Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique.

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

Systematic review of the effectiveness of prehospital critical care following out-of-hospital cardiac arrest.

BACKGROUND: Improving survival after out-of-hospital cardiac arrest (OHCA) is a priority for modern emergency medical services (EMS) and prehospital research. Advanced life support (ALS) is now the standard of care in most EMS. In some EMS, prehospital critical care providers are also dispatched to attend OHCA. This systematic review presents the evidence for prehospital critical care for OHCA, when compared to standard ALS care. METHODS: We searched the following electronic databases: PubMed, EmBASE, CINAHL Plus and AMED (via EBSCO), Cochrane Database of Systematic Reviews, DARE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, NIHR Health Technology Assessment Database, Google Scholar and ClinicalTrials.gov. Search terms related to cardiac arrest and prehospital critical care. All studies that compared patient-centred outcomes between prehospital critical care and ALS for OHCA were included. RESULTS: The review identified six full text publications that matched the inclusion criteria, all of which are observational studies. Three studies showed no benefit from prehospital critical care but were underpowered with sample sizes of 1028-1851. The other three publications showed benefit from prehospital critical care delivered by physicians. However, an imbalance of prognostic factors and hospital treatment in these studies systematically favoured the prehospital critical care group. CONCLUSION: Current evidence to support prehospital critical care for OHCA is limited by the logistic difficulties of undertaking high quality research in this area. Further research needs an appropriate sample size with adjustments for confounding factors in observational research design.

Improving the efficiency of advanced life support training: a randomized, controlled trial.

BACKGROUND: Each year, more than 1.5 million health care professionals receive advanced life support (ALS) training. OBJECTIVE: To determine whether a blended approach to ALS training that includes electronic learning (e-learning) produces outcomes similar to those of conventional, instructor-led ALS training. DESIGN: Open-label, noninferiority, randomized trial. Randomization, stratified by site, was generated by Sealed Envelope (Sealed Envelope, London, United Kingdom). (International Standardized Randomized Controlled Trial Number Register: ISCRTN86380392) SETTING: 31 ALS centers in the United Kingdom and Australia. PARTICIPANTS: 3732 health care professionals recruited between December 2008 and October 2010. INTERVENTION: A 1-day course supplemented with e-learning versus a conventional 2-day course. MEASUREMENTS: The primary outcome was performance in a cardiac arrest simulation test at the end of the course. Secondary outcomes comprised knowledge- and skill-based assessments, repeated assessment after remediation training, and resource use. RESULTS: 440 of the 1843 participants randomly assigned to the blended course and 444 of the 1889 participants randomly assigned to conventional training did not attend the courses. Performance in the cardiac arrest simulation test after course attendance was lower in the electronic advanced life support (e-ALS) group compared with the conventional advanced life support (c-ALS) group; 1033 persons (74.5%) in the e-ALS group and 1146 persons (80.2%) in the c-ALS group passed (mean difference, -5.7% [95% CI, -8.8% to -2.7%]). Knowledge- and skill-based assessments were similar between groups, as was the final pass rate after remedial teaching, which was 94.2% in the e-ALS group and 96.7% in the c-ALS group (mean difference, -2.6% [CI, -4.1% to 1.2%]). Faculty, catering, and facility costs were $438 per participant for electronic ALS training and $935 for conventional ALS training. LIMITATIONS: Many professionals (24%) did not attend the courses. The effect on patient outcomes was not evaluated. CONCLUSION: Compared with conventional ALS training, an approach that included e-learning led to a slightly lower pass rate for cardiac arrest simulation tests, similar scores on a knowledge test, and reduced costs. PRIMARY FUNDING SOURCE: National Institute of Health Research and Resuscitation Council (UK).

Assessment of CPR-D skills of nursing students in two institutions: reality versus recommendations in the guidelines.

Significant differences in basic life support skills including cardiopulmonary resuscitation and defibrillation (CPR-D) were detected when nurses working in one Finnish and one Swedish hospital were tested using an Objective Structured Clinical Examination (OSCE). The purpose of this study was to use OSCE test in assessing guideline based CPR-D skills of newly qualified nurses. The CPR-D skills of newly qualified registered nurses studying in Halmstad University (n = 30), Sweden, Helsinki Metropolia University of Applied Sciences (n = 30), and Finland were assessed using an OSCE which was built up with a case of cardiac arrest with ventricular fibrillation as the initial rhythm. The Angoff average, 32.47, was calculated as cutoff point to pass the test. Forty-seven percent of the students in the Swedish group (mean score 32.47/49, range 26-39, SD 3.76) and 13% of the students in the Finnish group (mean score 23.80/49, range 13-35, SD 4.32) passed the OSCE (P<0.0001), the cutoff point being 32.47. Performance grade for the Swedish group was 2.9/5.0 and for the Finnish group 2.1/5.0 (P<0.0001). Good nontechnical skills correlated with high grading of the clinical skills. In conclusion, CPR-D skills of the newly qualified nurses in both the institutes were clearly under par and were not adequate according to the resuscitation guidelines. Current style of teaching is unlikely to result in students being able to perform adequate CPR-D. Standardized testing would help in controlling the quality of learning.

Feasibility and reliability of remote assessment of PALS psychomotor skills via interactive videoconferencing.

AIM: This study determined inter-rater agreement between skill assessments provided by on-site PALS evaluators with ratings from evaluators at a remote site viewing the same skill performance over a videoconferencing network. Judgments about feasibility of remote evaluation were also obtained from the evaluators and PALS course participants. METHODS: Two remote and two on-site instructors independently rated performance of 27 course participants who performed cardiac and shock/respiratory emergency core cases. Inter-rater reliability was assessed with the intraclass correlation coefficient (ICC). Feasibility was assessed with surveys of evaluators and course participants. Core cases were under the direction of the remote evaluators. RESULTS: The ICC for overall agreement on pass/fail decisions was 0.997 for the cardiac cases and 0.998 for the shock/respiratory cases. Perfect agreement was reached on 52 of 54 pass/fail decisions. Across all evaluators, all core cases, and all participants, 2584 ratings of individual skill criteria were provided, of which 21 (0.8%) were ratings in which a single evaluator disagreed with the other three evaluators. No trends emerged for location of the disagreeing evaluator. Survey responses indicated that remote evaluation was acceptable and feasible to course participants and to the evaluators. CONCLUSIONS: Videoconferencing technology was shown to provide adequate spatial and temporal resolution for PALS evaluators at-a-distance from course participants to agree with ratings of on-site evaluators.

[Assessment of physicians employed in emergency medical services about their level of knowledge on basic life support, advanced cardiac life support and medicolegal responsibilities]. / 112 Acil Saglik Hizmetleri'nde görevli doktorlarin temel yasam destegi, ileri kardiyak yasam destegi ve doktorun adli sorumluluklari konularindaki bilgi düzeylerinin degerlendirilmesi.

BACKGROUND: We aimed to determine the level of knowledge of Emergency Medical Services (EMS) physicians on Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and medicolegal responsibilities in conjunction with related factors. METHODS: Fifty-three physicians (43 male, 10 females; mean age 39 years; range 28 to 50 years) employed in EMS were required to respond a questionnaire consisting of demographic data and educational background. They also answered 25 multiple-choice questions about BLS, ACLS and medicolegal responsibilities of physicians in a face-to-face manner. The data were analyzed using Mann-Whitney U-test and Kruskal-Wallis Analysis of Variance test. RESULTS: Mean level of knowledge was 45.4 on a hundred-point scale. Attendance to courses covering emergency aid and working as an ambulance physician for more than one year were associated with higher levels of knowledge (p=0.012; p=0.015). CONCLUSION: In-service training should be undertaken to raise the level of knowledge of the physicians employed in rural EMS and to improve the quality of field care.

Update on pediatric advanced life support guidelines.

Accidents are a leading cause of death for children in several nations. Motor vehicle accidents are among the most common causes of cardiac arrest. Other causes include drowning, burns, gunshot wounds, poisoning, smoke inhalation, and airway obstruction caused by asphyxiation from foreign bodies. Approximately 50% to 65% of children who require cardiopulmonary resuscitation are younger than 1 year of age, with most being younger than 6 months of age. To prevent loss and improve quality of life, it is imperative to initiate measures to improve oxygenation and treat cardiac dysfunction. Guidelines for the management of life-threatening emergencies in infants and children are internationally similar but not identical. The Australian Resuscitation Council, the American Heart Association, and the European Resuscitation Council current guidelines all have some basic essential techniques for management of pediatric emergencies.

Variability in the assessment of advanced life support skills.

The number of short 'life support' and emergency care courses available are increasing. Variability in examiner assessments has been reported previously in more traditional types of examinations but there is little data on the reliability of the assessments used on these newer courses. This study evaluated the reliability and consistency of instructor marking for the Resuscitation Council UK Advanced Life Support Course. Twenty five instructors from 15 centres throughout the UK were shown four staged video recorded defibrillation tests (one repeated) and three cardiac arrest simulation tests in order to assess inter-observer and intra-observer variability. These tests form part of the final assessment of competence on an Advanced Life Support course. Significant levels of variability were demonstrated between instructors with poor levels of agreement of 52-80% for defibrillation tests and 52-100% for cardiac arrest simulation tests. There was evidence of differences in the observation/recognition of errors and rating tendencies of instructors. Four instructors made a different pass/fail decision when shown defibrillation test 2 for a second time leading to only moderate levels of intra-observer agreement (kappa=0.43). In conclusion there is significant variability between instructors in the assessment of advanced life support skills, which may undermine the present assessment mechanisms for the advanced life support course. Validation of the assessment tools for the rapidly growing number of life support courses is required with urgent steps to improve reliability where required.

Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest.

OBJECTIVE: To evaluate the effects of basic life support, time to first defibrillation and emergency medical service arrival time on neurologic outcome and expenses for hospital care in patients after cardiac arrest. SETTING: Large urban emergency medical services system and emergency department in a 2000-bed university hospital. DESIGN: Outcome and cost benefit analysis of patients admitted to the hospital after witnessed, out-of-hospital, ventricular fibrillation cardiac arrest from October 1, 1991, until December 31, 1997. PATIENTS: Out of 1054 patients with out-of-hospital cardiac arrest, 276 were eligible. MEASUREMENTS AND RESULTS: The effects of basic and advanced life support measures on neurologic outcome and hospital expenses were evaluated. In contrast to intubation (odds ratio 1.08; 95% CI: 0.51-2.31; p=0.84), basic life support (odds ratio 0.44; 95% CI: 0.24-0.77; p=0.004) and time to first defibrillation (odds ratio 1.08; 95% CI: 1.03-1.13; p=0.001) were significantly correlated with good neurologic outcome. Among the patients who did not receive basic life support, the average cost per patient with good neurologic outcome significantly increased with the delay of the first defibrillation (p<0.001). CONCLUSIONS: In contrast to intubation, bystander basic life support and time to first defibrillation were significantly associated with good neurologic outcome and resulted in fewer expenses spent on in-hospital efforts.

Cardiac arrest management.

Approximately 1,000 people in the United States suffer cardiac arrest each day, most often as a complication of acute myocardial infarction (AMI) with accompanying ventricular fibrillation or unstable ventricular tachycardia. Increasing the number of patients who survive cardiac arrest and minimizing the clinical sequelae associated with cardiac arrest in those who do survive are the objectives of emergency medical personnel. In 1990, the American Heart Association (AHA) suggested the chain of survival concept, with four links--early access, cardiopulmonary resuscitation (CPR), defibrillation, and advanced care--as the way to approach cardiac arrest. The recently published International Resuscitation Guidelines 2000 of the AHA have addressed advances in our understanding of the chain of survival. While the chain of survival concept has withstood a decade of scrutiny, there are only a few scientifically rigorous research studies that support changes in prehospital patient care. Additional research efforts carried out in the prehospital setting are needed to support the concepts included in the chain of survival for cardiac arrest patients. Participants at the second Turtle Creek Conference, a meeting of experts in the field of emergency medicine held in Dallas, Texas, on March 29-31, 2000, discussed these and other issues associated with prehospital emergency care in the cardiac arrest patient. This paper addresses a number of the issues associated with each of the links of the chain of survival, the evidence that exists, and what should be done to achieve the clinical evidence needed for true clinical significance. Also included in this paper are the consensus statements developed from small discussion groups held after the main presentation. These comments provide another perspective to the problems and to possible approaches to deal with them.