Using simulation scenarios and a debriefing structure to promote feedback skills among interprofessional team members in clinical practice.

BACKGROUND: Team reflexivity and peer feedback in daily clinical work can improve patient safety. However, teams do not always engage in reflection after patient care. A reason could be that team members may lack skills in engaging in team reflection. This study explores the use of interprofessional team-based simulations to encourage and equip teams for reflective conversations in the real-world clinical practice. METHODS: This was a prospective, explorative study of team members' perceptions of the use of in situ simulation-based scenarios with critically ill patient cases to train team-based reflections and peer feedback. The study took place in two neurological wards. Prior to the intervention, a 1-day observation in each ward and semi-structured short interviews with physicians and nurses were conducted. RESULTS: A total of 94 staff members, 57 nurses, 8 nurse assistants and 29 physicians participated in the in situ simulation scenarios. All team members showed appreciation of the safe learning environment. The authors found that the simulations and the debriefing structure provided an opportunity for training of team reflexivity and feedback. The team members evaluated the simulation-based training very positively, and their initial reaction indicated that they found peer feedback useful for the individual and the team. This approach allowed them to reflect on their own clinical practice. CONCLUSION: The simulation-based training scenarios and the debriefing structure promoted team members' team reflexivity and peer feedback skills. The method is feasible and could be used in other specialties and situations. The team members' reactions to feedback were positive, and based on their reflections, there is a potential to increase both individual and team skills as well as improve patient treatment.

Whom Would You Help? The Impact of Perpetrator and Victim Gender on Bystander Behavior During a Sexual Assault.

We examined the impact of perpetrator and victim gender on bystander helping choices and assault perceptions. Participants (32 females, 37 males) read about two simultaneously occurring sexual assaults, indicated which victim they would help, and gave their perceptions of the assaults. We used a within-participants design that fully manipulated the perpetrator and victim gender for both assaults. Results showed female victims of male perpetrators and male victims of female perpetrators were most and least likely to be chosen for help, respectively. Cognitive networks derived from open-ended responses provided insight into the rationale used by participants to make helping decisions in ways that differed by perpetrator and victim gender.

Clinical assessment as a part of an early warning score-a Danish cluster-randomised, multicentre study of an individual early warning score.

BACKGROUND: The clinical benefit of Early Warning Scores (EWSs) is undocumented. Nursing staff's clinical assessment might improve the prediction of outcome and allow more efficient use of resources. We aimed to investigate whether the combination of clinical assessment and EWS would reduce the number of routine measurements without increasing mortality. METHODS: We did a cluster-randomised, crossover, non-inferiority study at eight hospitals in Denmark. Patients aged 18 years or older, admitted for more than 24 h were included. Admissions to paediatric or obstetric wards were excluded. The participating hospitals were randomly assigned 1:1 to start as either intervention or control with subsequent crossover. Primary outcomes were 30-day all-cause mortality (non-inferiority margin=0·5%) and average number of EWS per day per patient. The intervention was implementation of the Individual EWS (I-EWS), in which nursing staff can adjust the calculated score on the basis of their clinical assessment of the patient. I-EWS was compared with the National Early Warning Score (NEWS). The study is registered at ClinicalTrials.gov, NCT03690128 and is complete. FINDINGS: Unique admissions longer than 24 h were included from Oct 15, 2018 to Sept 30, 2019. Of 90 964 patients assessed, n=46 470 were assigned to the I-EWS group and n=44 494 to the NEWS group. Mortality within 30 days was 4·6% for the I-EWS group, and 4·3% for the NEWS group (adjusted odds ratio 1·05 [95% CI 0·99-1·12], p=0·12). In subgroup analyses I-EWS showed increased 30-day mortality for hospitals that did I-EWS in fall-winter, which was probably due to seasonality, and within patients admitted in a surgical specialty. Overall risk difference was 0·22% (95% CI -0·04 to 0·48) meaning that the non-inferiority criteria were met. The average number of scorings per patient per day was reduced from 3·14 to 3·10 (ie, a relative reduction of 0·64% [95% CI -0·16 to -1·11], p=0·0084) in the I-EWS group. INTERPRETATION: Including clinical assessment in I-EWS was feasible and overall non-inferior to the widely implemented NEWS in terms of all-cause mortality at 30 days, and the number of routine measurements was minimally reduced. However I-EWS should be used with caution in surgical patients. FUNDING: Capital Region Research Foundation, Gangsted Foundation, Candys Foundation, Herlev-Gentofte Hospital Research Foundation, Laerdal Foundation, and The Foundation of Director Boennelycke and wife.

Assessment of breathing in cardiac arrest: a randomised controlled trial of three teaching methods among laypersons.

BACKGROUND: The aim of this trial was to compare a video- and a simulation-based teaching method to the conventional lecture-based method, hypothesizing that the video- and simulation-based teaching methods would lead to improved recognition of breathing patterns during cardiac arrest. METHODS: In this Danish, investigator-initiated, stratified, randomised controlled trial, adult laypersons (university students, military conscripts and elderly retirees) participating in European Resuscitation Council Basic Life Support courses were randomised to receive teaching on how to recognise breathing patterns using a lecture- (usual practice), a video-, or a simulation-based teaching method. The primary outcome was recognition of breathing patterns in nine videos of actors simulating normal breathing, no breathing, and agonal breathing (three of each). We analysed outcomes using logistic regression models and present results as odds ratios (ORs) with 95% confidence intervals (CIs) and P-values from likelihood ratio tests. RESULTS: One hundred fifty-three participants were included in the analyses from February 2, 2018 through May 21, 2019 and recognition of breathing patterns was statistically significantly different between the teaching methods (P = 0.013). Compared to lecture-based teaching (83% correct answers), both video- (90% correct answers; OR 1.77, 95% CI: 1.19-2.64) and simulation-based teaching (88% correct answers; OR 1.48; 95% CI: 1.01-2.17) led to significantly more correct answers. Video-based teaching was not statistically significantly different compared to simulation-based teaching (OR 1.20; 95% CI: 0.78-1.83). CONCLUSION: Video- and simulation-based teaching methods led to improved recognition of breathing patterns among laypersons participating in adult Basic Life Support courses compared to the conventional lecture-based teaching method.

Data concerning the Copenhagen tool: A research tool for evaluation of basic life Support educational interventions.

The data presented in this article are supplementary data related to the research article entitled "The Copenhagen Tool: A research tool for evaluation of BLS educational interventions" (Jensen et al., 2019). We present the following supplementary materials and data: 1) a standardized scenario used to introduce the test for gathering data on internal structure and additional response process; 2) test sheets used for rating test participant via video recordings; 3) interview-guide for collecting additional response process data; 4) items deemed relevant but not essential for laypersons, first responders and health personnel in the modified Delphi consensus process; 5) inter-rater reliability values for raters using the essential items of the tool to evaluate test participants via video recordings; 6) main themes from coding interviews with raters; 7) comparison of rater results and manikin software output.

The Copenhagen Tool a research tool for evaluation of basic life support educational interventions.

INTRODUCTION: Over the past decades, major changes have been made in basic life support (BLS) guidelines and manikin technology. The aim of this study was to develop a BLS evaluation tool based on international expert consensus and contemporary validation to enable more valid comparison of research on BLS educational interventions. METHODS: A modern method for collecting validation evidence based on Messick's framework was used. The framework consists of five domains of evidence: content, response process, internal structure, relations with other variables, and consequences. The research tool was developed by collecting content evidence based on international consensus from an expert panel; a modified Delphi process decided items essential for the tool. Agreement was defined as identical ratings by 70% of the experts. RESULTS: The expert panel established consensus on a three-levelled score depending on expected response level: laypersons, first responders, and health care personnel. Three Delphi rounds with 13 experts resulted in 16 "essential" items for laypersons, 21 for first responders, and 22 for health care personnel. This, together with a checklist for planning and reporting educational interventional studies within BLS, serves as an example to be used for researchers. CONCLUSIONS: An expert panel agreed on a three-levelled score to assess BLS skills and the included items. Expert panel consensus concluded that the tool serves its purpose and can act to guide improved research comparison on BLS educational interventions.

Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS).

INTRODUCTION: Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS: In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION: The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER: NCT03690128.

Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review.

OBJECTIVES: Despite of the increasing knowledge about patient safety improvements in the handover process in hospitals, we still lack knowledge about what magnitude of patient safety gains can be expected from improvements in handover between the intensive care unit (ICU) and the general ward. The aim of this systematic review was to investigate which handover tools are devised and evaluated with the aim of improving patient safety in the handover process from ICU to ward and whether the described handover tools fulfill their purpose. METHODS: A systematic literature search of 6 databases was performed to answer the review question, developed by using the "Patient Population, Intervention, Comparison, Outcome" format. Two authors independently performed the selection process, as well as the data extraction and quality assessment. The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement were followed. RESULTS: Eight studies were finally included in the qualitative analysis. One study investigated a written information tool, 1 study investigated improved verbal information, 1 study investigated the effect of an additional safety check, and 5 studies investigated a Liaison Nurse as handover tool. Because of heterogeneity among the included studies, the study results could not be pooled. CONCLUSIONS: Not many well-conducted studies can shed light on this important topic. Giving patients and their families a supplementary written or verbal status report before transfer might improve patient safety. The introduction of a Liaison Nurse may be effective in improving communication between ICU and ward staff, which might reduce risks in patient safety. However, there is no evidence of improved mortality and/or readmission rates after introducing handover tools in the transfer from ICU to ward.

Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study.

PURPOSE: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship. METHODS: Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 h were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test. RESULTS: Among 3175 patients analyzed, triage-to-admission time was 2.1 ±â€¯3.9 h. Patients admitted within 4 h had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient -0.07, p < 0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99-1.58, p = 0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, CI 0.83-1.41, p = 0.58). CONCLUSIONS: Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.

[Review of Early Warning Score in preventing sudden critical illness and death].

Early Warning Score (EWS) are used extensively to identify patients at risk of deterioration during hospital admission. The validation of EWS has primarily focused on investigating predictive validity, i.e. the association between EWS and severe adverse events. Few studies have tested, whether EWS work in the clinical setting, and if it prevents severe adverse events from occurring. Many of these studies have methodological limitations, and their clinical relevance could be questioned. Currently, there is limited evidence to support, that the implementation of EWS reduces the occurrence of severe adverse events.