Exploring factors influencing time from dispatch to unit availability according to the transport decision in the pre-hospital setting: an exploratory study.

BACKGROUND: Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients' transport decisions. METHODS: Time from ambulance dispatch to availability (TDA) analysis according to the patients' transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan-Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring. RESULTS: The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan-Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the 'Not Transported' group demonstrated a higher incidence of prolonged TDA than the 'Transported' group at specified time points. CONCLUSIONS: Exploring TDA offers a novel perspective on ambulance services' efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence.

Reflective learning conversations model for simulation debriefing: a co-design process and development innovation.

BACKGROUND: Health practitioners must be equipped with effective clinical reasoning skills to make appropriate, safe clinical decisions and avoid practice errors. Under-developed clinical reasoning skills have the potential to threaten patient safety and delay care or treatment, particularly in critical and acute care settings. Simulation-based education which incorporates post-simulation reflective learning conversations as a debriefing method is used to develop clinical reasoning skills while patient safety is maintained. However, due to the multidimensional nature of clinical reasoning, the potential risk of cognitive overload, and the varying use of analytic (hypothetical-deductive) and non-analytic (intuitive) clinical reasoning processes amongst senior and junior simulation participants, it is important to consider experience, competence, flow and amount of information, and case complexity related factors to optimize clinical reasoning while attending group- based post-simulation reflective learning conversations as a debriefing method. We aim to describe the development of a post-simulation reflective learning conversations model in which a number of contributing factors to achieve clinical reasoning optimization were addressed. METHODS: A Co-design working group (N = 18) of doctors, nurses, researchers, educators, and patients' representatives collaboratively worked through consecutive workshops to co-design a post-simulation reflective learning conversations model to be used for simulation debriefing. The co-design working group established the model through a theoretical and conceptual-driven process and multiphasic expert reviews. Concurrent integration of appreciative inquiry, plus/delta, and Bloom's Taxonomy methods were considered to optimize simulation participants' clinical reasoning while attending simulation activities. The face and content validity of the model were established using the Content Validity Index CVI and Content Validity Ratio CVR methods. RESULTS: A Post-simulation reflective learning conversations model was developed and piloted. The model was supported with worked examples and scripted guidance. The face and content validity of the model were evaluated and confirmed. CONCLUSIONS: The newly co-designed model was established in consideration to different simulation participants' seniority and competence, flow and amount of information, and simulation case complexity. These factors were considered to optimize clinical reasoning while attending group-based simulation activities.

FIFA World Cup Qatar 2022TM stadium patient evacuation: A system testing simulation-based exercise.

BACKGROUND: As the State of Qatar is soon to host the Federation International of Football Associations (FIFA) 2022 World Cup tournament, the health sector has also been preparing for the event to increase its capacity to meet the expected additional health demand. The readiness of the health sector is being tested and improved through a number of simulation-based exercises. In this case, it relates to testing in a realistic manner the complete evacuation process of a patient using two very different modes of transportation, from a distant FIFA stadium up to the handover phase in the main trauma center in the State of Qatar. METHOD: In this controlled simulation-based pilot study, the total evacuation time of a patient from the 60,000-fan capacity Al Bayt Stadium (ABS), situated in a rural northern part of Qatar, to Hamad General Hospital (HGH) Trauma Resuscitation Unit (TRU) situated approximately 50 km away, was compared when transported by helicopter and by ambulance. The Scenario for the simulation was based on a player who sustained a fractured lower leg and a concussion during a football match and needed urgent evacuation from the ABS Players' Medical Clinic near Al Khor to HGH in Doha. The same Scenario was enacted twice, the first time with a ground Hamad Medical Corporation Ambulance Service (HMCAS) ambulance and the second time with an HMCAS LifeFlight helicopter. RESULTS: The transportation phase for Scenario 2 (LifeFlight helicopter) was 63% faster than for Scenario 1 (ground ambulance). However, upon arrival at HGH, the patient arrived sooner at the TRU in Scenario 1 compared with Scenario 2. The overall mission time was thus only 6 minutes and 22 seconds faster by LifeFlight helicopter as compared with the ground ambulance. CONCLUSIONS: According to this simulation-based pilot study, using a helicopter to transport patients 50 km from the ABS 2022 FIFA World Cup stadium to the HGH TRU was only marginally faster by helicopter than using a ground-based ambulance. In addition, the ambulance was not using emergency driving operations, which when used would have further reduced the time taken for the ambulance to reach HGH TRU. Therefore, having a helicopter on standby there would not significantly improve the transport time of a critically ill/injured patient's access to definitive care and will not be available during the FIFA World Cup Qatar 2022TM unless it is called upon to respond to a mass casualty incident or bring additional Critical Care Paramedic resources to the stadium.

Injuries related to pets, exotic animals, and falconry in Qatar.

INTRODUCTION: Pets and exotic animals are increasingly popular all over the world. Some of these animals may cause injuries to their owners or other people during interactions. Both injuries and systemic infections always present diagnosis and treatment challenges. Emergency physicians´ clinical experience in managing patients with injuries caused by pets and exotic animals, in particular, is limited; hence, we believe that it is a domain to explore in a Middle Eastern country to help raise awareness and provide reminders as to the best evidence-based medical practice. METHODS: Hamad Medical Corporation's hospital records of patients treated between 2015 and 2022 were analyzed retrospectively. Cases whose diagnosis was recorded as injuries caused by animals kept as pets were included in the study. Patients were evaluated in terms of demographic characteristics, type of injury, injury locations, injury severity, treatments applied, and complications. Descriptive statistics were carried out, and findings were expressed as percentages in a frequency table. RESULTS: Following a search of the electronic patient records during the period of interest, 43 patients were found to have sought treatment following an injury caused by a pet or domestic exotic animal. The mean age of the patients was 23.5 years; about three-quarters were male, and approximately half were children. All injuries were minor, and 74.4% were skin abrasions. The most commonly injured body parts were the hand, the leg, and facial injuries. It was observed that cats caused 53.5% of the injuries, whereas falcons were involved in 11.6% of the cases. All patients were prescribed prophylactic antibiotics, and 60.5% were administered a tetanus injection. CONCLUSION: Despite our study spanning over seven years, a relatively low number of patients reported to the government hospitals´ emergency departments. The injuries are most commonly caused by cats and often involve children and animal bites to hands. The key recommendations are for parents or childminders to always supervise children when interacting with animals, be particularly cautious, and wear some form of protection when handling pets and domestic, exotic animals. Whether it is a bite or a scratch, healthcare professionals should always anticipate the potential risk of infection, treat the patient accordingly, and prescribe prophylactic antibiotics.

Secure Bluetooth Communication in Smart Healthcare Systems: A Novel Community Dataset and Intrusion Detection System.

Smart health presents an ever-expanding attack surface due to the continuous adoption of a broad variety of Internet of Medical Things (IoMT) devices and applications. IoMT is a common approach to smart city solutions that deliver long-term benefits to critical infrastructures, such as smart healthcare. Many of the IoMT devices in smart cities use Bluetooth technology for short-range communication due to its flexibility, low resource consumption, and flexibility. As smart healthcare applications rely on distributed control optimization, artificial intelligence (AI) and deep learning (DL) offer effective approaches to mitigate cyber-attacks. This paper presents a decentralized, predictive, DL-based process to autonomously detect and block malicious traffic and provide an end-to-end defense against network attacks in IoMT devices. Furthermore, we provide the BlueTack dataset for Bluetooth-based attacks against IoMT networks. To the best of our knowledge, this is the first intrusion detection dataset for Bluetooth classic and Bluetooth low energy (BLE). Using the BlueTack dataset, we devised a multi-layer intrusion detection method that uses deep-learning techniques. We propose a decentralized architecture for deploying this intrusion detection system on the edge nodes of a smart healthcare system that may be deployed in a smart city. The presented multi-layer intrusion detection models achieve performances in the range of 97-99.5% based on the F1 scores.

Paramedics' knowledge, attitudes, and practices regarding the use of personal protective equipment against COVID-19.

The risk of novel coronavirus disease (COVID-19) transmission in the confined mobile ambulance compartment is increased during aerosol-generating procedures and close proximity. Paramedics are encouraged to increase body-surface-isolation by donning additional personal protective equipment (PPE) during patient encounters. This study aimed to better understand paramedics' knowledge, attitudes, and practices related to PPE use during the COVID-19 pandemic in the prehospital setting with a focus on mitigating risks associated with infection control. This prospective quantitative study collected descriptive data using a specifically designed data collection tool. The survey data was then cleaned and analyzed with Microsoft Excel® and the latest version of the Statistical Package for Social Sciences. One thousand frontline paramedics employed by the Hamad Medical Corporation Ambulance Service (HMCAS) were invited via email to participate in the study. A total of 282 (28.2% of frontline paramedics) paramedics completed the online survey, of which 80.1% completed the mandatory HMCAS online infection control training program within the last year, and 17.0% between one to two years ago. Approximately 83% of the participants had completed an N95 mask fit test at HMCAS within the past five years, and 91.5% completed the hand hygiene training. The study found that 98.2% of the paramedics were knowledgeable about COVID-19 and its transmission, while 96.1% agreed that aerosol-generating procedures increased airborne transmission. The paramedics' attitudes were mainly positive toward the use of PPE to prevent the spread of the virus, which was synchronous with their practice. The sample population demonstrated a strong knowledge of COVID-19 and its transmission. Their overall positive attitudes and good infection control practices were demonstrative of efforts to mitigate risks associated with the spread of the virus.

Health research-strengthening and capacity development: Research support system model in an academic healthcare system.

INTRODUCTION: Healthcare research contributes to the well-being of a population; hence, it is important to use the right system to ensure that junior researchers develop the required skills. Current research-strengthening and capacity development programs might lack a research process-based common framework or model leading to variable and suboptimal outcomes. This study aimed to describe the development and evaluation of a model for health research-capacity development at both individual and institutional levels in a Joint Commission International-accredited governmental healthcare organization in Qatar. METHODS: This retrospective observational study evaluated a research support system employed in Qatar for 1 year and constituted of16 stations, each covering a different topic and supported by an experienced faculty member. We recorded how many faculty members were involved and how many people accessed which stations. We developed an outcomes logistic model and obtained feedback about their experience of using the research support system through a short survey. RESULTS: Twenty-one faculty members supported a total of 77 participants, representing various professions and specialties. The majority of the participants received support on multiple stations, and the most solicited were study design and methodology (n = 45, 58.4%) and research idea (n = 29, 37.7%). The most common type of research that participants required support for was clinical research (n = 65, 84.4%). Moreover, 58.4% of the participants answered the survey, and their responses attested to their perceived benefit of making use of the research support system. CONCLUSION: The research support system presented was positively evaluated by participants and promoted networking. Such aspects are favorable to the development of a research culture within an organization and would be a good addition for implementation in universities running healthcare programs and hospitals with residency programs and a large and varied healthcare workforce. This would contribute to the development of health-related research capacity and quality of research outputs in these institutions.

Setting up a temporary isolation tent site for asymptomatic COVID-19 positive male migrant workers in Qatar.

BACKGROUND: Qatar has a unique demographic composition, involving hundreds of thousands of male blue-collar workers living in places where physical distancing measures are difficult to implement. This study aimed to describe the rapid development and operations of a temporary isolation facility, which was composed of tents, for asymptomatic COVID-19 positive migrant workers. DESIGN: The government established several temporary isolation facilities to house this important group of the community. This was achieved through daily meetings over a short period, thanks to the collaboration of government and private partners, in parallel to the facility being built and required resources procured. RESULTS: A 3,726-patient capacity isolation facility composed of large tents was constructed in 1 month and was kept operational from April 16 to June 20, 2020. Over that period, it received a total of 18,900 patients. It took 10 days from the decision to set up the first part of the isolation facility to admitting its first occupants. CONCLUSIONS: The COVID-19 pandemic necessitated the implementation of unprecedented global public health and physical distancing measures to contain the spread of the virus among the population. Rapidly opening a temporary COVID-19 isolation facility bought the healthcare sector time to set up more permanent solutions to contain the spread of the virus.

Transport and Retrieval on Extracorporeal Membrane Oxygenation (ECMO): Setup and Activities of an Immersive Transport and Retrieval on ECMO Workshop.

Extracorporeal life support and extracorporeal membrane oxygenation (ECMO) are widely used for acute severe refractory cardiac and respiratory failure. An increasing number of patients are treated with ECMO worldwide. This can be attributed to technical and technologic advancements, easier access to modern equipment, and more regular and accessible training opportunities for practitioners to maintain current skills and develop new ones. Typically, ECMO is provided at tertiary or regional centers that often are university- affiliated. In a significant number of patients, ECMO may be initiated at a peripheral hospital before they are transported to a tertiary facility by a specialized multiprofessional ECMO team. The transport phase is, however, fraught with challenges and untoward events are not uncommon during ECMO transportation, so a robust education and training program is critical to ensure patient safety and optimum outcome. This article describes the authors' experience of developing and running a simulation-based ECMO Transport and Retrieval workshop, with multiple immersive scenarios and opportunities for participants to familiarize themselves with the process and the ambulance equipment and environment. Preparation is a key element to successfully run scenarios that are technically challenging to facilitate due to the environment and equipment involved. To date, 136 multidisciplinary ECMO providers have attended the workshop and no incidents have been reported by the authors' teams during actual transfers and retrieval missions with patients on ECMO.

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar.

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar.Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015.Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25-0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30-6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0-1.04, p = 0.02).Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.

Position Paper on Global Extracorporeal Membrane Oxygenation Education and Educational Agenda for the Future: A Statement From the Extracorporeal Life Support Organization ECMOed Taskforce.

OBJECTIVES: The purpose of this position paper is two-fold: first, to describe the state of extracorporeal membrane oxygenation education worldwide, noting current limitations and challenges; and second, to put forth an educational agenda regarding opportunities for an international collaborative approach toward standardization. DESIGN: Relevant medical literature was reviewed through literature search, and materials from national organizations were accessed through the Internet. Taskforce members generated a consensus statement using an iterative consensus process through teleconferences and electronic communication. SETTING: In 2018, the Extracorporeal Life Support Organization convened the ECMOed Taskforce at two structured, face-to-face meetings of 40 healthcare practitioners and educators with expertise in caring for the extracorporeal membrane oxygenation patient and in extracorporeal membrane oxygenation education. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The ECMOed Taskforce identified seven educational domains that would benefit from international collaborative efforts. Of primary importance, the Taskforce outlined actionable items regarding 1) the creation of a standardized extracorporeal membrane oxygenation curriculum; 2) defining criteria for an extracorporeal membrane oxygenation course as a vehicle for delivering the curriculum; 3) outlining a mechanism for evaluating the quality of educational offerings; 4) utilizing validated assessment tools in the development of extracorporeal membrane oxygenation practitioner certification; and 5) promoting high-quality educational research to guide ongoing educational and competency assessment development. CONCLUSIONS: Significant variability and limitations in global extracorporeal membrane oxygenation education exist. In this position paper, we outline a road map for standardizing international extracorporeal membrane oxygenation education and practitioner certification. Ongoing high-quality educational research is needed to evaluate the impact of these initiatives.

A skills acquisition study on ECMOjo: a screen-based simulator for extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation relies heavily on didactic teaching, emphasizing on essential cognitive skills, but overlooking core behavioral skills such as leadership and communication. Therefore, simulation-based training has been adopted to instill clinical knowledge through immersive experiences. Despite simulation-based training's effectiveness, training opportunities are lessened due to high costs. This is where screen-based simulators come into the scene as affordable and realistic alternatives. AIM: This article evaluates the educational efficacy of ECMOjo, an open-source screen-based extracorporeal membrane oxygenation simulator that aims to replace extracorporeal membrane oxygenation didactic instruction in an interactive and cost-effective manner. METHOD: A prospective cohort skills acquisition study was carried out. A total of 44 participants were pre-assessed, divided into two groups, where the first group received traditional didactic teaching, and the second used ECMOjo. Participants were then evaluated through a wet lab assessment and two questionnaires. RESULTS: The obtained results indicate that the two assessed groups show no statistically significant differences in knowledge and efficacy. Hence, ECMOjo is considered an alternative to didactic teaching as per the learning outcomes. CONCLUSION: The present findings show no significant dissimilarities between ECMOjo and didactic classroom-based teaching. Both methods are very comparable in terms of the learner's reported self-efficacy and complementary to mannequin-based simulations.

Prehospital conversion of paroxysmal supraventricular tachycardia using the modified Valsalva maneuver: A case report.

The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.

Implementation of a drive-through testing clinic in Qatar for residents having recently returned from a country with a COVID-19 travel warning.

INTRODUCTION: The spread of the SARS-CoV-2 virus has caused chaos around the world. At the onset of the virus' detection in the State of Qatar, a free-testing system was rapidly established to invite individuals who had recently returned from countries with a COVID-19 disease travel warning to avoid putting other people at risk. The testing site needed to be accessible to individuals without requiring them to enter the hospital and congregate in a waiting area. The aim of this article is to share our experience with the early implementation of a drive-through testing clinic using the invited person's vehicle as an isolation compartment during screening to minimize person-to-person contamination. METHODS: A Hamad Medical Corporation site was selected to stage a drive-through testing facility to avoid congestion and offer space to facilitate the process. A process was rapidly agreed upon, and staff received the required training regarding infection control measures and documentation. At the testing site, individuals were subjected to the following steps: registration and history taking, temperature measurement, swabbing, and receipt of a sick leave certificate and a flyer about self-quarantine. RESULTS: Over the first six days of implementation, the relevant authorities determined that 687 individuals had to be contacted, 103 attended their testing appointment in that period, and an additional 327 people (close relations of the individuals contacted or individuals contacted but without a health card) also subjected themselves to the testing process, which took a median time of 11 minutes 39 seconds. No individual exhibited symptoms that warranted immediate isolation while they were at the drive-through testing clinic. However, four individuals were diagnosed with COVID-19 following laboratory analysis of the swab taken and followed up. The median time between swab collection and laboratory testing was 13 hours 41 minutes 59 seconds. CONCLUSIONS: Collaboration among various key health, governmental, and travel industry partners was essential to the successful and rapid implementation of a COVID-19 drive-through testing clinic in the early days of the pandemic in Qatar. The general public reacted well to this process. Communication, coordination, and planning were identified as critical factors at every step of the process. It started from the initial call to the travelers who had recently returned from a country with a newly instituted travel warning and concluded by them leaving with their sick leave certificate and an information flyer with reminders about preventative infection control measures and encouraging them to self-quarantine after having been swabbed.

Extracorporeal membrane oxygenation simulation-based training: methods, drawbacks and a novel solution.

INTRODUCTION: Patients under the error-prone and complication-burdened extracorporeal membrane oxygenation (ECMO) are looked after by a highly trained, multidisciplinary team. Simulation-based training (SBT) affords ECMO centers the opportunity to equip practitioners with the technical dexterity required to manage emergencies. The aim of this article is to review ECMO SBT activities and technology followed by a novel solution to current challenges. ECMO SIMULATION: The commonly-used simulation approach is easy-to-build as it requires a functioning ECMO machine and an altered circuit. Complications are simulated through manual circuit manipulations. However, scenario diversity is limited and often lacks physiological and/or mechanical authenticity. It is also expensive to continuously operate due to the consumption of highly specialized equipment. TECHNOLOGICAL AID: Commercial extensions can be added to enable remote control and to automate circuit manipulation, but do not improve on the realism or cost-effectiveness. A MODULAR ECMO SIMULATOR: To address those drawbacks, we are developing a standalone modular ECMO simulator that employs affordable technology for high-fidelity simulation.

Using thermochromism to simulate blood oxygenation in extracorporeal membrane oxygenation.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) training programs employ real ECMO components, causing them to be extremely expensive while offering little realism in terms of blood oxygenation and pressure. To overcome those limitations, we are developing a standalone modular ECMO simulator that reproduces ECMO's visual, audio and haptic cues using affordable mechanisms. We present a central component of this simulator, capable of visually reproducing blood oxygenation color change using thermochromism. METHODS: Our simulated ECMO circuit consists of two physically distant modules, responsible for adding and withdrawing heat from a thermochromic fluid. This manipulation of heat creates a temperature difference between the fluid in the drainage line and the fluid in the return line of the circuit and, hence, a color difference. RESULTS: Thermochromic ink mixed with concentrated dyes was used to create a recipe for a realistic and affordable blood-colored fluid. The implemented "ECMO circuit" reproduced blood's oxygenation and deoxygenation color difference or lack thereof. The heat control circuit costs 300 USD to build and the thermochromic fluid costs 40 USD/L. During a ten-hour in situ demonstration, nineteen ECMO specialists rated the fidelity of the oxygenated and deoxygenated "blood" and the color contrast between them as highly realistic. CONCLUSIONS: Using low-cost yet high-fidelity simulation mechanisms, we implemented the central subsystem of our modular ECMO simulator, which creates the look and feel of an ECMO circuit without using an actual one.

The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue - An important milestone.

Dr. Ibrahim Fawzy Hassan Local Host and QCCC 2019 Conference Chair Dear Friends and Colleagues, It is an honour to welcome everyone to the first Qatar Critical Care Conference (QCCC). It has been a long journey to make it happen, but this event has been much awaited by the local critical care community. Over the last few years, we have hosted a number of related events of various scales, ranging from Critical Care Grand Rounds targeting Hamad Medical Corporation (HMC) critical care clinicians, ran specialised courses, through to organising an international medical conference on extracorporeal life support in 2017.1 This inaugural QCCC event is the fruit of much planning and collaboration. The programme spans from 28th to 31st October 2019 and consists of two days of pre-conference workshops and two days for the main conference. The vast majority of the pre-conference workshops will be held in the state-of-the-art ITQAN Clinical Simulation and Innovation Centre located within Hamad bin Khalifa Medical City. Although the facility is yet to be offically inaugurated and opened, we have the privilege to have been granted access to it as a way of showcasing our forthcoming continuing professional development capability. "Itqan" in Arabic means quality and striving for perfection, which is very much in line with the mission of our established Critical Care Network (CCNW).2 Simulation-based education is an area in which we have started to be very active through various immersive courses as well as innovative technological developments to train our extracorporeal membrane oxygenation (ECMO) specialists.3,4 The scientific part of the conference will be hosted in the iconic Sheraton Grand Doha Resort & Convention Hotel in the West Bay area. It includes a varied selection of topics presented by many renowned experts in their respective domain. This comprehensive programme with a line-up of lectures and workshops addressing e-CPR, ECMO simulation, ECMO cannulation, hemodynamics and so much more will facilitate the exchange of knowledge and experiences to improve patient care in Qatar and beyond. We anticipate that the programme will appeal to a broad audience and hence will bring together clinicians from all professions involved with caring for acutely ill patients. It is QCCC's aim to connect and explore new insights and expertise at a national and international level through networking with other professionals in a multidisciplinary setting. We hope that during this event many fruitful discussions will take place and that it will enhance opportunities for collaboration to develop everyone's practice in critical care. The HMC Critical Care family has a capacity of 163 and 109 intensive care unit (UCI) beds, respectively for adult and paediatric patients, across 7 hospitals spread throughout Qatar. These numbers are complemented by another 52 adult and paediatric beds from non-HMC hospitals. This gives us a national ICU bed capacity of 11.8 per 100,000 inhabitants considering a current population of nearly 2,750,000 inhabitants.5 Although this number remains below the international benchmark which can be considered to be around 15/100,000 population,6 this quota in Qatar has more than quadrupled over the last ten years, which represents a very significant improvement in the care that can be provided to acutely ill patients. Within HMC only, it is supported by a workforce of 159 intensive care physicians, 1122 intensive care nurses, and many other clinical staff, all of whom undergo a well regulated programme of continuing professional development and are licensed to practise by the Qatar Council for Healthcare Practitioners (QCHP).7 The work they do across the various sites is coordinated and monitored by the CCNW2 who ensures the best level of care, up-to-date technology, and evidence-based practices are consistently adopted for the wellbeing of our patients. Once again, on behalf of the Scientific and Organizing Committees, it is my pleasure to welcome you all to Doha and we hope that you enjoy and gain meaningful insights during the conference regarding our local critical care setting and practices, but also learn from the experiences and best practices shared by our international guest speakers. Prof. Guillaume Alinier Guest Managing Editor, Qatar Medical Journal QCCC Special Issue and Abstracts Chair of the QCCC Scientific Committee. Dear Contributors and Conferences Delegates, Welcome to this special issue of the Qatar Medical Journal (QMJ) which has been dedicated to the inaugural conference of the Hamad Medical Corporation (HMC) Qatar Critical Care Network (QCCN) which celebrates its fifth anniversary in 2019. I would like to start by thanking everyone who has supported this arduous publication endeavour through their extended abstract submission(s) and the reviewers for the valuable feedback they have provided to the authors to ensure this publication is a representative legacy of the calibre of this conference which includes many local and international experts in their respective field of practice or interest. All the accepted abstracts are being published Open Access thanks to the support of the conference sponsors and this contributes greatly to the sharing of experiences and best practices worldwide, but also showcases the good work that is being done in Qatar in the domain of critical care thanks to the work of dedicated clinicians and the leadership of the CCNW.2 Being the Guest Managing Editor of the special issue of a journal is an honour but also an arduous task, especially when a large number of submissions from international authors needs to be handled. It is the second time that I have accepted to take on that role for Qatar Medical Journal as the previous time was in 2017 on the occasion of hosting the South West Asia and African Chapter (SWAAC) of the Extracorporeal Life Support Organisation (ELSO) in Doha.1 This was only a couple of years after HMC had established its Extracorporeal Membrane Oxygenation (ECMO) programme, and it was a very successful event with many of its associated open access publications having been downloaded hundreds of times from the QScience.com publishing platform. Working on this new Special Issue really made me reflect on how the domain of critical care is vast and encompasses so many aspects of patient care and so many professions and specialties. The topics of the abstracts published in this special issue of QMJ cover dietetics,8 sepsis,9 delirium,10,11 physical therapy,12 end of life care and organ donation,13,14 dealing with families,15 as well as education and training of clinicians,16,17 to only highlight a few. Critical care is fast moving as new clinical practices and technological innovations are adopted and contribute to continuously improving patient care. This is especially true in Qatar where significant investments are constantly made to develop and support healthcare in a strategic way.18 At HMC, the critical care phase that some patients have to go through so their medical needs can be met is well integrated across all stakeholder departments that can possibly be involved.2 The patient's journey through the healthcare system can be seen as a continuum of care facilitated by the fact that all parties involved belong to the same overarching organisation, HMC, which is the government funded main provider of secondary and tertiary healthcare in Qatar. This means that from initial contact with the Ambulance Service bringing a patient to the Emergency Department for example, right through to rehabilitation and even possible access upon discharge to a mobile healthcare service supported by family physicians, nurses, and paramedics, patients can expect the same high standards of care.19 Critical care provision relies on multidisciplinary communication during transition of care as well as during any acute episode. This needs to be underpinned by medical knowledge and understanding of the potential contributions of other professions as nothing can be left to chance when a patient's life is hanging by a thread. The present collection of editorials and abstracts brings different perspectives on a broad range of topics which should be highly relevant to all clinicians involved with critical care and contribute to improving patient outcome and satisfaction, and hence that of the multidisciplinary team members also involved in caring for them. We hope that the Qatar Medical Journal Special Issue publications on critical care meets your needs and expectations. The complete record of QCCC publications including additional open access abstracts and editorials relating to this conference will be made available in Qatar Medical Journal at the following link: https://www.qscience.com/content/journals/qmj. Thanks again to everyone for your contributions, and beyond our email communications, I now hope to meet you in person during the conference!

Critical Care Network in the State of Qatar.

Critical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.1 The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.2 It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.3 Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand. Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision - namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system. The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.4 For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC. As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.5 It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.6 This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients. The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas: 1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards. 2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required. 3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects. 4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers. 5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients. 6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment4 of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.7 The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various internationalaccreditation awards by prestigious organisations and professional bodies.

Addressing the challenges of ECMO simulation.

INTRODUCTION/AIM: The patient's condition and high-risk nature of extracorporeal membrane oxygenation (ECMO) therapy force clinical services to ensure clinicians are properly trained and always ready to deal effectively with critical situations. Simulation-based education (SBE), from the simplest approaches to the most immersive modalities, helps promote optimum individual and team performance. The risks of SBE are negative learning, inauthenticity in learning and over-reliance on the participants' suspension of disbelief. This is especially relevant to ECMO SBE as circuit/patient interactions are difficult to fully simulate without confusing circuit alterations. METHODS: Our efforts concentrate on making ECMO simulation easier and more realistic in order to reduce the current gap there is between SBE and real ECMO patient care. Issues to be overcome include controlling the circuit pressures, system failures, patient issues, blood colour and cost factors. Key to our developments are the hospital-university collaboration and research funding. RESULTS: A prototype ECMO simulator has been developed that allows for realistic ECMO SBE. The system emulates the ECMO machine interface with remotely controllable pressure parameters, haemorrhaging, line chattering, air bubble noise and simulated blood colour change. CONCLUSION: The prototype simulator allows the simulation of common ECMO emergencies through innovative solutions that enhance the fidelity of ECMO SBE and reduce the requirement for suspension of disbelief from participants. Future developments will encompass the patient cannulation aspect.

International overview of high-level simulation education initiatives in relation to critical care.

The use of simulation in health care education has become very topical across all professions and specialties in order to improve patient safety and quality of care. In the last decade, the adoption of more realistic simulation-based teaching methodologies, which serves as a bridge between the acquisition and application of clinical skills, knowledge, and attributes, has been accompanied by the development of a multitude of international and national simulation societies. These serve as important exchange fora for educators, clinicians, researchers, and engineers who desire to learn and share their experience and knowledge around simulation-based education. Several countries have derived their own strategy in order to promote the use of such training methodology. Current key national strategies will be presented in this paper alongside a discussion of their expected impact. Various approaches have been adopted and each has their own place and the potential to be adopted by other nations depending on their political, economic or even geographic context. Within the critical care arena, simulation has generated considerable interest and there is a growing evidence base for its use as a learning and teaching strategy within this environment. A number of critical care-related associations and societies are now recognizing simulation as an appropriate pedagogical approach and acknowledging its potential to improve patient care and clinical outcomes. Its implementation should be carefully considered to ensure that developments are based on current best educational practice to maximize the efficiency of these educational interventions.