Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

Significance of Objective Structured Clinical Examinations to Plastic Surgery Residency Training.

INTRODUCTION: Objective structured clinical examinations (OSCEs) have proven to be a powerful tool. They possess more than a 30-year track record in assessing the competency of medical students, residents, and fellows. Objective structured clinical examinations have been used successfully in a variety of medical specialties, including surgery. They have recently found their way into the subspecialty of plastic surgery. METHODS: This article uses a systematic review of the available literature on OSCEs and their recent use in plastic surgery. It incorporates survey results assessing program directors' views on the use of OSCEs. RESULTS: Approximately 40% of programs surveyed use OSCEs to assess the Accreditation Council for Graduate Medical Education core competencies. We found that 40% use OSCEs to evaluate specific plastic surgery milestones. Objective structured clinical examinations are usually performed annually. They cost anywhere between $100 and more than $1000 per resident. Four milestones giving residents the most difficulties on OSCEs were congenital anomalies, noncancer breast surgery, breast reconstruction, and practice-based learning and improvement. It was determined that challenges with milestones were due to lack of adequate general knowledge and surgical ward patient care, as well as deficits in professionalism and system-based problems. Programs were able to remediate weakness found by OSCEs using a variety of methods. CONCLUSIONS: Objective structured clinical examinations offer a unique tool to objectively assess the proficiency of residents in key areas of the Accreditation Council for Graduate Medical Education core competencies. In addition, they can be used to assess the specific milestones that plastic surgery residents must meet. This allows programs to identify and improve identified areas of weakness.

Using simulation technology to identify gaps between education and practice among new graduate nurses.

Applied knowledge was observed among nurse groups from a medical-surgical residency program to measure clinical performance during simulation training. Twenty groups of new graduate nurses were observed during five simulated clinical scenarios, and their performances were scored on a 24-item checklist. Nurse groups showed significant improvement (p < 0.001) in applied knowledge in four clinical domains from week 1 to week 5, and the results provided valuable information of the groups' overall performances. In two of the five scenarios, poor decisions and prioritization of competing tasks were factors associated with lower performance group scores. Complex patient conditions may pose a challenge for new graduate nurses, and standardized training during the residency program may help instructors recognize specific factors to address during the transition from education to practice.

Twitter as a tool to enhance student engagement during an interprofessional patient safety course.

Twitter and other social media forums are gaining popularity in both the academic and conference arenas as tools to increase participant engagement, attention and interaction. While Twitter has been used successfully to engage college students, it has not been explored for use in an interprofessional curriculum. We sought to explore it as a method to foster student engagement. During a weeklong interprofessional patient safety course we invited students and faculty to participate in a Twitter conversation. It was found that this form of social media successfully captured a "behind the scenes" conversation and the experiences of the students which would have not been otherwise captured. This information is guiding future interprofessional educational programming in both the medical and nursing schools.

A novel educational programme to improve knowledge regarding health care-associated infection and hand hygiene.

Lack of hand hygiene by health-care workers is the most significant cause of health care-associated infection. This programme was designed to make health-care workers want to wash their hands, to change their knowledge regarding hand hygiene and health care-associated infection, and influence practice. Improvement between pre- and post-test scores was statistically significant. Compliance is a multifactorial problem that involves knowledge and behaviour. Educational awareness and frequent reminders are critical to maintain high rates of hand hygiene compliance.

What participants learn, with, from and about each other during inter-professional education encounters: A qualitative analysis.

BACKGROUND: Safe healthcare requires teamwork and collaboration. To meet the needs of healthcare organizations and professionals, inter-professional education, is no longer an optional educational trend but rather a mandate of accrediting health education agencies. OBJECTIVE: In an effort to better understand the impact of inter- professional educational activities, this study sought to explore via qualitative methods what nursing and medical students learn with, from, and about one another during a week - long simulation-based inter-profession education course. DESIGN: A convenience sample of post-course survey responses from students participating in a week-long, inter-professional, simulation-based patient safety course was used to longitudinally explore what participants learn with, from, and about each other. SETTINGS: The setting for this study was a research university located in the southeast United States. PARTICIPANTS: The participants included a total of 272 second semester accelerated option Bachelor of Nursing students and 599 medical students entering the 3rd year of their program that participated in an annual patient safety course. The study analyzed responses of students to questions in a post-course survey regarding educational outcomes while learning with students from a different profession. RESULTS: In the responses from 871 students collected over four years, the following key themes emerged. Students: 1) articulated learning the importance of contributions of other professions to the healthcare team, 2) expressed an appreciation for areas where their colleagues' training was superior to their own; and 3) identified deficiencies in their own knowledge and skill sets. CONCLUSION: The findings of this study provide a basis for developing more specific curricular content as part of inter-professional education endeavors to strengthen constructive views of healthcare professions, foster a more collaborative shared mental model, and to correct perceived misconceptions.

An assessment of CPR skills using simulation: Are first responders prepared to save lives?

The American Heart Association's (AHA) recommendation for biyearly recertification and annual mandatory CPR training may be suboptimal for first responders (nurses and technicians) working in outpatient clinics (American Heart Association, 2013). To determine the efficacy of the AHA guidelines, 40 simulated sudden cardiac arrest (SCA) encounters were conducted followed by debriefing and a subsequent SCA to determine a basic level of CPR proficiency. First responders' CPR skills were evaluated using a 19-item assessment form to quantify the event. A comparison of scores using two different viewing modalities was performed to provide an assessment of the training program. Of the 40 sessions, group mean performance scores for the first encounter were just above the organization's minimum required score of 24. Performance scores increased slightly (27-28) after the second encounter. Proficiency of skills was poor and frequent basic life support training may be indicated to help first responders provide high-quality CPR.

Interprofessional Simulation Olympics as a platform to assess team work knowledge acquisition.

Introduction: Several years ago an on-stage competition called SimWars was introduced to the simulation community. This concept was adopted into a patient safety course as a way to further engage students and named Sim Olympics. We sought to evaluate it as a platform for assessment of learning in students who participated as audience members. Methods: A non-equivalent groups design was used to assess whether students could be taught to recognise features of effective teamwork, including a pair of expert raters. One-way repeated measures analysis of variance was used to compare students' attitudes toward interprofessional education (IPE) education, teamwork and simulation, before and after the course. Results: Student scores compared to expert scores showed good agreement. For team 1 there were no statistical differences noted (M=19.58, SD=4.34 given by the students, M=17.50, SD=2.12 given by the experts), t (192)=1.26, p=0.264. There was also no difference for team 2 (M=15.173, SD=5.52 given by the students, M=19.50, SD=3.53 given by the experts), t (173)=0.863, p=0.354. A premeasure and postmeasure of students' attitudes towards IPE education, teamwork and simulation, also showed significant time effect, p<0.001. Conclusions: Medical and nursing students were able to demonstrate their learning of teamwork dynamics by discerning differences between great teamwork and good teamwork as proficiently as seasoned experts. Findings of this study may further support the use of observation as a method to evaluate learning.

Establishing a convention for acting in healthcare simulation: merging art and science.

SUMMARY STATEMENT: Among the most powerful tools available to simulation instructors is a confederate. Although technical and logical realism is dictated by the simulation platform and setting, the quality of role playing by confederates strongly determines psychological or emotional fidelity of simulation. The highest level of realism, however, is achieved when the confederates are properly trained. Theater and acting methodology can provide simulation educators a framework from which to establish an acting convention specific to the discipline of healthcare simulation. This report attempts to examine simulation through the lens of theater arts and represents an opinion on acting in healthcare simulation for both simulation educators and confederates. It aims to refine the practice of simulation by embracing the lessons of the theater community. Although the application of these approaches in healthcare education has been described in the literature, a systematic way of organizing, publicizing, or documenting the acting within healthcare simulation has never been completed. Therefore, we attempt, for the first time, to take on this challenge and create a resource, which infuses theater arts into the practice of healthcare simulation.

Man versus machine: the preferred modality.

BACKGROUND: When learning objectives do not specifically dictate the use of one simulation modality over another, we sought to answer the question of which modality is preferred. We also assessed the impact of debriefing, and the frequency of participants asserting their leadership, as well as self-reported comfort and competence, and the ability to generate differential diagnoses when either a standardised patient (SP) or high-technology simulator (HTS) was used. METHODS: One hundred and forty medical students participated in a simulation-based activity focusing on teamwork, task delegation, role clarity and effective communication. Two similar clinical scenarios were presented, and either an HTS or an SP was used. Following each scenario, participants were surveyed on the realism of the simulation and the patient, and also on their self-assessed comfort and competence. They were also asked to indicate which role they played, to list possible differential diagnoses for the case and, following the second scenario, which modality they preferred. RESULTS: The surveys indicated that 91 per cent (127) of students preferred the SP. The perceived realism of the simulation was higher for the second scenario than for the first. Scenarios with an SP were found to be significantly more realistic than the scenarios where the HTS was used. Comfort and competence scores were higher following the second scenario. No differences in the ability of participants to generate a list of differentials were found, and nearly twice as many participants reported taking the leadership role during their second simulation. DISCUSSION: We have found low and high technology to have similar effectiveness for achieving learning objectives and for the demonstration of skills; however, students clearly preferred the SPs.

A patient safety course for preclinical medical students.

BACKGROUND: We developed a course to introduce incoming third-year medical students to the subject of patient safety, to focus their attention on teamwork and communication, and to create an awareness of patient-safe practices that will positively impact their performance as clinicians. METHODS: The course, held prior to the start of clinical rotations, consisted of lectures, web-based didactic materials, small group activities and simulation exercises, with an emphasis on experiential learning. First, students inspected a 'room of horrors', which is a simulated clinical environment riddled with errors. Second, we used lenticular puzzles in small groups to elicit teamwork behaviours that parallel real-life interactions in health care. Each team was given 8 minutes to complete a 48-piece puzzle, with five pieces removed at random and given to other teams. The salient teaching point of this exercise is that for a team to complete the task, team members must communicate with members of their own team as well as with other teams. Last, simulation scenarios provided a clinical context to reinforce the skills introduced through the puzzle exercise and lectures. The students were split into groups of six or seven members and challenged with two scenarios. Both scenarios focused on a 56-year-old man in respiratory distress. The teams were debriefed on both clinical management and teamwork. RESULTS: The vast majority of the students (93%) agreed that the course improved their patient safety knowledge and skills. DISCUSSION: The positive response from students to the introductory course is an important step in fostering a culture of patient safety.

A comparison of different types of hazardous material respirators available to anesthesiologists.

OBJECTIVE: Despite anesthesiology personnel involvement in initial treatment of patients exposed to potentially lethal agents, less than 40 percent of US anesthesiology training programs conduct training to manage these patients.(1) No previous studies have evaluated performance of anesthesiologists wearing protective gear. The authors compared the performance of anesthesiologists intubating a high-fidelity mannequin while wearing either a powered air-purifying respirator (PAPR) or a negative pressure respirator (NPR). METHODS: Twenty participants practiced intubations on a high-fidelity simulator until comfortable. Each subject performed 10 repetitions, initially without any gear, then while wearing a protective suit, gloves, and respirator. The order of gear use was randomized and all subjects used both devices. Time for task completion were recorded, and at the end of the trial, subjects were asked to rate their comfort with the equipment. RESULTS: After controlling for other variables, overall statistically slower total performance times were observed with use of the PAPR when compared to the control arm and use of the NPR (p 5 0.01 and p < 0.007, respectively). Of the total 90 intubations, only one proved to be esophageal and initially undetected. CONCLUSIONS: The use of an NPR or PAPR does not preclude an anesthesiologist from successfully intubating, but practice is necessary. The slightly better performance with the NPR is weighed against the improved comfort of the PAPR and the fact that PAPR users could wear eyeglasses. Neither type of gear allowed the users to auscultate the lung fields to confirm correct endotracheal tube placement.

Radiostethoscopes: an innovative solution for auscultation while wearing protective gear.

OBJECTIVE: To demonstrate a radiostethoscope that could be modified and successfully used while wearing protective gear to solve the problem of auscultation in a hazardous material or infectious disease setting. DESIGN: This study was a randomized, prospective, and blinded investigation. SETTING: The study was conducted at the University of Miami-Jackson Memorial Hospital Center for Patient Safety. PARTICIPANTS: Two blinded anesthesiologists using a radiostethoscope performed a total of 100 assessments (50 each) to evaluate endotracheal tube position on a human patient simulator (HPS). INTERVENTIONS: Each lung of the HPS was ventilated separately using a double lumen tube. Four ventilation patterns (ie, right lung ventilation only; left lung ventilation only; ventilation of both lungs; and an esophageal intubation or no breath sounds) were simulated. The ventilation pattern was determined randomly and participants were blinded. An Ambu-Bag was used for ventilation. An assistant moved the radiostethoscope to the right and left lung fields and then to the abdomen of the HPS while ventilating. Subjects had to identify the ventilation pattern after listening to all three locations. A third member of the research team collected responses. Each subject, who wore both types of respirator (positive and negative), performed a total of 25 trials. Participants later compared the two types of respirators and their ability to auscultate for breath sounds. RESULTS: Subjects were able to verify the correct ventilation pattern in all attempts (100 percent). CONCLUSIONS: Radiostethoscopes appear to provide a viable solution for the problem of patient auscultation while wearing protective gear.

Factors impacting hand hygiene compliance among new interns: findings from a mandatory patient safety course.

BACKGROUND: Residency is a critical transition during which individuals acquire lifelong behaviors important for professionalism and optimal patient care. One behavior is proper hand hygiene (HH), yet poor compliance with accepted HH practices remains a critical issue in many settings. This study explored the factors affecting hand hygiene compliance (HHC) in a diverse group of interns at the beginning of graduate training. METHODS: During a required patient safety course, we observed HH behaviors using a standardized patient encounter. Interns were instructed to perform a focused exam in a simulated inpatient environment with HH products available and clearly visible. Participants were blinded to the HH component of the study. An auditory alert was triggered if participants failed to perform prepatient encounter HH. Compliance rates and the number of alerts were recorded. All encounters were videotaped. RESULTS: The HHC among the 169 participants was 37.9% pre-encounter and was higher among female interns than males, although this difference was not statistically significant (41.6% versus 31.5%, P  =  .176). International medical graduates had significantly lower HHC compared with US graduates (23.2% versus 45.1%, P  =  .006). Most initially noncompliant participants performed HH after 1 alert (87.6%). DISCUSSION: The initial low rate of HHC in our sample is comparable to other studies. Using direct video surveillance and auditory alarms, we improved our success rates for prepatient encounter HHC. Our study identified medical school origin as an important factor for HHC, and the significantly lower compliance for international medical graduates compared with US graduates has not been previously reported. These findings should be considered in designing interventions such as intern orientation and clinical education programs to improve HH behaviors.

Creating a common patient safety denominator: the interns' course.

AIM: After finishing medical school, interns are in many ways unprepared for handling patient care challenges independently. Recognizing that interns may benefit from a patient safety orientation, we developed an innovative curriculum to impart competencies related to their role in preventing medical errors. In the course, which runs during the first week of the intern year, we specifically address 1) calling for help; 2) teamwork and communication; 3) hand hygiene compliance; and, 4) preventing medication and other system errors. METHODS: The course consists of a lecture, interactive workshop, and a Web-based didactic component. Small-group simulation sessions allow instructors to assess interns' baseline competence in hand hygiene and patient hand-offs. In an individual exercise, interns performed a directed physical exam on a standardized patient and their hand hygiene adherence was recorded. In a group exercise, team performance was evaluated in accepting a hand-off from another provider and managing a deteriorating patient. RESULTS: Of the 131 interns, 35% (41) did not wash their hands before and 95% (121) did not wash their hands after patient examination. In the team exercise, scores for 23 teams ranged from 8 to 18 out of 30. None of the participants asked for additional information prior to accepting responsibility for the patient, despite a clearly inadequate hand-off. Post-course surveys indicate that interns consider the course worthwhile: 95% (121) found it beneficial, acquired new teamwork skills, had more appreciation for patient safety, and felt better prepared for clinical duties. DISCUSSION: We observed serious gaps in hand-hygiene compliance and in communication during hand-offs, both significant impediments to quality patient care. Nevertheless, positive responses to the course from both the interns and the institution reflect an important step in fostering a culture of patient safety.