in clinical practice are also reviewed. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring categories, which are incorporated into the American College of Obstetricians and Gynecologists guidelines for intrapartum care, is examined. The implications of test interpretation to the practice of obstetric anesthesiology is also discussed. Anesthesia provider understanding of fetal assessment modalities is essential in improving communication with obstetricians and improving the planning of cesarean deliveries for high-risk obstetric patients.

Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections.

OBJECTIVE: Determine the impact of three stepwise interventions on the rate of central catheter-associated bloodstream infections. DESIGN: Quasi-experimental study. SETTING: Three surgical intensive care units (general surgery, trauma, and neurosurgery) at a 1500-bed county teaching hospital in the Miami metro area. PATIENTS: All consecutive central catheter-associated bloodstream infection cases as determined by the Infection Control Department. INTERVENTIONS: Three interventions aimed at catheter maintenance were implemented at different times in the units: chlorhexidine "scrub-the-hub," chlorhexidine daily baths, and daily nursing rounds aimed at assuring compliance with an intensive care unit goal-oriented checklist. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the monthly intensive care unit rate of central catheter-associated bloodstream infections (infections per 1000 central catheter days). Over 33 months of follow-up (July 2008 to March 2011), we found decreased rates in each of the three intensive care units evaluated during the interventions, especially after implementation of chlorhexidine daily baths. Rates in unit A decreased from a rate of 8.6 to 0.5, unit B from 6.9 to 1.6, and unit C from 7.8 to 0.6. Secondary bloodstream infection rates remained unchanged throughout the observation period in units A and B; however, unit C had a decrease in its rates over time. CONCLUSIONS: We report the progressive reduction of central catheter-associated bloodstream infection rates after the stepwise implementation of chlorhexidine "scrub-the-hub" and daily baths in surgical intensive care units, suggesting effectiveness of these interventions.

Are ultrasound-guided ophthalmic blocks injurious to the eye? A comparative rabbit model study of two ultrasound devices evaluating intraorbital thermal and structural changes.

BACKGROUND: Since Atkinson's original description of retrobulbar block in 1936, needle-based anesthetic techniques have become integral to ophthalmic anesthesia. These techniques are unfortunately associated with rare, grave complications such as globe perforation. Ultrasound has gained widespread acceptance for peripheral nerve blockade, but its translation to ocular anesthesia has been hampered because sonic energy, in the guise of thermal or biomechanical insult, is potentially injurious to vulnerable eye tissue. The US Food and Drug Administration (FDA) has defined guidelines for safe use of ultrasound for ophthalmic examination, but most ultrasound devices used by anesthesiologists are not FDA-approved for ocular application because they generate excessive energy. Regulating agencies state that ultrasound examinations can be safely undertaken as long as tissue temperatures do not increase >1.5°C above physiological levels. METHODS: Using a rabbit model, we investigated the thermal and mechanical ocular effects after prolonged ultrasonic exposure to single orbital- and nonorbital-rated devices. In a dual-phase study, aimed at detecting ocular injury, the eyes of 8 rabbits were exposed to continuous 10-minute ultrasound examinations from 2 devices: (1) the Sonosite Micromaxx (nonorbital rated) and (2) the Sonomed VuMax (orbital rated) machines. In phase I, temperatures were continuously monitored via thermocouples implanted within specific eye structures (n = 4). In phase II the eyes were subjected to ultrasonic exposure without surgical intervention (n = 4). All eyes underwent light microscopy examinations, followed at different intervals by histology evaluations conducted by an ophthalmic pathologist. RESULTS: Temperature changes were monitored in the eyes of 4 rabbits. The nonorbital-rated transducer produced increases in ocular tissue temperature that surpassed the safe limit (increases >1.5°C) in the lens of 3 rabbits (at 5.0, 5.5, and 1.5 minutes) and cornea of 2 rabbits (both at 1.5 minutes). A secondary analysis of temporal temperature differences between the orbital-rated and nonorbital transducers revealed statistically significant differences (Bonferroni-adjusted P < 0.05) in the cornea at 3.5 minutes, the lens at 2.5 minutes, and the vitreous at 4.0 minutes. Light microscopy and histology failed to elicit ocular injury in either group. CONCLUSIONS: The nonorbital-rated ultrasound machine (Sonosite Micromaxx) increases the ocular tissue temperature. A larger study is needed to establish safety. Until then, ophthalmic ultrasound-guided blocks should only be performed with ocular-rated devices.

Sexual assault forensic examiners' training and assessment using simulation technology.

INTRODUCTION: More than 190,000 sexual assaults involving persons aged 12 years or older occur annually in the United States. For these victims, a forensic examination is the first step in the process to justice. Assessment and treatment of victims, as well as the meticulous collection and documentation of evidence, are vital for a strong case. Providing timely services 24/7 by qualified professionals can be taxing on schedules and budgets. Using in-house resources to cross-train ED personnel, we developed a program that introduced novice forensic examiners to common clinical scenarios encountered in the treatment of victims and provided a framework for the evaluation and management of each case. METHODS: Seventeen ED personnel attended statewide sexual assault nurse examination training and participated in four simulation scenarios and debriefings. Pre-tests and post-tests were administered, and a checklist was used to assess competence in performing examinations independently. RESULTS: The majority of participants achieved competence (≥85% on the checklist) with their first case and had statistically significant gains in knowledge between pre-test and post-test (pre-test mean score [±SE] of 69.1 ± 1.7 vs. post-test mean score of 84.4 ± 2.6, P < .001). Course evaluations were favorable, with a mean score of 91.3%. DISCUSSION: Our results validated the use of simulation technology and in-house resources for cross-training in a sexual assault forensic examination program, together with a checklist to assess competence in performing examinations independently. Benefits of having a sexual assault forensic examination program in the emergency department are standardized and timely care for victims, as well as enhanced evidence collection and increased reporting and prosecution of crimes.