Duty to Family: Ethical Considerations in the Resuscitation Bay.

AbstractTo examine the ethical duty to patients and families in the setting of the resuscitation bay, we address a case with a focus on providing optimal care and communication to family members. We present a case of nonsurvivable traumatic injury in a minor, focusing on how allowing family more time at the bedside impacts the quality of death and what duty exists to maintain an emotionally optimal environment for family grieving and acceptance. Our analysis proposes tenets for patient and family-centric care that, in alignment with trauma-informed care principles, optimize the long-term well-being of the family, namely valuing family desires and sensitivity to location.

What the curtains do not shield: A phenomenological exploration of patient-witnessed resuscitation in hospital. Part 2: Healthcare professionals' experiences.

AIMS: To explore healthcare professionals' experiences of patient-witnessed resuscitation in hospital. DESIGN: Descriptive phenomenology. METHODS: Healthcare professionals involved in hospital resuscitation activities were recruited from medical, intensive care, resuscitation and education departments in a university hospital in England. Data were collected through face-to-face and focus group interviews, between August 2018 and January 2019. Data were analysed using Giorgi's phenomenological approach. RESULTS: Nine registered nurses, four healthcare assistants and seven doctors participated in four individual interviews and three focus groups. Findings were related to three themes: (1) Protecting patients from witnessing resuscitation: healthcare professionals used curtains to shield patients during resuscitation, but this was ineffective. Thus, they experienced challenges in explaining resuscitation events to the other patients and communicating sensitively. (2) Emotional impact of resuscitation: healthcare professionals recognized that witnessing resuscitation impacted patients, but they also felt emotionally affected from performing resuscitation and needed coping strategies and support. (3) Supporting patients who witnessed resuscitation: healthcare professionals recognized the importance of patients' well-being, but they felt unable to provide effective and timely support while providing life-saving care. CONCLUSION: Healthcare professionals involved in hospital resuscitation require specific support, guidance and education to care effectively for patients witnessing resuscitation. Improving communication, implementing regular debriefing for staff, and allocating a dedicated professional to support patients witnessing resuscitation must be addressed to improve clinical practice. IMPACT: The WATCH study uncovers patients' and healthcare professionals' experiences of patient-witnessed resuscitation, a phenomenon still overlooked in nursing research and practice. The main findings highlight that, in common with patients, healthcare professionals are subject to the emotional impact of resuscitation events and encounter challenges in supporting patients who witness resuscitation. Embedding the recommendations from this research into clinical guidelines will impact the clinical practice of healthcare professionals involved in hospital resuscitation and the quality and timeliness of care delivered to patients.

What the curtains do not shield: A phenomenological exploration of patient-witnessed resuscitation in hospital. Part 1: patients' experiences.

AIMS: The aim of the study was to explore the experiences of hospital patients who witnessed resuscitation of a fellow patient. DESIGN: Descriptive phenomenology. METHODS: Patients who witnessed resuscitation were recruited from nine clinical wards in a university hospital in England. Data were collected through face-to-face individual interviews. Participants were interviewed twice,in 1 week and 4 to 6 weeks after the resuscitation event. Data were collected between August 2018 and March 2019. Interviews were analysed using Giorgi's phenomenological analysis. RESULTS: Sixteen patients participated in the first interview and two patients completed follow-up interviews. Three themes were developed from the patients' interviews. (1) Exposure to witnessing resuscitation: patients who witness resuscitation felt exposed to a distressing event and not shielded by bed-space curtains, but after the resuscitation attempt, they also felt reassured and safe in witnessing staff's response. (2) Perceived emotional impact: patients perceived an emotional impact from witnessing resuscitation and responded with different coping mechanisms. (3) Patients' support needs: patients needed information about the resuscitation event and emotional reassurance from nursing staff to feel supported, but this was not consistently provided. CONCLUSION: The presence of other patients during resuscitation events must be acknowledged by healthcare professionals, and sufficient information and emotional support must be provided to patients witnessing such events. This study generates new evidence to improve patients' experience and healthcare professionals' support practices. IMPACT: The phenomenon of patient-witnessed resuscitation requires the attention of healthcare professionals, resuscitation officers and policymakers. Study findings indicate that witnessing resuscitation has an emotional impact on patients. Strategies to support them must be improved and integrated into the management of in-hospital resuscitation. These should include providing patients with comprehensive information and opportunities to speak about their experience; evacuating mobile patients when possible; and a dedicated nurse to look after patients witnessing resuscitation events.

Ethical Cultures in Perinatal Care: Do They Exist? Correlation of Provider Attitudes with Periviability Practices at Six Centers.

OBJECTIVE: This study aimed to compare attitudes of providers regarding perinatal management and outcomes for periviable newborns of caregivers at centers with higher resuscitation (HR) and lower resuscitation (LR) rates in the delivery room. STUDY DESIGN: All obstetric and neonatal clinical providers at six U.S. sites were invited to complete an anonymous online survey. Survey responses were compared with clinical data collected from a previous retrospective study comparing centers' rates of planned resuscitation. Responses were analyzed by multivariable logistic and linear regression to assess how HR versus LR center respondents differed in management preferences and outcome predictions. RESULTS: Paradoxically, HR versus LR respondents, when adjusting for other variables, were less likely to respond that interventions such as antenatal steroids (odds ratio: 0.61, 95% confidence interval [CI]: 0.42-0.88, p < 0.009) and resuscitation (OR: 0.59, 95% CI: 0.44-0.78, p < 0.001) should be given at 22 weeks. HR versus LR respondents also reported lower likelihood of survival and acceptable quality of life (OR: 0.7, 95% CI: 0.53-0.93, p = 0.012) at 23 weeks. CONCLUSION: Despite higher rates of planned resuscitation at 22 and 23 weeks, steroid usage and survival rates did not differ between HR and LR sites. In this subsequent survey, respondents from HR centers had a less favorable outlook on interventions for these newborns than those at LR centers, suggesting that instead of driving practices, attitudes may be more closely associated with experiences of clinical outcomes.

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure.

RATIONALE & OBJECTIVE: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010. EXPOSURES: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences. OUTCOMES: Documented discussions of dialysis treatment and supportive care. ANALYTICAL APPROACH: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions. RESULTS: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics. LIMITATIONS: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited. CONCLUSIONS: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

Healthcare worker knowledge and skills following coaching in WHO early essential newborn care program in the Solomon Islands: a prospective multi-site cohort study.

BACKGROUND: Newborn mortality in Oceania declined slower than other regions in the past 25 years. The World Health Organization (WHO) introduced the Early Essential Newborn Care program (EENC) in 2015 in Solomon Islands, a Small Island Developing State, to address high newborn mortality. We explored knowledge and skills retention among healthcare workers following EENC coaching. METHODS: Between March 2015 and December 2017, healthcare workers in five hospitals were assessed: pre- and post-clinical coaching and at a later evaluation. Standardised written and clinical skills assessments for breathing and non-breathing baby scenarios were used. Additionally, written surveys were completed during evaluation for feedback on the EENC experience. RESULTS: Fifty-three healthcare workers were included in the evaluation. Median time between initial coaching and evaluation was 21 months (IQR 18-26). Median written score increased from 44% at baseline to 89% post-coaching (p < 0.001), and was 61% at evaluation (p < 0.001). Skills assessment score was 20% at baseline and 95% post-coaching in the Breathing Baby scenario (p < 0.001). In the Non-Breathing Baby scenario, score was 63% at baseline and 86% post-coaching (p < 0.001). At evaluation, median score in the Breathing Baby scenario was 82% a reduction of 13% from post-coaching (p < 0.001) and 72% for the Non-Breathing Baby, a reduction of 14% post-coaching (p < 0.001). Nurse aides had least reduction in evaluation scores of - 2% for the Breathing Baby and midwives - 10% for the Non-Breathing Baby respectively from post-coaching to evaluation. CONCLUSIONS: EENC coaching resulted in immediate improvements in knowledge and skills but declined over time. Healthcare workers who used the skills in regular practice had higher scores. Complementary quality improvement strategies are needed to sustain resuscitation skills following training over time. TRIAL REGISTRATION: Australia New Zealand Trial Registry, Retrospective Registration (12/2/2019), registration number ACTRN12619000201178.

Effect of written outcome information on attitude of perinatal healthcare professionals at the limit of viability: a randomized study.

BACKGROUND: Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received. METHODS: This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals. RESULTS: Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of "survival without disability" at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages. CONCLUSION: Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.

Exploring patients' and healthcare professionals' experiences of patient-witnessed resuscitation: A qualitative study protocol.

AIM: The aim of this study was to explore the experiences of patients and healthcare professionals regarding patients witnessing resuscitation on another patient in hospital clinical wards. DESIGN: Phenomenological qualitative study. METHODS: Participants will be recruited from nine wards in a university hospital in England. Data collection will include two in-depth interviews with patients who witnessed resuscitation: the first interview one week after witnessing resuscitation and the second interview after one month. Individual and focus group interviews with healthcare professionals will be also conducted. Data will be transcribed, managed in NVivo 11 and analysed using phenomenological analysis. The National Health Service, Health Research Authority and University Ethics Committee approved the study (May 2018). The study is funded by Resuscitation Council UK (December 2017) and will be conducted between May 2018-March 2019. CONCLUSION: While witnessed resuscitation is a major topic of interest in nursing, specific research on the impact of patients who witness resuscitation on fellow patients is limited. This study will use qualitative methodology to inform the evidence base of a clinical problem with limited understanding. The findings of this study will contribute to the framework of witnessed resuscitation and to identifying the barriers and enablers towards a greater support of patients who witness resuscitation in hospital. This new acquired knowledge will be beneficial to the improvement of future nursing care. IMPACT: The evidence gained from this study can support the development and implementation of guidelines and inform hospital policies to support patients witnessing resuscitation to optimize the quality of nursing care provided.

BET 1: To debrief or not debrief.

A short cut review was carried out to establish whether a staff debriefing session after involvement in a traumatic resuscitation reduces stress and anxiety, reduces sickness, improves team working and morale and improves staff retention. Four papers presented the best evidence to answer the question. The author, date and country of publication, group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that there is no evidence about the efficacy of team debriefing in the ED. However, there is some desire among staff for it to occur. Further research is needed and in the meantime local advice should be followed.

Parents' Experience During a Child's Resuscitation: Getting Through It.

PURPOSE: The purpose of this study was to elucidate the experiences of parents during their child's resuscitation in the hospital setting. DESIGN AND METHODS: This qualitative descriptive study took place in a 280 bed children's hospital with parents whose children experienced resuscitation while they were present in the room or nearby. Semi-structured interviews were conducted between one and twelve months following a child's resuscitation. A rigorous thematic analysis was performed. RESULTS: This study elucidates parent experience during a child's resuscitation using four overarching themes; "Overwhelming chaos", "Getting through it", "Cognitive presence" and "Joy mixed with heartache". Parents described their experience to be stressful, yet identified things that helped them get through it and make sense of the experience. CONCLUSIONS: During a child's resuscitation parents perceived a sense of overwhelming chaos, yet still had an innate need to be present and know what was going on. While emotional support was appreciated, most important was to receive real time clinical information from healthcare staff and to see and feel that the team was personally invested in their child. PRACTICE IMPLICATIONS: During a child's resuscitation, parents should be allowed to choose their level of presence to meet their individual needs. A clinical staff member should answer questions and share clinical information with parents. In addition, clinicians should allow themselves to connect with parents on a personal level. This research provides a foundation for further study, including parents' experience after experiencing a child's resuscitation.

Family presence during resuscitation: Updated review and clinical pearls.

There is mounting evidence that Family Presence During Resuscitation (FPDR) can benefit family members who wish to observe the resuscitation efforts of a loved one. Given that older patients have poor resuscitation outcomes, presence of a family advocate could add value to the process of end of life decision making. A review of the current literature from the perspectives of patients, families, and health-care providers will help in reassessing family involvement during resuscitation and developing best practices for health care facilities.

Getting Inside the Expert's Head: An Analysis of Physician Cognitive Processes During Trauma Resuscitations.

STUDY OBJECTIVE: Crisis resource management skills are integral to leading the resuscitation of a critically ill patient. Despite their importance, crisis resource management skills (and their associated cognitive processes) have traditionally been difficult to study in the real world. The objective of this study was to derive key cognitive processes underpinning expert performance in resuscitation medicine, using a new eye-tracking-based video capture method during clinical cases. METHODS: During an 18-month period, a sample of 10 trauma resuscitations led by 4 expert trauma team leaders was analyzed. The physician team leaders were outfitted with mobile eye-tracking glasses for each case. After each resuscitation, participants were debriefed with a modified cognitive task analysis, based on a cued-recall protocol, augmented by viewing their own first-person perspective eye-tracking video from the clinical encounter. RESULTS: Eye-tracking technology was successfully applied as a tool to aid in the qualitative analysis of expert performance in a clinical setting. All participants stated that using these methods helped uncover previously unconscious aspects of their cognition. Overall, 5 major themes were derived from the interviews: logistic awareness, managing uncertainty, visual fixation behaviors, selective attendance to information, and anticipatory behaviors. CONCLUSION: The novel approach of cognitive task analysis augmented by eye tracking allowed the derivation of 5 unique cognitive processes underpinning expert performance in leading a resuscitation. An understanding of these cognitive processes has the potential to enhance educational methods and to create new assessment modalities of these previously tacit aspects of expertise in this field.

Constructing a Culturally Informed Spanish Decision-Aid to Counsel Latino Parents Facing Imminent Extreme Premature Delivery.

Objective How Latino parents perceive and understand antenatal counseling for extreme prematurity, < 26 weeks of gestational age (GA), is not clear. We aim to characterize Latino parental perceptions of antenatal counseling in order to construct and validate a Spanish decision-aid (SDA) to improve parental knowledge of prematurity after antenatal consults. Methods This is a three-phased, prospective, multicenter study. First, interviews of 22 Latino parents with a history of birth < 26 weeks GA were conducted. Thematic analysis identified themes valued during antenatal counseling for decisions regarding neonatal resuscitation. Next, we incorporated these themes into the SDA. Finally, improvement in knowledge of prematurity in two Spanish-speaking groups, 'experienced' parents with a history of extremely premature birth and 'naïve' adult Latino volunteers, was measured using a multiple choice test before and after simulated counseling with the SDA. Result Twenty-two interviews generated seven unique themes. An SDA was constructed that preserved six themes paralleled by those found in a previously studied English population, and addressed a novel theme of "intercultural linguistic barriers" unique to our population. Knowledge scores rose in "naive" volunteers, 41 ± 12% to 71 ± 15% (P < 0.001), after simulated counseling with the SDA. 'Experienced' parents had a ceiling effect in knowledge scores, 62 ± 9% to 65 ± 11% (P = 0.22). The SDA was well received by participants. Conclusions for Practice Interviews of Latino parents with a history of premature birth generated similar themes to English-speaking parents, with intercultural linguistic barriers as a novel theme. An SDA for Latino parents facing extremely premature birth may improve comprehension of antenatal counseling.

Beyond prognostication: ambulance personnel's lived experiences of cardiac arrest decision-making.

INTRODUCTION: The purpose of this study was to explore ambulance personnel's decisions to commence, continue, withhold or terminate resuscitation efforts for patients with out-of-hospital cardiac arrest. METHOD: Semistructured interviews with a purposive sample of 16 demographically diverse ambulance personnel, currently employed in a variety of emergency ambulance response roles, around New Zealand. RESULTS: Participants sought and integrated numerous factors, beyond established prognostic indicators, when making resuscitation decisions. Factors appeared to be integrated in four distinct phases, described under four main identified themes: prearrival impressions, immediate on-scene impressions, piecing together the big picture and transition to termination of resuscitation. Commencing or continuing resuscitation was sometimes a default action, particularly where ambulance personnel felt the context was uncertain, unfamiliar or overwhelming. Managing the impact of termination of resuscitation and resulting scene of a death required significant confidence, psychosocial skills and experience. CONCLUSION: This unique, exploratory study provides new insights into ambulance personnel's experiences of prehospital resuscitation decision-making. Prognostication in out-of-hospital cardiac arrest is known to be challenging, but results from this study suggest that confidence in a poor prognosis for the cardiac arrested patient is only part of the resuscitation decision-making picture. Results suggest ambulance personnel may benefit from greater educational preparation and mentoring in managing the scene of a death to avoid inappropriate or prolonged resuscitation efforts.

Force-Feeding and Resuscitation of Patients with Advanced Dementia: A Public Opinion Study.

BACKGROUND: The treatment of advanced dementia patients is very complex and presents a difficult dilemma for physicians, and especially for the patient's family. In many cases, when the advanced dementia patient has no decisional capacity, the family needs to decide about force-feeding and resuscitation for their relative. OBJECTIVES: To examine public opinion regarding force-feeding and resuscitation of patients with advanced dementia. METHODS: Data from 1002 people who accompanied a patient to a hospital emergency department in Israel were collected and analyzed. RESULTS: We noted the following results: the more religious the orientation of the respondents, the more likely they were to agree to forcefully feed and resuscitate advanced dementia patients and advanced dementia patients older than 80 years; those accompanying younger patients were more likely to think that the medical staff should resuscitate advanced dementia patients and advanced dementia patients older than 80 years compared to those accompanying elderly patients; younger people were more likely than older people to agree to force-feed and resuscitate patients. CONCLUSIONS: This paper attempts to provide decision-makers and medical staff with some knowledge about public opinion regarding a sensitive and complex issue. This awareness may guide physicians in making critical medical decisions about those with dementia.

Knowledge of the Avalanche Victim Resuscitation Checklist and Utility of a Standardized Lecture in Italy.

INTRODUCTION: To explore baseline knowledge about avalanche guidelines and the Avalanche Victim Resuscitation Checklist (AVReCh) in Italy and the knowledge acquisition from a standardized lecture. METHODS: Standardized lecture material discussing AVReCh was presented during 8 mountain medicine courses from November 2014 to April 2016 in different regions of Italy. To determine the knowledge acquisition from the lecture, a pre- and postlecture survey was utilized. RESULTS: A total of 193 surveys were analyzed. More than 50% of the participants had never participated in lectures/courses on avalanche guidelines, and less than 50% of the participants knew about the AVReCh before the lecture. The correct temporal sequence of reportable information in the basic life support section of the AVReCh was selected by 40% of the participants before the lecture and by 75% after the lecture (P<0.001). Within subgroups analysis, most groups saw significant improvement in performance (P<0.05). The selection of the correct burial time increased from 36 to 84% (P<0.05). CONCLUSIONS: Health care providers and mountain rescue personnel are not widely aware of avalanche guidelines. The standardized lecture significantly improved knowledge of the principles of avalanche management related to core AVReCh elements. However, the effect that this knowledge acquisition has on avalanche victim survival or adherence to the AVReCh in the field is yet to be determined.

Why do older people refuse resuscitation? A qualitative study examining retirement village residents' resuscitation decisions.

BACKGROUND: There is a dearth of qualitative research on resuscitation preferences of older New Zealanders. The aim of this study was to investigate the resuscitation preferences of older New Zealanders in a retirement village or residential care setting, as well as the reasons for these preferences. METHODS: This study had 37 participants from two retirement villages in Auckland, New Zealand. Participants were interviewed about a hypothetical case vignette about cardiopulmonary resuscitation, and then they completed a semi-structured interview. Interviews were subsequently transcribed and analyzed by two independent researchers using thematic qualitative methodology. RESULTS: The majority of the participants (n = 25, 67.6%) decided against resuscitation, 10 (27.0%) wanted resuscitation, and 2 (5.4%) were ambivalent about their resuscitation preferences. Three main themes emerged during the data analysis regarding participants' reasons for deciding against resuscitation: (i) the wish for a natural death; (ii) advanced age; and (iii) a realistic awareness about the consequences of resuscitation. Responses related to the third these had three subthemes: (i) reduced quality of life; (ii) loss of personal integrity and sense of existence; and (iii) concern that resuscitation could result in unnecessary costs or a burden on others. Among participants who preferred resuscitation, two main themes emerged regarding their reasons for wanting resuscitation: (i) the wish to prolong a good quality of life; and (ii) unrealistic expectations of resuscitation. CONCLUSIONS: Older people in this study were able to make reasoned decisions about resuscitation based on balancing their subjective estimations of quality of life and the presumed consequences of resuscitation. It is important therefore to educate older adults about the potential outcomes of resuscitation and explore (and document) their reasoning when discussing resuscitation preferences so their wishes can be respected.

The Role of Healthcare Chaplains in Resuscitation: A Rapid Literature Review.

Spirituality is becoming of increasing importance in the international healthcare context. While patients' spirituality or faith is often overlooked, there is a growing awareness that understanding, addressing and supporting patients' spiritual and faith needs can influence healthcare outcomes. This review aims to illuminate this role and highlight healthcare chaplains' potential in relation to the provision of pastoral support for families during and after patient resuscitation, and the dearth of interdisciplinary education in this field. A rapid structured review was undertaken using four databases-PubMed, CINAHL, PsycINFO and ATLA. Primary research studies published during the 10-year period 2007-2017 written in English addressing the chaplain's role or perceived role in resuscitation were included. An initial search using key terms yielded 18 relevant citations. This reduced to 11 once duplicates were removed. Ultimately five relevant primary research studies were included in the final analysis. This review found few studies that directly explored the topic. Certainly many view the chaplain as a key member of the resuscitation team, although this role has not been fully explored. Chaplains likely have a key role in supporting families during decisions about 'not for resuscitation' and in supporting families during and after resuscitation procedures. Chaplains are key personnel, already employed in many healthcare organisations, who are in a pivotal position to contribute to future developments of spiritual and pastoral care provision and support. Their role at the end of life, despite well described and supported, has received little empirical support. There is an emerging role for chaplains in healthcare ethics, supporting end-of-life decisions and supporting family witnessed resuscitation where relevant. Their role needs to be more clearly understood by medical staff, and chaplain's input into undergraduate medical education programmes is becoming vital.

Psychological Skills to Improve Emergency Care Providers' Performance Under Stress.

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

The Impact of Neonatal Simulations on Trainees' Stress and Performance: A Parallel-Group Randomized Trial.

OBJECTIVES: Assess impact of neonatal simulation and simulated death on trainees' stress and performance. DESIGN: A parallel-group randomized trial (November 2011 to April 2012). SETTING: Sainte-Justine University Hospital, Montreal, Canada. SUBJECTS: Sixty-two pediatric trainees eligible, 59 consented, and 42 completed the study. INTERVENTIONS: Trainees performed two simulations where a term neonate was born pulseless. They were randomized to start with either survival (manikin responded to appropriate resuscitation) or death scenario (manikin remained pulseless despite resuscitation). MEASUREMENTS AND MAIN RESULTS: Performance was assessed using the Neonatal Resuscitation Program megacode score sheet by two reviewers. Subjective stress was assessed with a questionnaire. Three salivary cortisol (objective stress) values were compared: at baseline (T0: during lecture), presimulation (T1), and postsimulation (T2: after first scenario). Performance scores were similar in both groups in the first (83% vs 82%; p = 0.85) and second scenarios (82% vs 79 %; p = 0.87). Salivary cortisol levels at T0 (0.10 vs 0.10; p = 0.54), T1 (0.15 vs 0.11; p = 0.35), and T2 (0.23 vs 0.17; p = 0.23) did not differ between groups. Perceived stress level was six out of 10 in survival group versus seven out of 10 in death group (p = 0.19). Salivary cortisol increased significantly from T0 to T1 (p < 0.01). T2 cortisol levels were significantly higher than T1 (p< 0.001), yet this increase was not scenario dependent (p = 0.41) nor associated with performance on either scenario. Subscores for bag mask ventilation were lower than subscores for advanced resuscitation skills. CONCLUSIONS: Neonatal simulations cause significant anticipatory and participatory stress. Despite this, trainees' performance score in simulation was over 80%. Simulated death did not impact performance, magnitude of rise in salivary cortisol level, and perceived stress level. Trainees performed better at advanced resuscitation skills (which are rarely needed) compared with basic skills routinely performed in practice.