The Use of Simulation to Improve Family Understanding and Support of Anesthesia Providers.

Introduction  Burnout in medical providers is associated with work dissatisfaction, reduction in patient safety, and provider depression. Simulation is a tool effectively used for specific task training but has not been broadly used as a means to combat medical professional stress and enhance wellness. The authors created a medical simulation program targeted at those involved in the social support of medical providers. The hypothesis was that education of non-medical persons involved in social support would translate into an enhanced understanding of the demands among medical providers in anesthesiology. This understanding would thereby open communication pathways within the social support system and contribute to enhanced wellness among providers. Methods To assess effectiveness and benefits of the event, survey data were obtained from anesthesia providers and their adult support persons before and after the event. The anesthesia providers were queried on their perception regarding the benefit of the event for their support persons. Support persons were asked questions regarding their understanding of the role of an anesthesia provider. Results Sixty-three family members and friends (adult=30, child=33) participated in a two-hour simulation event including activities for participants of all ages. Twenty-nine (96.7%) adult participants (age ≥ 14) completed the support person surveys before and/or after the event. The post-event survey results revealed participants' satisfaction with the event (n=26, 100%). This simulation event also demonstrated an improved understanding of the demands among anesthesia providers by their support persons (seven items, P values range from less than .0001 to .0313). Most anesthesia providers who attended the event enjoyed it a significant amount (n=19, 82.6%). Most providers whose primary work-related support persons attended the event believed that it would be easier to communicate work-related issues (n=12, 85.7%). Conclusion We outline "The Family Anesthesia Experience Day" as a wellness initiative for anesthesia providers. Our study demonstrated improved understanding of support persons' knowledge about anesthesia providers' work-related stress via an immersive two-hour simulation-based learning experience. The event was well-received and may be a useful approach to provide support persons with an opportunity to learn about and better support their beloved anesthesia provider.

Comparing Real-time Versus Delayed Video Assessments for Evaluating ACGME Sub-competency Milestones in Simulated Patient Care Environments.

Background Simulation is an effective method for creating objective summative assessments of resident trainees. Real-time assessment (RTA) in simulated patient care environments is logistically challenging, especially when evaluating a large group of residents in multiple simulation scenarios. To date, there is very little data comparing RTA with delayed (hours, days, or weeks later) video-based assessment (DA) for simulation-based assessments of Accreditation Council for Graduate Medical Education (ACGME) sub-competency milestones. We hypothesized that sub-competency milestone evaluation scores obtained from DA, via audio-video recordings, are equivalent to the scores obtained from RTA. Methods Forty-one anesthesiology residents were evaluated in three separate simulated scenarios, representing different ACGME sub-competency milestones. All scenarios had one faculty member perform RTA and two additional faculty members perform DA. Subsequently, the scores generated by RTA were compared with the average scores generated by DA. Variance component analysis was conducted to assess the amount of variation in scores attributable to residents and raters. Results Paired t-tests showed no significant difference in scores between RTA and averaged DA for all cases. Cases 1, 2, and 3 showed an intraclass correlation coefficient (ICC) of 0.67, 0.85, and 0.50 for agreement between RTA scores and averaged DA scores, respectively. Analysis of variance of the scores assigned by the three raters showed a small proportion of variance attributable to raters (4% to 15%). Conclusions The results demonstrate that video-based delayed assessment is as reliable as real-time assessment, as both assessment methods yielded comparable scores. Based on a department's needs or logistical constraints, our findings support the use of either real-time or delayed video evaluation for assessing milestones in a simulated patient care environment.

Validity of Simulation-Based Assessment for Accreditation Council for Graduate Medical Education Milestone Achievement.

INTRODUCTION: The Accreditation Council for Graduate Medical Education requires biannual evaluation of anesthesiology residents on 25 subcompetency milestones. Some milestone domains are particularly challenging to repeatedly and reliably observe during clinical care. Simulation-Based Milestones Assessment (SBMA) may help overcome these challenges. However, few studies have examined the external validation of simulation assessment scores (ie, the relationships between simulation-based assessment scores and other standard measures of ability) for milestones. This study analyzed whether SBMA scores (1) discriminate by postgraduate year, (2) improve over time, and (3) correlate with traditional measures of performance. METHODS: This is a retrospective analysis of 55 residents' SBMA data from 30 scenarios for two academic years. Each scenario was evaluated for time-in-training discrimination. Scenarios were then analyzed for SBMA scoring trends over time, and SBMA scores were compared with residents' clinical evaluations. RESULTS: Twenty-four SBMA scenarios discriminated by postgraduate year. Repeated measure analysis of variance showed statistically significant between-session score improvements (F (3, 54) = 17.79, P < 0.001). Pearson correlation coefficients demonstrated moderate to strong correlation between SBMA and clinical evaluations: January 2015 r = 0.67, P < 0.01 (n = 27); May 2015 r = 0.43, P = 0.09 (n = 17); November 2015 r = 0.70, P < 0.01 (n = 24); and April 2016 r = 70, P < 0.01 (n = 27). CONCLUSIONS: The associations between SBMA scores and experience level, time-in-training, and clinical performance evaluations provide evidence that SBMA may be used as metrics of residents' Accreditation Council for Graduate Medical Education milestone competencies.

Patient load effects on response time to critical arrhythmias in cardiac telemetry: a randomized trial.

OBJECTIVES: Remotely monitored patients may be at risk for a delayed response to critical arrhythmias if the telemetry watchers who monitor them are subject to an excessive patient load. There are no guidelines or studies regarding the appropriate number of patients that a single watcher may safely and effectively monitor. Our objective was to determine the impact of increasing the number of patients monitored on response time to simulated cardiac arrest. DESIGN: Randomized trial. SETTING: Laboratory-based experiment. SUBJECTS: Forty-two remote telemetry technicians and nurses from cardiac units. INTERVENTIONS: Number of patients monitored in a simulation of cardiac telemetry monitoring work. MEASUREMENTS AND MAIN RESULTS: We carried out a study to compare response times to ventricular fibrillation across five patient loads: 16, 24, 32, 40, and 48 patients. The simulation replicated the work of telemetry watchers using a combination of real recorded patient electrocardiogram signals and a simulated patient experiencing ventricular fibrillation. Study participants were assigned to one of the five patient loads and completed a 4-hour monitoring session, during which they performed tasks-including event documentation and phone calls to report events-similar to real monitoring work. When the simulated patient sustained ventricular fibrillation, the time required to report this arrhythmia was recorded. As patient loads increased, there was a statistically significant increase in response times to the ventricular fibrillation. In addition, frequency of failure to meet a response time goal of less than 20 seconds was significantly higher in the 48-patient condition than in all other conditions. Task performance decreased as patient load increased. CONCLUSIONS: As participants monitored more patients in a laboratory setting, their performance with respect to recognizing critical and noncritical events declined. This study has implications for the design of remote telemetry work and other patient monitoring tasks in critical and intermediate care units.

Standardized assessment for evaluation of team skills: validity and feasibility.

INTRODUCTION: The authors developed a Standardized Assessment for Evaluation of Team Skills (SAFE-TeamS) in which actors portray health care team members in simulated challenging teamwork scenarios. Participants are scored on scenario-specific ideal behaviors associated with assistance, conflict resolution, communication, assertion, and situation assessment. This research sought to provide evidence of the validity and feasibility of SAFE-TeamS as a tool to support the advancement of science related to team skills training. METHODS: Thirty-eight medical and nursing students were assessed using SAFE-TeamS before and after team skills training. The SAFE-TeamS pretraining and posttraining scores were compared, and participants were surveyed. Generalizability analysis was used to estimate the variance in scores associated with the following: examinee, scenario, rater, pretraining/posttraining, examinee type, rater type (actor-live vs. external rater-videotape), actor team, and scenario order. RESULTS: The SAFE-TeamS scores reflected improvement after training and were sensitive to individual differences. Score variance due to rater was low. Variance due to scenario was moderate. Estimates of relative reliability for 2 raters and 8 scenarios ranged from 0.6 to 0.7. With fixed scenarios and raters, 2 raters and 2 scenarios, reliability is greater than 0.8. Raters believed SAFE-TeamS assessed relevant team skills. Examinees' responses were mixed. CONCLUSIONS: The SAFE-TeamS was sensitive to individual differences and team skill training, providing evidence for validity. It is not clear whether different scenarios measure different skills and whether the scenarios cover the necessary breadth of skills. Use of multiple scenarios will support assessment across a broader range of skills. Future research is required to determine whether assessments using SAFE-TeamS will translate to performance in clinical practice.

The "Simulation Roulette" game.

INTRODUCTION: "Simulation Roulette" is a new method of "on-the-fly" simulation scenario creation that incorporates a game-like approach to critical scenarios and emphasizes prescenario preparation. We designed it to complement our traditional anesthesia simulation curriculum, in which residents are exposed to predefined "critical" scenarios. During typical scenarios, trainees are often given minimum preparatory information; they then start the scenario knowing only that "something bad" is going to happen. As a result, trainees often report anxiety, which can be a barrier to learning. To overcome this barrier and to augment traditional critical incident training, we developed the "Simulation Roulette" game. METHODS: "Simulation Roulette" consists of premade cards that are randomly selected to create a patient, another set of premade cards to assist in selecting "complications," worksheets to guide a thorough "prebrief" discussion before the scenario, and scoresheets to facilitate the "debrief" discussion at the end. Similar to traditional scenarios, it requires coordination by a facilitator to ensure plausible scenarios and evaluation of trainee performance. RESULTS: Although we have not conducted formal testing, we believe that (1) incorporating an element of random chance to scenario selection, (2) using a game-like framework, and (3) emphasizing the "prebrief" portion of simulation all have the potential to decrease trainee anxiety. CONCLUSIONS: We present the rationale for designing such a game; examples of instructions, cards, and scoresheets; and our initial experience with implementing this game within our simulation curriculum.

Assessing teamwork in medical education and practice: relating behavioural teamwork ratings and clinical performance.

BACKGROUND: Problems with communication and team coordination are frequently linked to adverse events in medicine. However, there is little experimental evidence to support a relationship between observer ratings of teamwork skills and objective measures of clinical performance. AIM: Our main objective was to test the hypothesis that observer ratings of team skill will correlate with objective measures of clinical performance. METHODS: Nine teams of medical students were videotaped performing two types of teamwork tasks: (1) low fidelity classroom-based patient assessment and (2) high fidelity simulated emergent care. Observers used a behaviourally anchored rating scale to rate each individual on skills representative of assertiveness, decision-making, situation assessment, leadership, and communication. A checklist-based measure was used to assess clinical team performance. RESULTS: Moderate to high inter-observer correlations and moderate correlations between cases established the validity of a behaviourally anchored team skill rating tool for simulated emergent care. There was moderate to high correlation between observer ratings of team skill and checklist-based measures of team performance for the simulated emergent care cases (r = 0.65, p = 0.06 and r = 0.97, p < 0.0001). CONCLUSIONS: These results provide prospective evidence of a positive relationship between observer ratings of team skills and clinical team performance in a simulated dynamic health care task.

The use of high-fidelity human patient simulation as an evaluative tool in the development of clinical research protocols and procedures.

Errors in clinical research can be costly, in terms of patient safety, data integrity, and data collection. Data inaccuracy in early subjects of a clinical study may be associated with problems in the design of the protocol, procedures, and data collection tools. High-fidelity patient simulation centers provide an ideal environment to apply human-centered design to clinical trial development. A draft of a complex clinical protocol was designed, evaluated and modified using a high-fidelity human patient simulator in the Duke University Human Simulation and Patient Safety Center. The process included walk-throughs, detailed modifications of the protocol and development of procedural aids. Training of monitors and coordinators provided an opportunity for observation of performance that was used to identify further improvements to the protocol. Evaluative steps were used to design the research protocol and procedures. Iterative modifications were made to the protocol and data collection tools. The success in use of human simulation in the preparation of a complex clinical drug trial suggests the benefits of human patient simulation extend beyond training and medical equipment evaluation. Human patient simulation can provide a context for informal expert evaluation of clinical protocol design and for formal "rehearsal" to evaluate the efficacy of procedures and support tools.

Preliminary report on the use of high-fidelity simulation in the training of study coordinators conducting a clinical research protocol.

Training of health care research personnel is a critical component of quality assurance in clinical trials. Interactivity (such as simulation) is desirable compared with traditional methods of teaching. We hypothesized that the addition of an interactive simulation exercise to standard training methods would increase the confidence of study coordinators. A simulation exercise was developed to replicate a complex clinical trial. Eighteen study coordinators completed pre- and postexercise confidence questionnaires. Questions were targeted at key trial components using a 0-10 scale (not confident to confident) and were categorized using Bloom's Taxonomy. The primary analysis compared overall mean pre- and postexercise responses. Secondary analyses assessed affective, psychomotor, and cognitive confidence. Significance was at P < 0.05. A significant increase in overall confidence (8.64 versus 5.77; P < 0.0001) was reproduced in the subcategory analyses (affective, 8.24 versus 4.89; P < 0.0001; cognitive, 8.75 versus 6.42; P = 0.0003; psychomotor, 8.63 versus 5.26; P < 0.0001). A high level of internal consistency and reliability in question responses within domains was observed, validating the questionnaire tool. In this preliminary report, we confirmed that addition of a simulation exercise to the training of study coordinators resulted in increased confidence. Simulation exercises should be considered when training study coordinators for clinical research trials.

Evaluation of the System O2 Inc portable nonpressurized oxygen delivery system.

OBJECTIVE: To evaluate the performance of the System O2 portable non-pressurized delivery system (SysO2). This device produces oxygen through chemical reaction and might have utility for emergency/field use. METHODS: Performance was evaluated with 10 unmanned trials conducted under standard laboratory conditions. Measures included oxygen flow (mean and peak), total oxygen yield, and system weight-indexed yield. RESULTS: Oxygen flow peaked at 5.74 +/- 0.28 L x min(-1) (mean +/- SD) at 16.9 +/- 1.5 minutes before rapidly falling to zero. Mean flow was 2.98 +/- 1.52 L x min(-1) with a total yield of 62.9 +/- 6.6 L. Mean oxygen fraction was 0.96 +/- 0.15. The weight per unit of oxygen is substantially higher than for commercially available pressurized cylinders; e.g., 47.7 vs. 10.2 g x L(-1) for the small 246 L M9 cylinder. CONCLUSIONS: Given the limited flow rate and supply duration, we believe the SysO2 system does not offer significant advantage over the available pressurized oxygen systems as a source for emergency oxygen.