How we developed a comprehensive resuscitation-based simulation curriculum in emergency medicine.

Over the past decade, simulation-based education has emerged as a new and exciting adjunct to traditional bedside teaching and learning. Simulation-based education seems particularly relevant to emergency medicine training where residents have to master a very broad skill set, and may not have sufficient real clinical opportunities to achieve competence in each and every skill. In 2006, the Emergency Medicine program at Queen's University set out to enhance our core curriculum by developing and implementing a series of simulation-based teaching sessions with a focus on resuscitative care. The sessions were developed in such as way as to satisfy the four conditions associated with optimum learning and improvement of performance; appropriate difficulty of skill, repetitive practice, motivation, and immediate feedback. The content of the sessions was determined with consideration of the national training requirements set out by the Royal College of Physicians & Surgeons of Canada. Sessions were introduced in a stepwise fashion, starting with a cardiac resuscitation series based on the AHA ACLS guidelines, and leading up to a more advanced resuscitation series as staff became more adept at teaching with simulation, and as residents became more comfortable with this style of learning. The result is a longitudinal resuscitation curriculum that begins with fundamental skills of resuscitation and crisis resource management (CRM) in the first 2 years of residency and progresses through increasingly complex resuscitation cases where senior residents are expected to play a leadership role. This paper documents how we developed, implemented, and evaluated this resuscitation-based simulation curriculum for Emergency Medicine postgraduate trainees, with discussion of some of the challenges encountered.

Catalytic effect of multisource feedback for trauma team captains: a mixed-methods prospective study.

OBJECTIVES: To evaluate the impact and feasibility of multisource feedback compared with traditional feedback for trauma team captains (TTCs). DESIGN: A mixed-methods, non-randomised prospective study. SETTING: A level one trauma centre in Ontario, Canada. PARTICIPANTS: Postgraduate medical residents in emergency medicine and general surgery participating as TTCs. Selection was based on a convenience sampling method. INTERVENTION: Postgraduate medical residents participating as TTCs received either multisource feedback or standard feedback following trauma cases. MAIN OUTCOME MEASURES: TTCs completed questionnaires designed to measure the self-reported intention to change practice (catalytic effect), immediately following a trauma case and 3 weeks later. Secondary outcomes included measures of perceived benefit, acceptability, and feasibility from TTCs and other trauma team members. RESULTS: Data were collected following 24 trauma team activations: TTCs from 12 activations received multisource feedback and 12 received standard feedback. The self-reported intention for practice change was not significantly different between groups initially (4.0 vs 4.0, p=0.57) and at 3 weeks (4.0 vs 3.0, p=0.25). Multisource feedback was perceived to be helpful and superior to the existing feedback process. Feasibility was identified as a challenge. CONCLUSIONS: The self-reported intention for practice change was no different for TTCs who received multisource feedback and those who received standard feedback. Multisource feedback was favourably received by trauma team members, and TTCs perceived multisource feedback as useful for their development.

Simulation vs workplace-based assessment in resuscitation: a cross-specialty descriptive analysis and comparison.

Background: Simulation-based assessment can complement workplace-based assessment of rare or difficult to assess Entrustable Professional Activities (EPAs). We aimed to compare the use of simulation-based assessment for resuscitation-focused EPAs in three postgraduate medical training programs and describe faculty perceptions of simulation-based assessment. Methods: EPA assessment scores and setting (simulation or workplace) were extracted from 2017-2020 for internal medicine, emergency medicine, and surgical foundations residents at the transition to discipline and foundations of discipline stages. A questionnaire was distributed to clinical competency committee members. Results: Eleven percent of EPA assessments were simulation-based. The proportion of simulation-based assessment did not differ between programs but differed between transition (38%) and foundations (4%) stages within surgical foundations only. Entrustment scores differed between settings in emergency medicine at the transition level only (simulation: 4.82 ± 0.60 workplace: 3.74 ± 0.93). 70% of committee members (n=20) completed the questionnaire. Of those that use simulation-based assessment, 45% interpret them differently than workplace-based assessments. 73% and 100% trust simulation for high-stakes and low-stakes assessment, respectively. Conclusions: The proportion of simulation-based assessment for resuscitation focused EPAs did not differ between three postgraduate medical training programs. Interpretation of simulation-based assessment data between committee members was inconsistent. All respondents trust simulation-based assessment for low-stakes, and the majority for high-stakes assessment. These findings have practical implications for the integration simulation into programs of assessment.

Contexte: Pour les activités professionnelles confiables (APC) qui sont rarement observées ou difficiles à évaluer, une évaluation en séance de simulation peut compléter celle en milieu de travail. Nous avons comparé le recours à une évaluation en séance de simulation pour les APC axées sur la réanimation dans trois programmes de formation médicale postdoctorale et décrit les perceptions de membres du corps professoral à propos de cette modalité d'évaluation. Méthodes: Nous avons extrait les scores et le cadre (simulation ou lieu de travail) d'évaluation des APC de 2017 à 2020 pour les résidents en médecine interne, en médecine d'urgence et en fondements chirurgicaux aux étapes de transition vers la discipline et de fondements de la discipline. Un questionnaire a été distribué aux membres des comités des compétences cliniques. Résultats: Onze pour cent des évaluations d'APC étaient faites lors de séances de simulation. Cette proportion était la même pour tous les programmes, mais dans le cadre des fondements chirurgicaux elle était différente selon qu'il s'agissait de l'étape de transition (38 %) ou de celle des fondements (4 %). Les scores de confiance différaient selon le cadre de l'évaluation uniquement pour les résidents en médecine d'urgence à l'étape de la transition (simulation : 4,82 ± 0,60; lieu de travail : 3,74 ± 0,93). Le questionnaire a été rempli par 70 % des membres des comités (n=20). Parmi ceux qui avaient eu recours à une évaluation en séance de simulation, 45 % avaient interprété les données de l'évaluation différemment de la façon dont ils interprètent les données d'évaluation en milieu de travail. Soixante-treize pour cent et 100 % d'entre eux font confiance à la simulation pour les évaluations à enjeux élevés et à faibles enjeux, respectivement. Conclusions: La proportion d'évaluations en séance de simulation pour les APC axées sur la réanimation était la même dans trois programmes de formation médicale postdoctorale. Les membres des comités de compétences cliniques n'ont pas interprété les données de ce type d'évaluation de manière uniforme. Tous les répondants font confiance à l'évaluation en séance de simulation pour les évaluations à faibles enjeux, et la plupart d'entre eux pour les évaluations à enjeux élevés. Ces données ont des implications pratiques pour l'intégration de la simulation dans les programmes d'évaluation.

Cognitive load theory in action: e-learning modules improve performance in simulation-based education. A pilot study.

PURPOSE: Learners participating in simulation-based education may experience cognitive overload with potential detrimental effects to learning and performance. Multiple strategies have been proposed to mitigate this detrimental response. However, these strategies have not fully considered the potential benefits of using online platforms, such as accessibility, cost-effectiveness, efficiency, and scalability. Addressing this gap in the literature, preparatory online modules were developed by applying concepts from cognitive load theory and simulation-based education. This study assessed whether using preparatory online modules to deliver weekly pre-briefing content could impact cognitive load and performance. The participants were first-year postgraduate medical trainees participating in a simulation-based resuscitation curriculum. METHODS: Fifty-three trainees were allocated to receive preparatory online modules (online modules group, n = 27) or not (control group, n = 26) during the course component of a simulation-based resuscitation curriculum. Then, these trainees participated in a simulation-based objective structured clinical examination (OSCE). Sources of cognitive load (intrinsic, extraneous, and germane) were measured using a modified cognitive load questionnaire. Performance was assessed using the Ottawa Surgical Competency Operating Room Evaluation. Data were analyzed with descriptive statistics, and principal component analysis. RESULTS: During the course component, the online modules group was found to have higher intrinsic and germane cognitive load, and lower extraneous cognitive load compared to the control group. During the OSCE, the online modules group scored significantly higher in performance scores (p = 0.0077, d = 0.39, 95% confidence interval = 0.10;0.68) compared to the control group. Principal component analysis supported the results obtained with the modified cognitive load questionnaire. CONCLUSION: Trainees using preparatory online modules during the course component of a simulation-based resuscitation curriculum experienced cognitive load changes consistent with cognitive optimization. This may have contributed to their superior performance in the subsequent OSCE. Future research should explore the long-term impacts of online preparatory training and consider potential barriers to implementation in diverse healthcare environments.

RéSUMé: OBJECTIF: Les personnes apprenantes qui participent à un enseignement basé sur la simulation peuvent éprouver une surcharge cognitive pouvant avoir des effets néfastes sur l'apprentissage et le rendement. Plusieurs stratégies ont été proposées pour atténuer cette réaction préjudiciable. Toutefois, ces stratégies n'ont pas pleinement tenu compte des avantages potentiels de l'utilisation de plateformes en ligne, comme l'accessibilité, la rentabilité, l'efficience et l'évolutivité. Pour combler cette lacune dans la littérature, des modules préparatoires en ligne ont été développés en appliquant les concepts de la théorie de la charge cognitive et de l'éducation basée sur la simulation. Cette étude a évalué si l'utilisation de modules en ligne préparatoires pour fournir un contenu de pré-briefing hebdomadaire pourrait avoir un impact sur la charge cognitive et la performance. Les participants étaient des étudiants en médecine de troisième cycle de première année participant à un programme de réanimation par simulation. MéTHODES: Cinquante-trois stagiaires ont reçu des modules préparatoires en ligne (groupe de modules en ligne, n = 27) ou non (groupe témoin, n = 26) au cours de la composante de cours d'un programme de réanimation par simulation. Ces stagiaires ont ensuite participé à un examen clinique objectif structuré basé sur la simulation (OSCE). Les sources de charge cognitive (intrinsèque, étrangère et pertinente) ont été mesurées à l'aide d'un questionnaire sur la charge cognitive modifiée. Le rendement a été évalué à l'aide de l'évaluation de la salle d'opération des compétences en chirurgie d'Ottawa. Les données ont été analysées à l'aide de statistiques descriptives et d'une analyse en composantes principales. RéSULTATS: Au cours de la composante de cours, le groupe des modules en ligne s'est avéré avoir une charge cognitive intrinsèque plus élevée et une charge cognitive étrangère plus faible par rapport au groupe témoin. Au cours de l'OSCE, le groupe des modules en ligne a obtenu des scores de performance significativement plus élevés (p = 0,0077, d = 0,39, intervalle de confiance à 95 % = 0,10;0,68) que le groupe témoin. L'analyse en composantes principales a appuyé les résultats obtenus avec le questionnaire sur la charge cognitive modifiée. CONCLUSION: Les stagiaires utilisant des modules préparatoires en ligne pendant la composante de cours d'un programme de réanimation basé sur la simulation ont subi des changements de charge cognitive compatibles avec l'optimisation cognitive. Cela peut avoir contribué à leur performance supérieure dans l'OSCE ultérieure. Les recherches futures devraient explorer les impacts à long terme de la formation préparatoire en ligne et examiner les obstacles potentiels à la mise en œuvre dans divers environnements de soins de santé.

Navigating gaps in practice: consensus recommendations for educational and support structures for emergency physicians returning from gaps in practice.

OBJECTIVE: The purpose of this study was to identify the learning needs of emergency physicians returning to Emergency Medicine (EM) practice after clinical leaves of less than 2 years, summarize existing return to practice programs, and propose recommendations regarding ideal educational and support structures for these physicians both during their practice gaps and upon return to EM. METHODS: A multiple-phased study was conducted to establish recommendations regarding ideal educational and support structures for emergency physicians returning from practice gaps of less than 2 years. The overall design involved an initial environmental scan of existing and exemplar programs and regulatory body positions, followed by interviews with EM Department Heads from across Canada, and then subsequent content analysis and recommendation derivation by EM medical education expert group consensus. These summary recommendations were further revised by consensus at the 2022 CAEP conference academic symposium to derive a final set of consensus recommendations. CONCLUSIONS: We have developed a set of recommendations regarding ideal educational and support structures for physicians experiencing gaps in practice of less than 2 years. This set of recommendations was informed by review of existing and exemplar programs, policies and experience of regulatory bodies, interviews with EM Department Heads across Canada, and a subsequent process of consensus at the 2022 CAEP conference academic symposium. It is hoped that this set of recommendations will inform discussions and potential strategies employed by departments to facilitate the smooth and effective return to EM practice for individuals experiencing gaps.

ABSTRAIT: OBJECTIFS: Le but de cette étude était de déterminer les besoins d'apprentissage des médecins d'urgence qui retournent à la pratique de la médecine d'urgence (ME) après des congés cliniques de moins de deux ans, de résumer les programmes de retour à la pratique existants. et de proposer des recommandations concernant les structures de formation et de soutien idéales pour ces médecins, à la fois pendant leurs lacunes dans la pratique et à leur retour à la GU. MéTHODES: Une étude en plusieurs phases a été menée afin d'établir des recommandations concernant les structures de formation et de soutien idéales pour les médecins d'urgence qui reviennent de lacunes de moins de deux ans. La conception globale comprenait une première analyse de l'environnement des programmes existants et exemplaires et des postes d'organismes de réglementation, suivie d'entrevues avec les chefs des services de GU de partout au Canada. et ensuite l'analyse du contenu et la formulation de recommandations par consensus du groupe d'experts en éducation médicale de la SE. Ces recommandations résumées ont été révisées par consensus lors du symposium universitaire de la conférence 2022 de l'ACMU afin d'en arriver à une série finale de recommandations consensuelles. CONCLUSION: Nous avons élaboré une série de recommandations concernant les structures de formation et de soutien idéales pour les médecins qui connaissent des lacunes dans la pratique depuis moins de deux ans. Cette série de recommandations a été éclairée par l'examen des programmes, des politiques et de l'expérience des organismes de réglementation existants et exemplaires, des entrevues avec les chefs des services de GU partout au Canada et un processus subséquent de consensus au symposium universitaire de la conférence 2022 de la CAEP. On espère que cette série de recommandations éclairera les discussions et les stratégies potentielles employées par les ministères pour faciliter le retour en douceur et efficace à la pratique de GU pour les personnes qui connaissent des lacunes.

Interpretation Services in a Canadian Emergency Department: How Often Are They Utilized for Patients With Limited English Proficiency?

Introduction Patients with limited English proficiency (LEP) face barriers to communication leading to inferior health outcomes when compared with English-proficient patients. Professional interpretation services have been shown to improve healthcare outcomes for patients with LEP but are often underutilized. Methods We conducted a retrospective chart review of all patients who visited the Kingston Health Sciences Centre's ED and urgent care centre between July 2015 and August 2021 and identified as having a non-English preferred language. The demographic and visit information of LEP patients who used LanguageLine (Monterey, CA) were compared to LEP patients who did not use the service. Variables were analysed using t-tests and chi-squared tests. A survey distributed to ED physicians and residents collected perspectives on the facilitators/barriers to LanguageLine use. Results Of the 37,500 visits from LEP patients between 2015 and 2021, 118 (0.31%) used LanguageLine. LEP patients were more likely to access LanguageLine if they were younger (p < 0.001), had a more acute Canadian Triage Acuity Scale (CTAS) score (p < 0.001), and spoke Arabic (p<0.001). All 16 staff/residents who responded to the survey (30% response rate) had at least one LEP patient in the preceding month, and 3/16 (19%) accessed LanguageLine for these patients. Further, 5/16 (31%) reported never using the service, with 4/5 (80%) unaware the service existed. Among those aware of LanguageLine, 7/12 (58%) reported the availability of an ad-hoc interpreter as a reason for not accessing the service. Conclusion Interpretation services are underutilized for LEP patients in the ED, with less than 1% of these patients accessing LanguageLine. Patients were more likely to access LanguageLine if they were younger, spoke Arabic, and had a more acute triage score. Most ED physicians were either unaware of or not accessing LanguageLine despite seeing LEP patients. Future work should aim to improve the use of language services and patient-centred care for LEP patients in the ED.

Multi-source feedback following simulated resuscitation scenarios: a qualitative study.

Background: The direct observation and assessment of learners' resuscitation skills by an attending physician is challenging due to the unpredictable and time-sensitive nature of these events. Multisource feedback (MSF) may address this challenge and improve the quality of assessments provided to learners. We aimed to describe the similarities and differences in the assessment rationale of attending physicians, registered nurses, and resident peers in the context of a simulation-based resuscitation curriculum. Methods: We conducted a qualitative content analysis of narrative MSF of medical residents in their first postgraduate year of training who were participating in a simulation-based resuscitation course at two Canadian institutions. Assessments included an entrustment score and narrative comments from attending physicians, registered nurses, and resident peers in addition to self-assessment. Narrative comments were transcribed and analyzed thematically using a constant comparative method. Results: All 87 residents (100%) participating in the 2017-2018 course provided consent. A total of 223 assessments were included in our analysis. Four themes emerged from the narrative data: 1) Communication, 2) Leadership, 3) Demeanor, and 4) Medical Expert. Relative to other assessor groups, feedback from nurses focused on patient-centred care and communication while attending physicians focused on the medical expert theme. Peer feedback was the most positive. Self-assessments included comments within each of the four themes. Conclusions: In the context of a simulation-based resuscitation curriculum, MSF provided learners with different perspectives in their narrative assessment rationale and may offer a more holistic assessment of resuscitation skills within a competency-based medical education (CBME) program of assessment.

Contexte: Le contexte imprévisible et contraignant au niveau du temps lors de l'observation directe et de la rétroaction associée sur les compétences en réanimation des apprenants constituent un défi pour un médecin superviseur. La rétroaction multisources (RMS) peut être un moyen de relever ce défi et d'améliorer la qualité des rétroactions fournies aux apprenants. Nous visons à décrire les similitudes et les différences quant à la démarche évaluative auprès de médecins traitants, d'infirmières cliniciennes et de pairs résidents dans le cadre d'un cours de réanimation offert par simulation. Méthodes: Nous avons réalisé une analyse de contenu à partir des rétroactions narratives offertes aux résidents en première année de formation postdoctorale dans deux universités canadiennes dans le cadre d'un cours de réanimation offert par simulation. En plus de l'auto-évaluation, la rétroaction comportait un score de confiance et des commentaires narratifs de la part de médecins superviseurs, d'infirmières cliniciennes et des pairs. Les commentaires ont été transcrits et analysés par thèmes en appliquant la méthode générale de comparaison constante. Résultats: Un consentement pour participer à l'étude a été obtenu auprès des 87 résidents (100 %) qui ont suivi le cours en 2017-2018. Nous avons analysé un total de 223 rétroactions. Quatre thèmes ont émergé à partir des données narratives soit : 1) la communication, 2) le leadership, 3) le comportement, et 4) l'expertise médicale. Alors que les infirmières ont ciblé leurs commentaires sur les soins centrés sur le patient et la communication, les médecins superviseurs ont les ont ciblés sur l'expertise médicale. Les commentaires des pairs étaient les plus positifs. Les auto-évaluations comportaient des commentaires sur chacun des quatre thèmes. Conclusions: Dans le contexte d'un cours de réanimation offert par simulation, la RMS a permis aux apprenants d'obtenir des évaluations narratives selon différentes perspectives. Permettant ainsi une approche plus holistique de rétroaction sur les habiletés en réanimation dans le cadre d'un programme d'évaluation axé sur les compétences .

"R1 Nightmares": a resident-led on-call medical emergency simulation course for junior residents.

Implication Statement On-call medical emergencies can be a source of anxiety for junior medical residents. Senior resident teachers are well-positioned to teach a safe approach to managing on-call emergencies, and simulation-based training has educational and patient safety advantages. We describe the implementation of a resident-facilitated, on-call emergency simulation course for first-year residents. The course was low-cost, time-efficient, increased residents' self-rated comfort with acutely deteriorating patients and was highly recommended by participants. The "R1 Nightmares" course could be adapted for other residency programs and institutions.

Énoncé des implications de la rechercheLes urgences durant la garde peuvent être une source d'anxiété pour les résidents juniors. Les résidents seniors se trouvent en situation privilégiée pour enseigner une approche sûre de la gestion des urgences sur la garde. De plus, la formation basée sur la simulation présente des avantages sur le plan pédagogique et sur le plan de la sécurité des patients. Nous décrivons la mise en œuvre d'un cours de simulation d'urgences survenant durant le service de garde destiné aux résidents de première année et animé par leurs collègues séniors. Nécessitant peu de temps et de ressources financières, le cours a permis aux résidents d'améliorer leur niveau de confort auprès des patients dont l'état se détériore rapidement et il a été fortement recommandé par les participants. Le cours «Cauchemars de R1¼ peut être adapté à d'autres programmes de résidence et à d'autres établissements.

The Assessment Rationale of Postgraduate Medical Trainees With Incongruent Self and Faculty Assigned Entrustment Scores.

Background Self-assessment is a central skill in competency-based medical education (CBME) and should be fostered in order to promote life-long learning. One measure that will guide the development of self-assessment is the alignment between it and external expert assessment. In this study, we explored the qualitative themes in the self-assessment rationale among trainees with incongruent self and faculty-assigned entrustment scores. Methods A total of 40 postgraduate medical trainees completed a four-scenario summative objective structured clinical examination (OSCE) as part of a simulation-based resuscitation curriculum in December 2017. After each scenario, an assessment involving an entrustment score and narrative rationale was completed by both trainee (self) and faculty. The differences between the trainee and faculty scores were calculated for each scenario and summed to give a single "incongruence score". Trainees who consistently scored themselves higher than the faculty were said to have a "positive-incongruence score" and those scoring below the faculty were said to have a "negative-incongruence" score. Through this method, 10 trainees with the highest and lowest scores were assigned to each group and their narrative rationales were coded and thematically analyzed. Results The content of the self-assessment narrative rationale differed between the two groups. Trainees in the positive-incongruence group focused on the concepts of speed and situational management, while trainees in the negative-incongruence group commented on lack of support, and a need to improve communication, diagnosis, and code blue management. The quality of the self-assessment rationale also differed between groups. Trainees in the negative-incongruence group provided higher-quality comments that were more detailed and granular. Conclusion We found differences in the content and quality of the self-assessment rationale between trainees whose self and faculty-assigned assessment is incongruent. This provides insight into how these groups differ and has valuable implications for the development of curricula targeting self-assessment skills.

Multisource Feedback in the Trauma Context: Priorities and Perspectives.

OBJECTIVES: Trauma resuscitations require competence in both clinical and nonclinical skills but these can be difficult to observe and assess. Multisource feedback (MSF) is workplace-based, involves the direct observation of learners, and can provide feedback on nonclinical skills. We sought to compare and contrast the priorities of multidisciplinary trauma team members when assessing resident trauma team captain (TTC) performance. Additionally, we aimed to describe the nature of the assessment and perceived the utility of incorporating MSF into the trauma context. METHODS: A convenience sample of 10 trauma team activations were observed. Following each activation, the attending physician trauma team leader (TTL), TTC, and a registered nurse (RN) participated in a semistructured interview. MSF was not provided to the TTC for the purpose of this study because MSF was not part of the assessment process of TTCs at the time of this study and maintaining anonymity may have encouraged more honest interview responses. Transcripts from each assessor group (TTL, TTC, RN) were coded and assigned to one of the five crisis resource management skills: leadership, communication, situational awareness, resource utilization, and problem-solving. Comments were also coded as positive, negative, or neutral as interpreted by the coder. RESULTS: All assessor groups mentioned communication skills most frequently. After communication, the RN and TTC groups commented on situational awareness most frequently, comprising 15 and 29% of their total responses, respectively, whereas 31% of the TTL comments focused on leadership skills. The RN and TTL groups provided positive assessments, with 51 and 42% of their respective comments coded as positive. Forty-five percent of self-assessment comments in the TTC group were negative. All (100%) of the TTC and TTL respondents felt that incorporating MSF would add to the quality of feedback, only 66% of the RN group felt that way. CONCLUSIONS: We found that each assessor group brings a unique focus and perspective to the assessment of resident TTC performance. The future inclusion of MSF in the trauma team context has the potential to enhance the learning environment in a clinical arena that is difficult to directly observe and assess.

An Evaluation of the Surgical Foundations Curriculum: A National Study.

BACKGROUND: Canadian Surgical Foundations (SF) residency programs transitioned to competency-based medical education in 2018. It is unknown how well the SF curriculum prepares surgery residents to recognize and manage common perioperative patient presentations. We sought to evaluate the national SF curriculum using the Kirkpatrick model of curriculum evaluation. METHODS: We administered online surveys to 300 first-year English-speaking surgery residents across Canada to assess self-reported confidence in recognizing and managing 7 common perioperative patient presentations at 3 timepoints: pre-SF (July 2019), mid-SF (December 2019), and post-SF (May 2020). We conducted multistation simulation-based objective structured clinical examinations for surgery residents at our institution pre-SF (August 2019) and mid-SF (December 2019), and collected workplace-based assessment (WBA) data, including entrustment scores and narrative feedback, for 6 preselected entrustable professional activities (EPAs) (July 2019 to May 2020). RESULTS: Fifty-five residents (18%) completed pre-SF, 31 (10%) completed mid-SF, and 52 (17%) completed post-SF surveys. Residents' confidence in recognizing 6 out of 7 patient presentations was high pre-SF and did not improve significantly during the SF curriculum except for recognizing poor glycemic control (p < 0.01). Residents' confidence in managing 7 out of 7 patient presentations improved significantly (p < 0.05). Objective structured clinical examinations performance did not change significantly between pre-SF and mid-SF (4 [3.5-4.5] vs 4 [3-4]; p = 0.28). Analysis of WBA data showed that residents received high entrustment scores from the start of the SF curriculum. Entrustment scores improved significantly during the SF curriculum for 2 out of 6 EPAs. Only 56% of WBA assessments had narrative feedback, 16% of which had somewhat constructive feedback. CONCLUSION: Participation in the SF curriculum was associated with improved confidence of surgery residents in managing common perioperative patient presentations, and greater level of entrustment for some EPAs. Consideration should be given to further faculty development to increase the quantity and quality of narrative feedback in the SF curriculum.

Multiprofessional perspectives on the identification of latent safety threats via in situ simulation: a prospective cohort pilot study.

Objectives: To describe the association between participant profession and the number and type of latent safety threats (LSTs) identified during in situ simulation (ISS). Secondary objectives were to describe the association between both (a) participants' years of experience and LST identification and (b) type of scenario and number of identified LSTs. Methods: Emergency staff physicians (MDs), registered nurses (RNs) and respiratory therapists (RTs) participated in ISS sessions in the emergency department (ED) of a tertiary care teaching hospital. Adult and paediatric scenarios were designed to be high-acuity, low-occurrence resuscitation cases. Simulations were 10 min in duration. A written survey was administered to participants immediately postsimulation, collecting demographic data and perceived LSTs. Survey data was collated and LSTs were grouped using a previously described framework. Results: Thirteen simulation sessions were completed from July to November 2018, with 59 participants (12 MDs, 41 RNs, 6 RTs). Twenty-four unique LSTs were identified from survey data. RNs identified a median of 2 (IQR 1, 2.5) LSTs, significantly more than RTs (0.5 (IQR 0, 1.25), p=0.04). Within respective professions, MDs and RTs most commonly identified equipment issues, and RNs most commonly identified medication issues. Participants with ≤10 years of experience identified a median of 2 (IQR 1, 3) LSTs versus 1 (IQR 1, 2) LST in those with >10 years of experience (p=0.06). Adult and paediatric patient scenarios were associated with the identification of a median of 4 (IQR 3.0, 4.0) and 5 LSTs (IQR 3.5, 6.5), respectively (p=0.15). Conclusions: Inclusion of a multidisciplinary team is important during ISS in order to gain a breadth of perspectives for the identification of LSTs. In our study, participants with ≤10 years of experience and simulations with paediatric scenarios were associated with a higher number of identified LSTs; however, the difference was not statistically significant.

Shaken and stirred: emotional state, cognitive load, and performance of junior residents in simulated resuscitation.

BACKGROUND: Patient resuscitation can be overwhelming for junior postgraduate medical residents due to its inherent complexity and high-stakes environment. Emotional states of unpleasant hyperarousal burden cognitive resources, contributing to cognitive overload and performance decline. Our objective is to characterize the associations between pre-scenario emotional state and junior residents' cognitive load and performance in a simulated-resuscitation, to provide evidence for informed curricular development. METHODS: PGY-1 residents self-rated their emotional state before four simulated-resuscitation scenarios, and their cognitive load after. Faculty assessed performance with entrustment scores. Factor analysis identified the principal components of emotional state data. Linear regression models examined the relationship between pre-scenario emotional components, cognitive load, and performance scores. RESULTS: 47/47 medical and surgical residents (100%) participated and completed Emotional State (99.5%) and Cognitive Load (98.9%) surveys. Positive invigoration and negative tranquility were the principal components. Pre-scenario tranquility was negatively associated with cognitive load (b= -0.23, p < 0.0001), and cognitive load was negatively associated with performance scores (b= -0.27, p < 0.0001). Pre-scenario invigoration was negatively associated with cognitive load (b=-0.18, p = 0.0001), and positively associated with performance scores (b= 0.08, p = 0.0193). CONCLUSION: Amongst junior residents participating in simulated resuscitation scenarios, pre-scenario agitation (negative tranquility) is associated with increased cognitive load, which itself is associated with lower performance scores. These findings suggest residency programs should consider developing curriculum aimed at modulating residents' emotional agitation and reducing residents' cognitive burden to improve resuscitation performance.

CONTEXTE: La réanimation de patients peut être éprouvante pour les stagiaires postdoctoraux juniors en raison de la complexité qui y est inhérente et de la gravité de l'enjeu. Les états émotionnels désagréables d'hyperexcitation épuisent les ressources cognitives, contribuant ainsi à la surcharge cognitive et à la baisse de la performance. Notre objectif était de mettre en évidence le rapport entre l'état émotionnel des résidents juniors avant une simulation de réanimation d'un côté et leur charge cognitive et leur performance lors de celle-ci de l'autre, pour produire des données probantes pouvant servir à la conception éclairée de programmes d'enseignement. MÉTHODES: Des résidents de première année ont autoévalué leur état émotionnel avant chacun des quatre scénarios de réanimation simulée, ainsi que leur charge cognitive après les simulations. Des membres du corps professoral ont évalué leur performance par l'attribution de scores de confiance. Les principales composantes des données sur l'état émotionnel ont été déterminées par le biais d'une analyse factorielle. On s'est servi de modèles de régression linéaire pour établir la relation entre les composantes émotionnelles avant la simulation, la charge cognitive et les scores de performance. RÉSULTATS: Les 47 résidents en médecine et en chirurgie qui ont participé à l'étude (100 %) ont rempli les questionnaires sur l'état émotionnel (99,5 %) et la charge cognitive (98,9 %). La stimulation positive et la tranquillité négative sont les principales composantes dégagées. La tranquillité avant la simulation était négativement corrélée avec la charge cognitive (b= -0,23, p<0,0001), et la charge cognitive était négativement liée aux scores de performance (b= -0,27, p<0,0001). La stimulation avant la simulation était négativement corrélée avec la charge cognitive (b=-0.18, p=0.0001), et positivement corrélée avec les scores de performance (b= 0.08, p=0.0193). CONCLUSION: Chez les résidents juniors qui ont participé à des scénarios de réanimation simulée, l'agitation précédant cette dernière (tranquillité négative) était liée à une charge cognitive accrue, qui elle-même a donné lieu à des scores de performance plus faibles. Ces résultats montrent la pertinence de concevoir des programmes qui visent à réduire l'agitation émotionnelle et la charge cognitive des résidents afin d'améliorer leurs performances en réanimation.

Simulation in the Continuing Professional Development of Academic Emergency Physicians: A Canadian National Survey.

INTRODUCTION: Simulation is becoming a popular educational modality for physician continuing professional development (CPD). This study sought to characterize how simulation-based CPD (SBCPD) is being used in Canada and what academic emergency physicians (AEPs) desire in an SBCPD program. METHODS: Two national surveys were conducted from March to June 2018. First, the SBCPD Needs Assessment Survey was administered online to all full-time AEPs across 9 Canadian academic emergency medicine (EM) sites. Second, the SBCPD Status Survey was administered by telephone to the department representatives (DRs)-simulation directors or equivalent-at 20 Canadian academic EM sites. RESULTS: Response rates for the SBCPD Needs Assessment and the SBCPD Status Survey were 40% (252/635) and 100% (20/20) respectively. Sixty percent of Canadian academic EM sites reported using SBCPD, although only 30% reported dedicated funding support. Academic emergency physician responses demonstrated a median annual SBCPD of 3 hours. Reported incentivization for SBCPD participation varied with AEPs reporting less incentivization than DRs. Academic emergency physicians identified time commitments outside of shift, lack of opportunities, and lack of departmental funding as their top barriers to participation, whereas DRs thought AEPs fear of peer judgment and inexperience with simulation were substantial barriers. Content areas of interest for SBCPD were as follows: rare procedures, pediatric resuscitation, and neonatal resuscitation. Lastly, interprofessional involvement in SBCPD was valued by both DRs and AEPs. CONCLUSIONS: Simulation-based CPD programs are becoming common in Canadian academic EM sites. Our findings will guide program coordinators in addressing barriers to participation, selecting content, and determining the frequency of SBCPD events.

The Documentation of Goals of Care Discussions at a Canadian Academic Hospital.

INTRODUCTION: Patient-centered care is a core principle of the Canadian healthcare system. In order to facilitate patient-centered care, the documentation of a patient's medical goals and expectations is important, especially in the event of acute decompensation when an informed conversation with the patient may not be possible. The 'Goals of Care Discussion Form (GCF)' at Kingston Health Sciences Centre (KHSC) documents goals of care discussions between patients and healthcare providers. All patients admitted to the Internal Medicine service are expected to have this form completed within 24 hours of admission. Formal measurement of form completion at our center has not previously been done, though anecdotally this form is often incomplete. The purpose of this study is to quantify the rate of completion and assess quality of documentation of the GCF at KHSC. METHODS: This prospective chart review took place between August 25, 2018, and March 25, 2019. Charts were reviewed for the presence of a completed GCF, and the quality of notation was assessed, as appropriate. Given there are no existing tools for assessing the quality of a document such as the GCF, authors TC and JM created one de novo for this study. Extracted data included the amount of time elapsed between admission and completion of the GCF, whether the 'yes/no cardiopulmonary resuscitation (CPR)' order in the patient's chart aligned with their wishes as outlined on the GCF, and whether or not a patient's GCF was uploaded to the hospital's electronic medical record (EMR). RESULTS:  Two hundred sixteen charts were reviewed. Of these, 136 (63.0%) had a complete GCF. The mean GCF quality score was 3.4/7 (95% CI [3.2, 3.6]). The mean time elapsed from admission to the completion of the GCF was 1.5 days (95% CI [0.6, 2.4]). There were 130 charts with both a complete GCF and a 'yes/no CPR' order, and of these, 20 (15.4%) showed a discrepancy. Eighty-six (63.2%) of the completed GCFs were uploaded to the EMR. DISCUSSION AND CONCLUSIONS:  The rate of GCF completion at KHSC is noticeably higher than expected based on the previous literature. However, our assessment of the quality of completion indicates that there is room for improvement. Most concerning, discrepancies were found between the 'yes/no CPR' order in a patient's chart and their stated wishes on the GCF. Furthermore, less than two-thirds of completed GCFs were found to have been uploaded to the hospital's EMR. Given the emphasis on patient-centered care in the Canadian healthcare system, our findings suggest that improvement initiatives are needed with respect to documenting goals of care discussions with patients.

Harnessing the power of simulation for assessment: Consensus recommendations for the use of simulation-based assessment in emergency medicine.

OBJECTIVES: To address the increasing demand for the use of simulation for assessment, our objective was to review the literature pertaining to simulation-based assessment and develop a set of consensus-based expert-informed recommendations on the use of simulation-based assessment as presented at the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education. METHODS: A panel of Emergency Medicine (EM) physicians from across Canada, with leadership roles in simulation and/or assessment, was formed to develop the recommendations. An initial scoping literature review was conducted to extract principles of simulation-based assessment. These principles were refined via thematic analysis, and then used to derive a set of recommendations for the use of simulation-based assessment, organized by the Consensus Framework for Good Assessment. This was reviewed and revised via a national stakeholder survey, and then the recommendations were presented and revised at the consensus conference to generate a final set of recommendations on the use of simulation-based assessment in EM. CONCLUSION: We developed a set of recommendations for simulation-based assessment, using consensus-based expert-informed methods, across the domains of validity, reproducibility, feasibility, educational and catalytic effects, acceptability, and programmatic assessment. While the precise role of simulation-based assessment will be a subject of continued debate, we propose that these recommendations be used to assist educators and program leaders as they incorporate simulation-based assessment into their programs of assessment.

A case for feedback and monitoring assessment in competency-based medical education.

PURPOSE: Within competency-based medical education, self-regulated learning (SRL) requires residents to leverage self-assessment and faculty feedback. We sought to investigate the potential for competency-based assessments to foster SRL by quantifying the relationship between faculty feedback and entrustment ratings as well as the congruence between faculty assessment and resident self-assessment. MATERIALS AND METHODS: We collected comments in (a) an emergency medicine objective structured clinical examination group (objective structured clinical examinations [OSCE] and emergency medicine OSCE group [EMOG]) and (b) a first-year resident multidisciplinary resuscitation "Nightmares" course assessment group (NCAG) and OSCE group (NOG). We assessed comments across five domains including Initial Assessment (IA), Diagnostic Action (DA), Therapeutic Action (TA), Communication (COM), and entrustment. Analyses included structured qualitative coding and (non)parametric and descriptive analyses. RESULTS: In the EMOG, faculty's positive comments in the entrustment domain corresponded to lower entrustment score Mean Ranks (MRs) for IA (<11.1), DA (<11.2), and entrustment (<11.6). In NOG, faculty's negative comments resulted in lower entrustment score MRs for TA (<11.8 and <10) and DA (<12.4), and positive comments resulted in higher entrustment score MRs for IA (>15.4) and COM (>17.6). In the NCAG, faculty's positive IA comments were negatively correlated with entrustment scores (ρ = -.27, P = .04). Across programs, faculty and residents made similar domain-specific comments 13% of the time. CONCLUSIONS: Minimal and inconsistent associations were found between narrative and numerical feedback. Performance monitoring accuracy and feedback should be included in assessment validation.

Simulation-based research in emergency medicine in Canada: Priorities and perspectives.

OBJECTIVE: Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM). METHODS: Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators. RESULTS: Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. CONCLUSION: This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

The Implementation of a Multi-institutional Multidisciplinary Simulation-based Resuscitation Skills Training Curriculum.

Competency-based curricula require the development of novel simulation-based programs focused on the assessment of entrustable professional activities. The design and delivery of simulation-based programs are labor-intensive and expensive. Furthermore, they are often developed by individual programs and are rarely shared between institutions, resulting in duplicate efforts and the inefficient use of resources. The purpose of this study is to demonstrate the feasibility of implementing a previously developed simulation-based curriculum at a second institution. We sought to demonstrate comparable program-level outcomes between our two study sites. A multi-disciplinary, simulation-based, resuscitation skills training curriculum developed at Queen's University was implemented at the University of Saskatchewan. Standardized simulation cases, assessment tools, and program evaluation instruments were used at both institutions. Across both sites, 87 first-year postgraduate medical trainees from 14 different residency programs participated in the course and the related research. A total of 226 simulated cases were completed in over 80 sessions. Program evaluation data demonstrated that the instructor experience and learner experience were consistent between sites. The average confidence score (on a 5-point scale) across sites for resuscitating acutely ill patients was 3.14 before the course and 4.23 (p < 0.001) after the course. We have described the successful implementation of a previously developed simulation-based resuscitation curriculum at a second institution. With the growing need for competency-based instructional methods and assessment tools, we believe that programs will benefit from standardizing and sharing simulation resources rather than developing curricula de novo.

The Nightmares Course: A Longitudinal, Multidisciplinary, Simulation-Based Curriculum to Train and Assess Resident Competence in Resuscitation.

BACKGROUND: Postgraduate medical education programs would benefit from a robust process for training and assessment of competence in resuscitation early in residency. OBJECTIVE: To describe and evaluate the Nightmares Course, a novel, competency-based, transitional curriculum and assessment program in resuscitation medicine at Queen's University in Kingston, Ontario, Canada. METHODS: First-year residents participated in the longitudinal Nightmares Course at Queen's University during the 2015-2016 academic year. An expert working group developed the entrustable professional activity and curricular design for the course. Formative feedback was provided following each simulation-based session, and we employed a summative objective structured clinical examination (OSCE) utilizing a modified Queen's Simulation Assessment Tool. A generalizability study and resident surveys were performed to evaluate the course and assessment process. RESULTS: A total of 40 residents participated in the course, and 23 (58%) participated in the OSCE. Eight of 23 (35%) did not meet the predetermined competency threshold and required remediation. The OSCE demonstrated an acceptable phi coefficient of 0.73. The approximate costs were $240 per Nightmares session, $10,560 for the entire 44-session curriculum, and $3,900 for the summative OSCE. CONCLUSIONS: The Nightmares Course demonstrated feasibility and acceptability, and is applicable to a broad array of postgraduate medical education programs. The entrustment-based assessment detected several residents not meeting a minimum competency threshold, and directed them to additional training.