A Tribute to Chad Epps: A Mentor, Educator, Leader, Collaborator, and Friend.

SUMMARY STATEMENT: Dr Chad Epps' journey in healthcare simulation touched countless lives in his role as a mentor, educator, leader, collaborator, and friend. Here, we highlight Chad's lasting impact upon which we all stand today.

Institution of Just Culture Physician Peer Review in an Academic Medical Center.

OBJECTIVES: For academic medical centers to improve quality outcomes, identification and optimization of opportunities for improvement are necessary. Effective clinical peer review frequently has limitations on timeliness, transparency, and consideration of system processes related to untoward clinical outcomes. We developed a process to overcome these barriers and capture opportunities for process improvement identified within the clinical peer review system. METHODS: A multidisciplinary committee was formed to evaluate the current process of physician peer review at Magee Womens Hospital of the University of Pittsburgh Medical Center. Evaluation of current peer review triggers, processes, communication, transparency, and actionable outcomes was performed. A new approach was established that incorporated a protected electronic portal to improve communication and provider engagement, as well as initiation of a Just Culture peer review algorithm to realize opportunities for system improvements. RESULTS: The new process has been operative for 2 years. After initiation, the average time necessary for full case review decreased by 66% (6-2 months). Provider engagement and input have increased to 71%, from less than 10% before implementation. Most cases (51%) were identified as having more than one causative factor, with systems issues being the most frequent contributor to untoward outcomes. CONCLUSIONS: Given the recognized benefits, this approach is being considered for implementation on a broader scale within service-line quality initiatives across the University of Pittsburgh Medical Center health system. Although first implemented among faculty, consideration of incorporation into graduate medical education programs is ongoing.

A Multidisciplinary Intubation Algorithm for Suspected COVID-19 Patients in the Emergency Department.

INTRODUCTION: Intubation of patients suspected of having coronavirus disease 2019 (COVID-19) is considered to be a high-risk procedure due to the aerosolization of viral particles. In an effort to minimize the risk of exposure and optimize patient care, we sought to develop, test, provide training, and implement a standardized algorithm for intubating these high-risk patients at our institution. METHODS: We developed an initial intubation algorithm, incorporating strategic use of equipment and incorporating emerging best practices. By combining simulation-based training sessions and rapid-cycle improvement methodology with physicians, nurses, and respiratory therapists, and incorporating their feedback into the development, we were able to optimize the process prior to implementation. Training sessions also enabled the participants to practice the algorithm as a team. Upon completion of each training session, participants were invited to complete a brief online survey about their overall experience. RESULTS: An algorithm and training system vetted by simulation and actual practice were developed. A training video and dissemination package were made available for other emergency departments to adopt. Survey results were overall positive, with 97.92% of participants feeling confident in their role in the intubation process, and many participants citing the usefulness of the multidisciplinary approach to the training. CONCLUSION: A multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic.

Physician Versus Nonphysician Instruction: Evaluating an Expert Curriculum-Competent Facilitator Model for Simulation-Based Central Venous Catheter Training.

INTRODUCTION: Healthcare simulation supports educational opportunities while maintaining patient safety. To reduce costs and increase the availability of training, a randomized controlled study evaluated central venous catheter (CVC) insertion training in the simulation laboratory with nonphysician competent facilitators (NPCFs) as instructors. METHOD: A group of learners naive to central line placement participated in a blended curriculum consisting of interactive online materials and simulation-based training. Learners were randomized to training with NPCFs or attending physician faculty. The primary outcome was simulated CVC insertion task performance, graded with a validated checklist by blinded physician reviewers. Learner knowledge and satisfaction were also evaluated. Analysis was conducted using noninferiority testing. RESULTS: Eighty-five students, 11 attending physicians, and 7 NPCFs voluntarily participated. Noninferiority testing of the difference in CVC insertion performance between NPCF-trained learners versus physician-trained learners found no significant difference [rejecting the null hypothesis of inferiority using an 8% noninferiority margin (P < 0.01)]. In addition, there was no difference found between the 2 groups on pre/post knowledge scores, self-reported learner comfort, course satisfaction, or instructor satisfaction. CONCLUSIONS: An introductory CVC curriculum can be taught to novice learners by carefully trained and supported NPCFs and achieve skill and knowledge outcomes similar to learners taught by physicians.

Comparing Trainee and Staff Perceptions of Patient Safety Culture.

PURPOSE: The Accreditation Council for Graduate Medical Education implemented the Clinical Learning Environment Review (CLER) program to evaluate and improve the learning environment in teaching hospitals. Hospitals receive a report after a CLER visit with observations about patient safety, among other domains, the accuracy of which is unknown. Thus, the authors set out to identify complementary measures of trainees' patient safety experience. METHOD: In 2014, they administered the Hospital Survey on Patient Safety Culture to residents and fellows and general staff at 10 hospitals in an integrated health system. The survey measured perceptions of patient safety in 12 domains and incorporated two outcome measures (number of medical errors reported and overall patient safety). Domain scores were calculated and compared between trainees and staff. RESULTS: Of 1,426 trainees, 926 responded (65% response rate). Of 18,815 staff, 12,015 responded (64% response rate). Trainees and staff scored five domains similarly-communication openness, facility management support for patient safety, organizational learning/continuous improvement, teamwork across units, and handoffs/transitions of care. Trainees scored four domains higher than staff-nonpunitive response to error, staffing, supervisor/manager expectations and actions promoting patient safety, and teamwork within units. Trainees scored three domains lower than staff-feedback and communication about error, frequency of event reporting, and overall perceptions of patient safety. CONCLUSIONS: Generally, trainees had comparable to more favorable perceptions of patient safety culture compared with staff. They did identify opportunities for improvement though. Hospitals can use perceptions of patient safety culture to complement CLER visit reports to improve patient safety.

Airway Management: A Structured Curriculum for Critical Care Transport Providers.

OBJECTIVE: Airway assessment and management are vital skills for the critical care transport provider. Nurses and paramedics often enter a transport program with limited or no exposure to airway management. Many programs lack a structured curriculum to show skill competence. Optimal methods in the development of airway management competence and the frequency of training needed to maintain skills have not been clearly defined. Because of this lack of standardization, the actual level of competence in both new and experienced critical care transport providers is unknown. METHODS: A pretest, post-test repeated measures approach using an online curriculum combined with a deliberate practice model was used. Competence in airway management was measured using 3 evaluation points: static mannequin head, simulation scenario, and the live patient. RESULTS: A convenience sample of critical care transport providers participated (N = 9). Knowledge improvement was significant, with a higher percentage of participants scoring above 85% on the post-test compared with the pretest (P = .028). Mean scores in completion of the airway checklist pre- versus postintervention were significantly increased on all 3 evaluation points (P < .001 for all comparisons). Significant changes were noted in the response profile evaluating participants' confidence in their ability to verbalize indications for endotracheal intubation (P < .05). CONCLUSION: The development of a standardized, blended learning curriculum combined with deliberate simulation practice and rigorous assessment showed improvements in multiple areas of airway assessment and management.

Rapid Development and Deployment of Ebola Readiness Training Across an Academic Health System: The Critical Role of Simulation Education, Consulting, and Systems Integration.

STATEMENT: In this article, we describe an Ebola preparedness initiative with implementation across an academic health system. Key stakeholder centers of various disciplines and clinical experts collaborated in the development and design. Subject matter experts in the areas of Centers for Disease Control and Prevention and World Health Organization protocols for personal protective equipment donning and doffing conducted initial train-the-trainer sessions for program instructors. These trainers represented a cross-section of key clinical responders and environmental services. Through a parallel development process, a blended learning curriculum consisting of online modules followed by on-site training sessions was developed and implemented in both the simulation laboratory and the actual clinical care spaces in preparation for a Department of Health inspection. Lessons learned included identification of the need for iterative refinement based on instructor and trainee feedback, the lack of tolerance of practitioners in wearing full-body personal protective equipment for extended periods, and the ability of a large system to mount a rapid response to a potential public health threat through leveraging of expertise of its Simulation Program, Center for Quality, Safety and Innovation as well as a wide variety of clinical departments.

Comparison of video laryngoscopy and direct laryngoscopy in a critical care transport service.

OBJECTIVE: We evaluated video laryngoscopy (VL) (C-MAC, Karl Storz, Tuttlingen, Germany) for use in a critical care transport system. We hypothesized that the total number of airway attempts would decrease when using a video laryngoscope versus use of direct laryngoscopy (DL). METHODS: We performed a nonrandomized group-controlled trial where six aircraft were outfitted with VL and the remainder utilized DL responding to a mix of scene runs and interfacility transports. Our primary outcome measure was the number of intubation attempts. We also compared the first-pass success (FPS) rates, laryngoscopic grades, and frequencies of rescue device use (including utilization of surgical airways) between VL and DL. RESULTS: Crews intubated 348 patients with VL and 510 with DL. Successful endotracheal intubation within three attempts occurred 97.6% (confidence interval [CI] 96.5-98.6) of the time. The FPS rate was 85.8% (CI 83.4-88.1). In this cohort of patients, VL did not differ from DL with respect to total number of airway attempts (1.17 [CI 1.11-1.22] vs. 1.16 [CI 1.12-1.20]), FPS rate (85.6% [CI 82-89%] vs. 86.1% [CI 83-89]), or use of rescue airways (2.6% vs. 2.2%). The laryngoscopic view was superior in the VL group relative to the DL group (median Cormack-Lehane grade 1 [interquartile range (IQR) 1, 2] vs. 2 [IQR 1, 2]). CONCLUSION: VL using the C-MAC video laryngoscope did not reduce the total number of airway attempts or improve intubation compared with DL in a system of highly trained providers.

Impact of stylet use in a simulated difficult airway model.

BACKGROUND: Stylet use during endotracheal intubation (ETI) is variable across medical specialty and geographic location; however, few objective data exist regarding the impact of stylet use on ETI performance. OBJECTIVE: We evaluated the impact of stylet use on the time required to perform ETI in cases of simulated difficult airways in novice and experienced providers. METHODS: We performed a prospective, randomized observational study of experienced (attending anesthesiologists and emergency physicians) vs inexperienced airway providers (emergency medical technician, paramedic and medical students) comparing the use of stylet vs no stylet in random order using a simulated difficult airway. The primary outcome was attempt time for each of 6 attempts defined as entry of the laryngoscope in the mouth until successfully passing the endotracheal tube past the vocal cords. We analyzed the data using descriptive statistics including means with SDs and t tests. We used generalized estimating equations to evaluate potential changes in the attempt time over multiple attempts. RESULTS: There were 23 providers per group. The mean (SD) inexperienced attempt time in seconds was 25.88 (28.46) and 10.50 (5.47) for experienced providers (P < .0001). Stylet use did not alter attempt time for either group. When adjusting for stylet use, the attempt time did not change over repeated intubations (P = .541). When adjusting for experience status, inexperienced intubators had shorter attempt times with each successive trial, whereas experienced intubators attempt times remained constant (P < .001). CONCLUSION: Stylet use does not improve attempt time in a simulated difficult airway model for either inexperienced or experienced intubators.

Multiple airways. Rapid assessment is key for managing numerous patients.

Encountering a situation that necessitates the assessment and management of patients requiring airway management can present a significant challenge. It will require a different thought process and set of decision-making skills that vary from the routine practice of airway management during a single patient encounter. Rapid triaging of the need for airway management is important. Creating a categorization of those patients who simply need supplemental oxygen from those who require assistance with the mechanical opening of the airway, a need for positive-pressure ventilation and those who require protection from aspiration can be a useful starting place for the creation of a treatment plan. Treatment decisions will depend on the amount of equipment and personnel resources that are available. Non-traditional decision procedures and positioning may need to be implemented, such as placing patients in a lateral recumbent position to use gravity to assist in keeping the airway patent. In the setting of multiple patient encounters requiring airway management, it's important to consider the length of time each procedure will take and the amount of equipment that will be required. A rapid securing of the airway by a supraglottic device in suitable patients may be favored over traditional approaches of ETI secondary to the relative complexity of the procedure.

Motion capture measures variability in laryngoscopic movement during endotracheal intubation: a preliminary report.

INTRODUCTION: Success rates with emergent endotracheal intubation (ETI) improve with increasing provider experience. Few objective metrics exist to quantify differences in ETI technique between providers of various skill levels. We tested the feasibility of using motion capture videography to quantify variability in the motions of the left hand and the laryngoscope in providers with various experience. METHODS: Three providers with varying levels of experience [attending physician (experienced), emergency medicine resident (intermediate), and postdoctoral student with no previous ETI experience (novice)] each performed ETI 4 times on a mannequin. Vicon, a 16-camera system, tracked the 3-dimensional orientation and movement of markers on the providers, handle of the laryngoscope, and mannequin. Attempt duration, path length of the left hand, and the inclination of the plane of the laryngoscope handle (mean square angular deviation from vertical) were calculated for each laryngoscopy attempt. We compared interattempt and interprovider variability of each measure. RESULTS: All ETI attempts were successful. Mean (SD) duration of laryngoscopy attempts differed between experienced [5.50 (0.68) seconds], intermediate [6.32 (1.13) seconds], and novice [12.38 (1.06) seconds] providers (P = 0.021). Mean path length of the left hand did not differ between providers (P = 0.37). Variability of the plane of the laryngoscope differed between providers: 8.3 (experienced), 28.7 (intermediate), and 54.5 (novice) degrees squared. CONCLUSIONS: Motion analysis can detect interprovider differences in hand and laryngoscope movements during ETI, which may be related to provider experience. This technology has potential to objectively measure training and skill in ETI.

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

PURPOSE: Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center. METHODS: A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe. RESULTS: One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity. CONCLUSIONS: One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.

International collaborative faculty development program on simulation-based healthcare education: a report on its successes and challenges.

PURPOSE: Countries that are less experienced with simulation-based healthcare education (SBHE) often import Western programs to initiate their efforts to deliver effective simulation training. Acknowledging cultural differences, we sought to determine whether faculty development program on SBHE in the United States could be transported successfully to train faculty members in Korea. METHODS: An international, collaborative, multi-professional program from a pre-existing Western model was adapted. The process focused on prioritization of curricular elements based on local needs, translation of course materials, and delivery of the program in small group facilitation exercises. Three types of evaluation data were collected: participants' simulation experience; participants' ratings of the course; and participant's self-assessment of the impact of the course on their knowledge, skills, and attitudes (KSA) toward simulation teaching. RESULTS: Thirty faculty teachers participated in the course. Eighty percent of the participants answered that they spent less than 25% of their time as simulation instructors. Time spent on planning, scenario development, delivering training, research, and administrative work ranged from 10% to 30%. Twenty-eight of 30 participants agreed or strongly agreed that the course was excellent and relevant to their needs. The participants' assessment of the impact of the course on their KSA toward simulation teaching improved significantly. CONCLUSION: Although there were many challenges to overcome, a systematic approach in the adaptation of a Western simulation faculty development course model was successfully implemented in Korea, and the program improves self-confidence and learning in participants.