Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS: A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS: A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS: This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.

Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program.

OBJECTIVES: The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS: This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS: A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS: This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.

Interprofessional Simulation: From the Classroom to Clinical Practice.

Interprofessional simulation (IPS), frequently referred to in the literature as simulation-enhanced interprofessional education (IPE), has been widely studied in nursing and medical education. For decades, the literature has suggested IPE as a valuable strategy for enhancing communication and collaboration among health professionals. Interprofessional collaborative practice (IPCP) is foundational to developing high-functioning healthcare teams and can lead to reduced medical errors and increased patient safety. This chapter addresses IPS from both the academic and practice perspectives. The foundations of IPE and IPCP are reviewed, as well as the standards of best practice in simulation. Planning, development, and implementation will be discussed, including benefits, barriers, and possible solutions. Recommendations from relevant research on debriefing and evaluation of IPS are also reviewed. Outcomes from the growing body of research on IPS will be presented and include perceptions of interprofessional practice, better understanding of professional roles and responsibilities, development of communication and teamwork skills, and shared problem-solving and decision-making. Future implications and recommendations are provided based on the state of the science on IPS. Optimum design, implementation, and evaluation of IPS, along with a thorough understanding of the benefits, barriers, and opportunities, can help faculty and clinical educators prepare a collaborative healthcare workforce and reduce medical errors to ultimately improve patient outcomes.

Use of Simulation to Improve the Comfort of Pediatric Residents Managing Critically Ill Emergency Department Patients.

OBJECTIVES: The aims of this study were to identify the needs for further critical care experience for pediatric and internal medicine-pediatric residents, to describe a multidisciplinary approach to education, and to assess the impact of high-fidelity simulation on critical care comfort and perceived competence in pediatric residents. In addition, this study assessed pediatric residents' attitudes toward simulation as a means of providing additional education with critically ill patients. METHODS: Residents on their pediatric emergency medicine (PEM) rotation voluntarily participated in a 2-hour simulation session. Each session involved the evaluation and management of 3 critically ill pediatric patients with emergency medicine and pediatric/PEM faculty facilitating and debriefing as a team. All resident participants were asked to complete a presession and postsession survey including questions rating their comfort level with common emergent pediatric disease processes and procedures on a 5-point Likert scale. RESULTS: Overall, the participants reported a significant improvement in comfort level in most categories with P < 0.05. The majority of the resident participants rated the simulation program as a valuable learning tool for managing pediatric emergencies and felt that it would be beneficial to have additional simulation experiences in the PEM curriculum. CONCLUSIONS: This simulation program improved resident comfort in important aspects of the care of critically ill pediatric patients. The use of simulation as an educational tool for pediatric emergencies is considered valuable to residents in our program. In addition, simulation provides an opportunity for educational collaboration between academic departments.

Feasibility of upright patient positioning and intubation success rates At two academic EDs.

OBJECTIVES: Endotracheal intubation is most commonly taught and performed in the supine position. Recent literature suggests that elevating the patient's head to a more upright position may decrease peri-intubation complications. However, there is little data on the feasibility of upright intubation in the emergency department. The goal of this study was to measure the success rate of emergency medicine residents performing intubation in supine and non-supine, including upright positions. METHODS: This was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed. The number of attempts required for successful intubation was recorded by faculty and espiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0-10° (supine), 11-44° (inclined), and ≥45° (upright); first past success was also analyzed in 5 degree angle increments. RESULTS: A total of 231 intubations performed by 58 residents were analyzed. First pass success was 65.8% for the supine group, 77.9% for the inclined group, and 85.6% for the upright group (p=0.024). For every 5 degree increase in angle, there was increased likelihood of first pass success (AOR=1.11; 95% CI=1.01-1.22, p=0.043). CONCLUSIONS: In our study emergency medicine residents had a high rate of success intubating in the upright position. While this does not demonstrate causation, it correlates with recent literature challenging the traditional supine approach to intubation and indicates that further investigation into optimal positioning during emergency department intubations is warranted.

Front-Line Health Care Workers' COVID-19 Infection Contamination Risks: A Human Factors and Risk Analysis Study of Personal Protective Equipment.

Infectious risks escalate with complex donning and doffing personal protective equipment (PPE) protocols. Recent studies suggest that PPE donning and doffing behaviors that deviate from protocol during PPE reuse compounded the risks of health care worker (HCW) self-contamination. This study quantified the occurrence of behaviors associated with known risks in PPE use and reuse. We conducted a prospective study of emergency department HCWs and video-recorded PPE donning and doffing 5 times in simulated patient encounters. Trained coders recorded HCW behaviors according to an evidence-based guide. All 28 participants deviated from the Centers for Disease Control and Prevention (CDC) sanctioned donning and doffing protocol order, and most were documented to have (92.85%) self-contaminated at least once during each simulated clinical encounter. Behaviors that compounded self-contamination due to PPE reuse were also observed. Wide variation in PPE donning and doffing behaviors was found among front-line, experienced HCWs. Future work is needed to determine which deviations put HCWs at increased risk for accidental self-contamination and what changes are needed to the CDC protocol for protecting HCW from infections.

Improved simulated ventilation with a novel tidal volume and peak inspiratory pressure controlling bag valve mask: A pilot study.

Introduction: The dangers of hyperventilation during resuscitation are well known. Traditional bag valve mask (BVM) devices rely on end users to control tidal volume (Vt), rate, and peak inspiratory pressures (PIP) of ventilation. The Butterfly BVM (BBVM) is a novel device intending to give greater control over these parameters. The objective of this pilot study was to compare the BBVM against a traditional device in simulated resuscitations. Methods: Senior emergency medicine residents and fellows participated in a three-phase simulation study. First, participants used the Ambu Spur II BVM in adult and pediatric resuscitations. Vt, PIP, and rate were recorded. Second, participants repeated the resuscitations after a brief introduction to the BBVM. Third, participants were given a longer introduction to the BBVM and were tested on their ability to adjust its various settings. Results: Nineteen participants were included in the adult arm of the study, and 16 in the pediatric arm. The BBVM restricted Vt delivered to a range of 4-8 ml/kg vs 9 ml/kg and 13 ml/kg (Ambu adult and Ambu pediatric respectively). The BBVM never exceeded target minute ventilations while the Ambu BVMs exceeded target minute ventilation in 2 of 4 tests. The BBVM failed to reliably reach higher PIP targets in one test, while the pediatric Ambu device had 76 failures of excessive PIP compared to 2 failures by the BBVM. Conclusion: The BBVM exceeded the Ambu Spur II in delivering appropriate Vts and in keeping PIPs below target maximums to simulated adult and pediatric patients in this pilot study.

An investigation into emergency medicine resident cricothyrotomy competency: Is three the magic number?

Objectives: Cricothyrotomy is a high-stakes emergency procedure. Because the procedure is rare, simulation is often used to train residents. The Accreditation Council for Graduate Medical Education (ACGME) requires performance of three cricothyrotomies during residency, but the optimal number of training repetitions is unknown. Additional repetitions beyond three could increase proficiency, though it is unknown whether there is a threshold beyond which there is no benefit to additional repetition. The objective of this study was to establish a minimum number of simulated cricothyrotomy attempts beyond which additional attempts did not increase proficiency. Methods: This was a prospective, observational study conducted over 3 years at the simulation center of an academic emergency medicine residency program. Participants were residents participating in a cricothyrotomy training as part of a longitudinal airway curriculum course. The primary outcome was time to successful completion of the procedure as first-year residents. Secondary outcomes included time to completion as second- and third-year residents. Procedure times were plotted as a function of attempt number. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and correlation analysis. Preprocedure surveys collected further data regarding procedure experience, confidence, and comfort. Results: Sixty-nine first-year residents participated in the study. Steady improvement in time to completion was seen through the first six attempts (from a mean of 75 to 41 sec), after which no further significant improvement was found. Second- and third-year residents initially demonstrated slower performance than first-year residents but rapidly improved to surpass their first-year performance. Resident mean times at five attempts were faster with each year of residency (first-year 48 sec, second-year 30 sec, third-year 24 sec). There was no statistically significant correlation between confidence and time to complete the procedure. Conclusions: Additional repetition beyond the ACGME-endorsed three cricothyrotomy attempts may help increase proficiency. Periodic retraining may be important to maintain skills.

Stress and resident interdisciplinary team performance: Results of a pilot trauma simulation program.

BACKGROUND: Excessive stress negatively impacts surgical residents' technical performance. The effect of stress on trainee nontechnical skills, however, is less well studied. Given that nontechnical skills are known to impact clinical performance, the purpose of this study was to assess the relationship between residents' perceived stress and nontechnical skills during multidisciplinary trauma simulations. METHODS: First-year surgery and emergency medicine residents voluntarily participated in this study. Residents participated in 3 trauma simulations across 2 training sessions in randomly assigned teams. Each team's nontechnical skills were evaluated by faculty using the Trauma Nontechnical Skills scale. The Trauma Nontechnical Skills scale consists of 5 items: leadership, cooperation, communication, assessment, and situation awareness/coping with stress. After each scenario, residents completed the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index to detail their perceived stress and workload during scenarios. Linear regressions were run to assess relationships between stress, workload, and nontechnical skills. RESULTS: Twenty-five residents participated in the first simulation day, and 24 residents participated in the second simulation day. Results from regressions revealed that heightened stress and workload predicted significantly lower nontechnical skills performance during trauma scenarios. In regard to specific aspects of nontechnical skills, residents' heightened stress and workload predicted statistically significant lower situation awareness and decision-making during trauma scenarios. CONCLUSION: Residents' perceived stress and workload significantly impaired their nontechnical skills during trauma simulations. This finding highlights the need to offer stress management and performance-optimizing mental skills training to trainees to lower their stress and optimize nontechnical skills performance during challenging situations.

Effect of an Aerosol Box on Intubation in Simulated Emergency Department Airways: A Randomized Crossover Study.

INTRODUCTION: The use of transparent plastic aerosol boxes as protective barriers during endotracheal intubation has been advocated during the severe acute respiratory syndrome coronavirus 2 pandemic. There is evidence of worldwide distribution of such devices, but some experts have warned of possible negative impacts of their use. The objective of this study was to measure the effect of an aerosol box on intubation performance across a variety of simulated difficult airway scenarios in the emergency department. METHODS: This was a randomized, crossover design study. Participants were randomized to intubate one of five airway scenarios with and without an aerosol box in place, with randomization of intubation sequence. The primary outcome was time to intubation. Secondary outcomes included number of intubation attempts, Cormack-Lehane view, percent of glottic opening, and resident physician perception of intubation difficulty. RESULTS: Forty-eight residents performed 96 intubations. Time to intubation was significantly longer with box use than without (mean 17 seconds [range 6-68 seconds] vs mean 10 seconds [range 5-40 seconds], p <0.001). Participants perceived intubation as being significantly more difficult with the aerosol box. There were no significant differences in the number of attempts or quality of view obtained. CONCLUSION: Use of an aerosol box during difficult endotracheal intubation increases the time to intubation and perceived difficulty across a range of simulated ED patients.

Failure of an Educational Intervention to Improve Consultation and Implications for Healthcare Consultation.

INTRODUCTION: Consultation of another physician for his or her specialized expertise regarding a patient's care is a common occurrence in most physicians' daily practice, especially in the emergency department (ED). Therefore, the ability to communicate effectively with another physician during a patient consultation is an essential skill. However, there has been limited research on a standardized method for a physician to physician consultation with little guidance on teaching consultations to physicians in training. The objective of our study was to measure the effect of a structured consultation intervention on both content standardization and quality of medical student consultations. METHODS: Senior medical students were assessed on a required emergency medicine rotation with a physician phone consultation during a standardized, simulated chest pain case. The intervention groups received a standard consult checklist as part of their orientation to the rotation, followed by a video recording of a good consult call and a bad consult call with commentary from an emergency physician. The intervention was given to students every other month, alternating with a control group who received no additional education. Recordings were reviewed by three second-year internal medicine residents pursuing a fellowship in cardiology. Each recording was evaluated by two of the three reviewers and scored using a standardized checklist. RESULTS: Providing a standardized consultation intervention did not improve students' ability to communicate with consultants. In addition, there was variability between evaluators in regards to how they received the same information and how they perceived the quality of the same recorded consultation calls. Evaluator inter-rater reliability (IRR) was poor on the questions of 1) would you have any other questions of the student calling the consult and 2) did the student calling the consult provide an accurate account of information and case detail. The IRR was also poor on objective data such as whether the student stated their name. CONCLUSIONS: A brief intervention may not be enough to change complex behavior such as a physician to physician consultant communication. Importantly, despite consultants listening to the same audio recordings, the information was processed differently. Future investigations should focus on both those delivering as well as those receiving a consultation.

Factors that Contribute to Resident Teaching Effectiveness.

Background One of the key components of residency training is to become an educator. Resident physicians teach students, advanced practice providers, nurses, and even faculty on a daily basis. Objective The goal of this study was to identify the objective characteristics of residents, which correlate with perceived overall teaching effectiveness. Methods We conducted a one-year, retrospective study to identify factors that were associated with higher resident teaching evaluations. Senior emergency medicine (EM) teaching residents are evaluated by medical students following clinical teaching shifts. Eighteen factors pertaining to resident teaching effectiveness were chosen. Two items from the medical students' evaluations were analyzed against each factor: teaching effectiveness was measured on a five-point Likert scale and an overall teaching score (1-75). Results A total of 46 EM residents and 843 medical student evaluations were analyzed. The ACGME milestones for systems-based practice (p = 0.02) and accountability (p = 0.05) showed a statistically significant association with a rating of "five" on the Likert scale for teaching effectiveness. Three other ACGME milestones, systems-based practice (p = 0.01), task switching (p = 0.04), and team management (p = 0.03) also showed a statically significant association of receiving a score of 70 or greater on the overall teaching score. Conclusion Residents with higher performance associated with system management and accountability were perceived as highly effective teachers. USMLE and in-service exams were not predictive of higher teaching evaluations. Our data also suggest that effective teachers are working in both academic and community settings, providing a potential resource to academic departments and institutions.

Human Factors and Simulation in Emergency Medicine.

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Changing Systems Through Effective Teams: A Role for Simulation.

Teams are the building blocks of the healthcare system, with growing evidence linking the quality of healthcare to team effectiveness, and team effectiveness to team training. Simulation has been identified as an effective modality for team training and assessment. Despite this, there are gaps in methodology, measurement, and implementation that prevent maximizing the impact of simulation modalities on team performance. As part of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes," we explored the impact of simulation on various aspects of team effectiveness. The consensus process included an extensive literature review, group discussions, and the conference "workshop" involving emergency medicine physicians, medical educators, and team science experts. The objectives of this work were to: 1) explore the antecedents and processes that support team effectiveness, 2) summarize the current role of simulation in developing and understanding team effectiveness, and 3) identify research targets to further improve team-based training and assessment, with the ultimate goal of improving healthcare systems.