Effect of In Situ High-Fidelity Simulation Training on the Emergency management of Pneumonia (INSTEP): a mixed-methods study.

Background: The patient safety agenda has propelled the rise of simulation education, but relatively few evaluations of simulation-based educational interventions have focused on patient outcomes. Objective: To evaluate the impact of an in situ, high-fidelity simulation teaching intervention on the management of community-acquired pneumonia in the ambulatory care unit of a district general hospital. Methods: This study used a mixed-methods approach to evaluate the impact of a programme of 10 in situ high-fidelity simulation education sessions delivered to a total of 10 junior doctors, nine nurses and seven healthcare assistants. Participants were tasked with managing a manikin simulating a patient with pneumonia in real time in a working clinical area. Subsequent structured debrief emphasised key themes from the national guidelines on pneumonia management. The intervention was evaluated through an immediate feedback form, follow-up semistructured interviews by independent qualitative researchers that underwent content analysis and triangulation with audit data on compliance with national pneumonia guidelines before and after the simulation intervention. Results: The in situ simulation intervention was valued by participants both in immediate written feedback and in follow-up semistructured interviews. In these interviews, 17 of 18 participants were able to identify a self-reported change in practice following the simulation intervention. Furthermore, most participants reported observing a change in the clinical practice of their colleagues following the training. Collected audit data did not show a statistically significant change in compliance with the guidelines for the management of pneumonia. Conclusion: This study found evidence of a change in both self-reported and observed clinical practice following a simulation intervention, supporting expert opinion that simulation education can impact clinician behaviours and patient outcomes in complex clinical scenarios. Furthermore, this feasibility study provides a transferrable method to evaluate the real-world impact of simulation education that merits further investigation through an appropriately powered study.

Beta-lactam resistance in Staphylococcus aureus cells that do not require a cell wall for integrity.

Staphylococcus aureus ATCC 9144 cells with defective cell walls were generated on a medium with elevated osmolality in the presence of sublethal levels of penicillin G. On removal of antibiotic pressure, the cells exhibited stable penicillin and methicillin resistance. The resistance was homogeneous and its acquisition was enhanced following transient cell wall-defective growth. The resistant cells were mecA negative, beta-lactamase negative and did not contain any mutations in the coding regions of pbp genes. When penicillin was added back to resistant cells, they continued to grow and produced a diffuse cell wall that was resistant to the action by lysostaphin but was very sensitive to lysis with Triton X-100. These data indicate that the resistant cells are not dependent upon an intact cell wall for osmotic stability and they are able to switch readily to this mode of growth in the presence of penicillin G.