Oiling the wheels of intensive care to reduce "machine friction": the best way to improve outcomes?

INTRODUCTION: A number of costly trials of interventions for the critically ill have had results that are initially positive, and then subsequent trials are less positive. This has led to uncertainty and a feeling that our scientific approach may need reevaluation. What are we missing when performing these trials? Are there simple, less costly ways of improving outcomes for patients? DISCUSSION: Many of the large interventional trials have included patients on the basis of syndromic enrollment criteria. This inevitably leads to a heterogeneous profile of patients, precipitating conditions, and chronic health. The realistic effect of an intervention may vary depending on the individual circumstances of a particular patient, contributing to trial "noise." The assumption that trial size and randomization will deal with this may not hold true and in some circumstances may be biologically questionable. Perhaps we should consider alternatives? In common with other areas of medicine, it is well-known that intensive care outcomes are variable, reflecting differing performance. Until recently, little attention has been focused on a detailed understanding of variation in performance and delivery of care and how such knowledge might be used to improve patient outcomes. A number of recent efforts that have demonstrated positive improvements have been based around understanding and reducing individual and organizational underperformance. This human and organizational factors-based research does not conflict with more pharmacologic-based research and may be complimentary. CONCLUSION: By properly understanding the way we do things and the optimal local balance of protocolized and individualized care, we may deliver greater improvements to the outcome of intensive care unit patients than many of the more expensive, pharmacologic, and technological attempts of recent years.

Unannounced in situ simulations: integrating training and clinical practice.

Simulation-based training for healthcare providers is well established as a viable, efficacious training tool, particularly for the training of non-technical team-working skills. These skills are known to be critical to effective teamwork, and important in the prevention of error and adverse events in hospitals. However, simulation suites are costly to develop and releasing staff to attend training is often difficult. These factors may restrict access to simulation training. We discuss our experiences of 'in situ' simulation for unannounced cardiac arrest training when the training is taken to the clinical environment. This has the benefit of decreasing required resources, increasing realism and affordability, and widening multidisciplinary team participation, thus enabling assessment and training of non-technical team-working skills in real clinical teams. While there are practical considerations of delivering training in the clinical environment, we feel there are many potential benefits compared with other forms of simulation training. We are able to tailor the training to the needs of the location, enabling staff to see a scenario that is relevant to their practice. This is particularly useful for staff who have less exposure to cardiac arrest events, such as radiology staff. We also describe the important benefit of risk assessment for a clinical environment. During our simulations we have identified a number of issues that, had they occurred during a real resuscitation attempt, may have led to patient harm or patient death. For these reasons we feel in situ simulation should be considered by every hospital as part of a patient safety initiative.

The "Resus:Station": the use of clinical simulations in a randomised crossover study to evaluate a novel resuscitation trolley.

BACKGROUND AND AIM: Inadequately designed equipment has been implicated in poor efficiency and critical incidents associated with resuscitation. A novel resuscitation trolley (Resus:Station) was designed and evaluated for impact on team efficiency, user opinion, and teamwork, compared with the standard trolley, in simulated cardiac arrest scenarios. METHODS: Fifteen experienced cardiac arrest teams were recruited (45 participants). Teams performed recorded resuscitation simulations using new and conventional trolleys, with order of use randomised. After each simulation, efficiency ("time to drugs", un-locatable equipment, unnecessary drawer opening) and team performance (OSCAR) were assessed from the video recordings and participants were asked to complete questionnaires scoring various aspects of the trolley on a Likert scale. RESULTS: Time to locate the drugs was significantly faster (p=0.001) when using the Resus:Station (mean 5.19s (SD 3.34)) than when using the standard trolley (26.81s (SD16.05)). There were no reports of missing equipment when using the Resus:Station. However, during four of the fifteen study sessions using the standard trolley participants were unable to find equipment, with an average of 6.75 unnecessary drawer openings per simulation. User feedback results clearly indicated a highly significant preference for the newly designed Resus:Station for all aspects. Teams performed equally well for all dimensions of team performance using both trolleys, despite it being their first exposure to the Resus:Station. CONCLUSION: We conclude that in this simulated environment, the new design of trolley is safe to use, and has the potential to improve efficiency at a resuscitation attempt.

Team performance in resuscitation teams: comparison and critique of two recently developed scoring tools.

BACKGROUND AND AIM: Following high profile errors resulting in patient harm and attracting negative publicity, the healthcare sector has begun to focus on training non-technical teamworking skills as one way of reducing the rate of adverse events. Within the area of resuscitation, two tools have been developed recently aiming to assess these skills - TEAM and OSCAR. The aims of the study reported here were: METHODS: The study consisted of two phases - reliability assessment; and content comparison, and correlation. Assessments were made by two resuscitation experts, who watched 24 pre-recorded resuscitation simulations, and independently rated team behaviours using both tools. The tools were critically appraised, and correlation between overall score surrogates was assessed. RESULTS: Both OSCAR and TEAM achieved high levels of inter-rater reliability (in the form of adequate intra-class coefficients) and minor significant differences between Wilcoxon tests. Comparison of the scores from both tools demonstrated a high degree of correlation (and hence concurrent validity). Finally, critique of each tool highlighted differences in length and complexity. CONCLUSION: Both OSCAR and TEAM can be used to assess resuscitation teams in a simulated environment, with the tools correlating well with one another. We envisage a role for both tools - with TEAM giving a quick, global assessment of the team, but OSCAR enabling more detailed breakdown of the assessment, facilitating feedback, and identifying areas of weakness for future training.