Healthcare providers' perceptions of a situational awareness display for emergency department resuscitation: a simulation qualitative study.

IMPORTANCE: Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. OBJECTIVES: To determine resuscitation team members' perceptions of the Situational Awareness Display's utility. DESIGN: We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. SETTING: Dual site tertiary care level 1 trauma centre in Ottawa, Canada. PARTICIPANTS: We recruited by email physicians, nurses and respiratory therapist. INTERVENTION: Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. MAIN OUTCOMES AND MEASURES: Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. RESULTS: We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4-5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display's utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. CONCLUSION: Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care.

Are we talking about practice? A randomized study comparing simulation-based deliberate practice and mastery learning to self-guided practice.

OBJECTIVES: Simulation-based technical skills training is now ubiquitous in medicine, particularly for high acuity, low occurrence (HALO) procedures. Mastery learning and deliberate practice (ML + DP) are potentially valuable educational methods, however, they are resource intensive. We sought to compare the effect of deliberate practice and mastery learning versus self-guided practice on skill performance of the rare, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). METHODS: We conducted a multi-center, randomized study at five North American emergency medicine (EM) residency programs. We randomly assigned 176 EM residents to either the ML + DP or self-guided practice groups. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test), after (post-test) and 6-12 months (retention) after the training session. The primary outcome was post-test skill performance using a global rating score (GRS). Secondary outcomes included performance time and skill performance at the retention test. RESULTS: Immediately following training, GRS scores were significantly higher as mean performance improved from pre-test, (22, 95% CI = 21-23) to post-test (27, 95% CI = 26-28), (p < 0.001) for all participants. However, there was no difference between the groups on GRS scores (p = 0.2) at the post-test or at the retention test (p = 0.2). At the retention test, participants in the ML + DP group had faster performance times (66 s, 95% CI = 57-74) compared to the self-guided group (77 s, 95% CI = 67-86), (p < 0.01). CONCLUSIONS: There was no significant difference in skill performance between groups. Residents who received deliberate practice and mastery learning demonstrated an improvement in skill performance time.

ABSTRAIT: OBJECTIFS: La formation aux compétences techniques fondée sur la simulation est maintenant omniprésente en médecine, en particulier pour les procédures de grande acuité et de faible occurrence (HALO). L'apprentissage de la maîtrise et la pratique délibérée (ML+DP) sont des méthodes éducatives potentiellement précieuses, mais elles exigent beaucoup de ressources. Nous avons cherché à comparer l'effet de la pratique délibérée et de l'apprentissage de la maîtrise par rapport à la pratique autoguidée sur le rendement des compétences de la rare intervention de sauvetage, une cricothyroïdotomie à la bougie. MéTHODES: Nous avons mené une étude multicentrique randomisée dans le cadre de cinq programmes nord-américains de résidence en médecine d'urgence. Nous avons affecté au hasard 176 résidents en SE aux groupes de ML+DP ou de pratique autoguidée. Trois experts des voies respiratoires aveuglés ont évalué de façon indépendante la performance des compétences en BAC par examen vidéo avant (pré-test), après (post-test) et 6 à 12 mois (rétention) après la séance de formation. Le principal résultat a été le rendement des compétences après le test au moyen d'une cote globale (SRC). Les résultats secondaires comprenaient le temps consacré au rendement et le rendement des compétences au test de rétention. RéSULTATS: Immédiatement après la formation, les résultats des SRC étaient beaucoup plus élevés, car le rendement moyen s'est amélioré entre le prétest (22, IC à 95 % = 21 à 23) et le post-test (27, IC à 95 % = 26 à 28), (p < 0,001) pour tous les participants. Cependant, il n'y avait aucune différence entre les groupes sur les scores GRS (p = 0,2) au post-test ou au test de rétention (p = 0,2). Au test de rétention, les participants du groupe ML+DP avaient des temps de performance plus rapides (66 secondes, IC à 95 % = 57 à 74) que ceux du groupe autoguidé (77 secondes, IC à 95 % = 67 à 86) (p < 0,01). CONCLUSIONS: Il n'y avait pas de différence significative dans le rendement des compétences entre les groupes. Les résidents qui ont bénéficié d'une pratique délibérée et d'un apprentissage de la maîtrise ont démontré une amélioration du temps consacré aux compétences.

Rapid deployment of a virtual simulation curriculum to prepare for critical care triage during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic in Ontario, Canada, an Emergency Standard of Care for Major Surge was created to establish a uniform process for the "triage" of finite critical care resources. This proposed departure from usual clinical care highlighted the need for an educational tool to prepare physicians for making and communicating difficult triage decisions. We created a just-in-time, virtual, simulation-based curriculum and evaluated its impact for our group of academic Emergency Physicians. METHODS: Our curriculum was developed and evaluated following Stufflebeam's Context-Input-Process-Product model. Our virtual simulation sessions, delivered online using Microsoft Teams, addressed a range of clinical scenarios involving decisions about critical care prioritization (i.e., Triage). Simulation participants completed a pre-course multiple-choice knowledge test and rating scales pertaining to their attitudes about using the Emergency Standard of Care protocol before and 2-4 weeks after participating. Qualitative feedback about the curriculum was solicited through surveys. RESULTS: Nine virtual simulation sessions were delivered over 3 weeks, reaching a total of 47 attending emergency physicians (74% of our active department members). Overall, our intervention led to a 36% (95% CI 22.9-48.3%) improvement in participants' self-rated comfort and attitudes in navigating triage decisions and communicating with patients at the end of life. Scores on the knowledge test improved by 13% (95% CI 0.4-25.6%). 95% of participants provided highly favorable ratings of the course content and similarly indicated that the session was likely or very likely to change their practice. The curriculum has since been adopted at multiple sites around the province. CONCLUSION: Our novel virtual simulation curriculum facilitated rapid dissemination of the Emergency Standard of Care for Major Surge to our group of Emergency Physicians despite COVID-19-related constraints on gathering. The active learning afforded by this method improved physician confidence and knowledge with these difficult protocols.

RéSUMé: CONTEXTE: Au cours de la pandémie de COVID-19 en Ontario, au Canada, une norme de soins d'urgence pour les poussées majeures a été créée afin d'établir un processus uniforme pour le " triage " des ressources limitées en soins intensifs. Cette proposition d'écart par rapport aux soins cliniques habituels a mis en évidence la nécessité d'un outil éducatif pour préparer les médecins à prendre et à communiquer des décisions de triage difficiles. Nous avons créé un programme d'études virtuel, juste à temps, basé sur la simulation et avons évalué son impact sur notre groupe de médecins urgentistes universitaires. MéTHODES: Notre programme d'études a été développé et évalué selon le modèle Contexte-Intrant-Processus-Produit de Stufflebeam. Nos sessions de simulation virtuelle, réalisées en ligne à l'aide de Microsoft Teams, ont abordé une série de scénarios cliniques impliquant des décisions sur la priorisation des soins intensifs (c.-à-d. le triage). Les participants à la simulation ont rempli un test de connaissances à choix multiples avant le cours et des échelles d'évaluation concernant leurs attitudes à l'égard de l'utilisation du protocole de soins d'urgence standard avant et deux à quatre semaines après leur participation. Des commentaires qualitatifs sur le programme ont été sollicités par le biais d'enquêtes. RéSULTATS: Neuf sessions de simulation virtuelle ont été dispensées sur trois semaines, touchant au total 47 médecins urgentistes titulaires (74 % des membres actifs de notre service). Dans l'ensemble, notre intervention a conduit à une amélioration de 36 % (IC 95 % 22,9-48,3 %) de l'auto-évaluation du confort et des attitudes des participants en matière de décisions de triage et de communication avec les patients en fin de vie. Les scores au test de connaissances se sont améliorés de 13% (IC 95% 0,4-25,6%). 95 % des participants ont donné une évaluation très favorable du contenu du cours et ont également indiqué que la session était susceptible ou très susceptible de modifier leur pratique. Le programme d'études a depuis été adopté à plusieurs endroits dans la province. CONCLUSION: Notre nouveau programme de simulation virtuelle a facilité la diffusion rapide des normes de soins d'urgence en cas de crise majeure à notre groupe d'urgentistes, malgré les contraintes de rassemblement liées au COVID-19. L'apprentissage actif que permet cette méthode a amélioré la confiance et les connaissances des médecins concernant ces protocoles difficiles.

Faculty Sim: Implementation of an Innovative, Simulation-based Continuing Professional Development Curriculum for Academic Emergency Physicians.

BACKGROUND: Maintaining and enhancing competence in the breadth of emergency medicine (EM) is an ongoing challenge. In particular, resuscitative care in EM involves high-risk clinical encounters that demand strong procedural skills, effective team leadership, and up-to-date clinical knowledge. Simulation-based medical education is an effective modality for enhancing technical and nontechnical skills in crisis situations and has been effectively embedded in undergraduate and postgraduate medical curricula worldwide. To our knowledge, there are few existing systematic department-wide simulation programs to address continuing professional development (CPD) for practicing academic EM faculty. DEVELOPMENT PROCESS: We developed our novel, simulation-based CPD program following Kern's six-step model. Based on the results of a multimodal needs assessment, a longitudinal curriculum was mapped and tailored to the available resources. Institutional support was provided in the form of a departmental grant to fund a physician program lead, monthly session instructors, and operating costs. OUTCOMES: CPD simulation sessions commenced in January 2017. Our needs assessment identified two key types of educational needs: 1) crisis resource management skills and 2) frequent practice of high-stakes critical care procedures (e.g., surgical airways). Simulation sessions involve two high-fidelity simulated resuscitations and one skills lab per day. To date, 21 sessions have been delivered, reaching 161 practicing EPs. Feedback from our faculty has been positive. REFLECTIVE DISCUSSION: We have successfully introduced a curriculum of monthly simulation-based CPD based on the educational needs of our EPs. Future work will include more detailed program evaluation linked to clinical outcomes and program expansion to support nearby institutions.

Ten (+1) lessons from conducting a mass casualty in situ simulation exercise in a Canadian academic hospital setting.

Providing care in a twenty-first century urban emergency department (ED) and trauma center is a complex high-pressure practice environment. The pressure is intensified during patient surge scenarios commonly seen during mass casualty incidents, such that response must be practiced regularly. Beyond clinical mastery of individual patient trauma care, a coordinated system-level response is essential to optimize patient care during these relatively infrequent events. This paper highlights the need to perform exercises in hospitals while providing practical advice on how to utilize in situ simulation for mass casualty testing. Eleven lessons are presented to assist other emergency management professionals, hospital administrators, or clinical staff to achieve success with in situ simulation. Based upon our experience designing and executing an in situ mass casualty simulation within an ED, we offer lessons applicable to any type of disaster exercise. Simulation offers a powerful tool for the conduct of disaster preparedness exercises for staff across multiple hospital departments and professions.

Integration of In Situ Simulation Into an Emergency Department Code Orange Exercise in a Tertiary Care Trauma Referral Center.

OBJECTIVES: Disaster-preparedness and response are a commonly overlooked aspect of hospital policy and can frequently be outdated and undertested. Simulation-based education has become a core education modality within Canadian medical training programs. We hypothesized that integrating in situ simulation (ISS) into a hospital-wide, mass-casualty response exercise would enhance realism and our ability to identify latent safety threats (LSTs). METHODS: Using ISS we created a simulated mass shooting scenario with 20 patients, played by actors in full moulage, presenting to a large tertiary care hospital over a 50-minute period. RESULTS: Integrating ISS into our exercise created a realistic experience for the participants involved and improved participant education, while imparting enough systemic stress to expose LSTs associated within patient care and hospital policy. CONCLUSION: Overall, ISS was successfully used and enhanced a large-scale test of our hospital's mass-casualty response plan.

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.

Evaluating the potential impact of an emergency department extracorporeal resuscitation (ECPR) program: a health records review.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program. METHODS: This retrospective health records review included patients aged 18-75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both "liberal" and "restrictive" ECPR criteria were defined and applied to our cohort. RESULTS: A total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31-53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR. CONCLUSION: At our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department.

OBJECTIVES: Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. METHODS: As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. RESULTS: During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases. CONCLUSIONS: Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

Regional needs assessment for emergency physician audit and feedback.

OBJECTIVES: Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. METHODS: We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. RESULTS: A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. CONCLUSION: This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

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.

Team communication patterns in emergency resuscitation: a mixed methods qualitative analysis.

BACKGROUND: In order to enhance patient safety during resuscitation of critically ill patients, we need to optimize team communication and enhance team situational awareness but little is known about resuscitation team communication patterns. The objective of this study is to understand how teams communicate during resuscitation; specifically to assess for a shared mental model (organized understanding of a team's relationships) and information needs. METHODS: We triangulated 3 methods to evaluate resuscitation team communication at a tertiary care academic trauma center: (1) interviews; (2) simulated resuscitation observations; (3) live resuscitation observations. We interviewed 18 resuscitation team members about shared mental models, roles and goals of team members and procedural expectations. We observed 30 simulated resuscitation video recordings and documented the timing, source and destination of communication and the information category. We observed 12 live resuscitations in the emergency department and recorded baseline characteristics of the type of resuscitations, nature of teams present and type and content of information exchanges. The data were analyzed using a qualitative communication analysis method. RESULTS: We found that resuscitation team members described a shared mental model. Respondents understood the roles and goals of each team member in order to provide rapid, efficient and life-saving care with an overall need for situational awareness. The information flow described in the interviews was reflected during the simulated and live resuscitations with the most responsible physician and charting nurse being central to team communication. We consolidated communicated information into six categories: (1) time; (2) patient status; (3) patient history; (4) interventions; (5) assistance and consultations; 6) team members present. CONCLUSIONS: Resuscitation team members expressed a shared mental model and prioritized situational awareness. Our findings support a need for cognitive aids to enhance team communication during resuscitations.