Crew Autonomy During Simulated Medical Event Management on Long Duration Space Exploration Missions.

OBJECTIVE: Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. BACKGROUND: There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. METHOD: We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. RESULTS: Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. CONCLUSION: Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support. APPLICATION: Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Objective Measurement of Learners' Cognitive Load During Simulation-Based Trauma Team Training: A Pilot Study.

INTRODUCTION: Literature has shown cognitive overload which can negatively impact learning and clinical performance in surgery. We investigated learners' cognitive load during simulation-based trauma team training using an objective digital biomarker. METHODS: A cross-sectional study was carried out in a simulation center where a 3-h simulation-based interprofessional trauma team training program was conducted. A session included three scenarios each followed by a debriefing session. One scenario involved multiple patients. Learners wore a heart rate sensor that detects interbeat intervals in real-time. Low-frequency/high-frequency (LF/HF) ratio was used as a validated proxy for cognitive load. Learners' LF/HF ratio was tracked through different phases of simulation. RESULTS: Ten subjects participated in 12 simulations. LF/HF ratios during scenario versus debriefing were compared for each simulation. These were 3.75 versus 2.40, P < 0.001 for scenario 1; 4.18 versus 2.77, P < 0.001 for scenario 2; and 4.79 versus 2.68, P < 0.001 for scenario 3. Compared to single-patient scenarios, multiple-patient scenarios posed a higher cognitive load, with LF/HF ratios of 3.88 and 4.79, P < 0.001, respectively. CONCLUSIONS: LF/HF ratio, a proxy for cognitive load, was increased during all three scenarios compared to debriefings and reached the highest levels in a multiple-patient scenario. Using heart rate variability as an objective marker of cognitive load is feasible and this metric is able to detect cognitive load fluctuations during different simulation phases and varying scenario difficulties.

Developing Consensus on Simulation Fellowship Requirements on the Path to Accreditation Council of Graduate Medical Education Accreditation.

INTRODUCTION: Nonaccredited simulation fellowships have multiplied resulting in fellowship differences. Standardization of fellowship content and requirements is needed, especially if accreditation is to be achieved. Simulation fellowship criteria were developed using expert consensus and the Accreditation Council for Graduate Medical Education requirements to frame the supporting pillars for accreditation. METHODS: Core curricular components, subelements, and requirements for graduation were derived from a literature review and existing fellowship curricula. A modified Delphi process was performed to establish fellowship program content and requirements. A priori criteria for inclusion or exclusion were used during 3 iterative rounds. Experts could recommend items for inclusion. RESULTS: Fourteen publications and 71 curricula were reviewed with 7 core curriculum components and 44 subelements identified for subsequent expert panel review. All core components were included by consensus: application of teaching and debriefing, business and leadership, curriculum development, educational theory, operational support, research, and assessment and evaluation. Thirty-eight subelements reached consensus. Graduation requirements included a research or scholarly project and a minimum number of debriefing activities, evaluation activities, original simulation curricula, skill-based teaching activities, scenario-based activities, and interprofessional education activities. The maximum number of clinical hours per week was 16 to 20. CONCLUSIONS: Using a modified Delphi process, experts reached consensus on core curriculum components, subelements, graduation requirements, and maximum number of clinical hours to establish Accreditation Council for Graduate Medical Education accreditation criteria for a simulation standardization of simulation fellowships for physicians. Further work is needed to define other parameters including program infrastructure and assessment.

Evaluating Nontechnical Skills in US Emergency Departments Using Simulation: Validating and Contextualizing a UK Assessment Tool.

INTRODUCTION: Nontechnical skills (NTS) in medicine are the "cognitive, social, and personal resource skills that complement technical skills contributing to safe and efficient care." We aimed to (1) evaluate the validity and reliability of a 12-element United Kingdom emergency medicine (EM) NTS assessment tool in the context of United States (US) EM practice and (2) identify behaviors unique to US clinical practice. METHODS: This was a mixed methods study conducted in 2 phases, following Kane's validity framework. The intended use of the NTS tool is to provide formative assessment of US EM physicians (EPs) from a video of simulated clinical encounters. In phase I, a focus group assessed the appropriateness of each aspect of the tool in the context of US EM practice by reviewing and identifying the NTS of an EP in a simulated clinical scenario. In phase II, EPs (N = 208) attending a national EM conference evaluated an EP's behaviors in 1 of 2 video simulations. Reliability in the form of internal consistency was calculated using Cronbach α. All participants suggested exemplar behaviors for the 12 elements in the context of their own clinical practice and generated new assessment elements. RESULTS: Internal consistency was acceptable (α > 0.7) for all categories, except teamwork and cooperation. Participants proposed 4 novel behavioral elements and suggested US exemplar behaviors for all 12 original elements. CONCLUSIONS: This tool can be used to assess US EP's NTS for the purpose of formative assessment. Refinement of exemplar behaviors and inclusion of novel US-specific elements may optimize usability.

Ultrasound-guided regional anesthesia in the emergency department: an argument for multidisciplinary collaboration to increase access while maintaining quality and standards.

The practice of ultrasound-guided regional anesthesia (UGRA) by emergency medicine physicians in the emergency department (ED) is increasing. The need for effective alternatives to opioid analgesia in the acute care setting likely exceeds the current capacity of UGRA-trained anesthesia teams. In this daring discourse, we outline several matters of relevance to be considered as protocols are put into place to facilitate the practice of UGRA by emergency medicine physicians in the ED. There are opportunities for collaboration between anesthesiology and emergency medicine societies in guideline development as well as educational resources. The sustained interest in UGRA shown by many emergency medicine physicians should be viewed open-mindedly by anesthesiologists. Failure to collaborate on local and national scales could lead to delays in the development and implementation of patient-centered, safe procedural care, and limit patient access to the benefits of regional anesthesia.

Brain Death Determination: An Interprofessional Simulation to Determine Brain Death and Communicate with Families Focused on Neurology Residents.

Introduction: Significant variation exists in determining brain death despite an expectation of competence for all neurology residents. In addition, family discussions regarding brain death are challenging and may influence organ donation. Methods: We developed two simulations of increasing complexity for PGY 2 and PGY 3 neurology residents. High-fidelity mannequins were used to simulate patients; standardized actors portrayed family members. In the first simulation, residents determined brain death and shared this information with a grieving family. In the second simulation, residents determined brain death in a more complicated scenario, requiring ancillary testing and accurate result interpretation. Following the determination, residents met with a challenging family. The residents worked with an interdisciplinary team and responded to the family's emotions, used active listening skills, and supported the family through next steps. Results: Twelve residents completed the simulations. Prior to the simulation, three (25%) residents felt comfortable discussing a brain death diagnosis; following the simulation, eight (67%) residents felt comfortable/very comfortable discussing brain death. Prior to the simulation, eight (67%) residents stated they knew prerequisites for performing a brain death examination and seven (58%) agreed they knew indications for ancillary testing; these numbers increased to 100% following the simulation. The number of residents who felt comfortable performing the brain death exam increased from five (42%) to 10 (83%). Discussion: This simulation of determining brain death and leading difficult family meetings was well-received by neurology residents. Further work should focus on the effects of simulation-based education on practice variation and organ donation consent rates.

Medical Event Management for Future Deep Space Exploration Missions to Mars.

BACKGROUND: Long-duration exploration missions (LDEMs), such as voyages to Mars, will present unique medical challenges for astronaut crews, including communication delays and the inability to return to Earth early. Medical events threaten crewmember lives and increase the risk of mission failure. Managing a range of potential medical events will require excellent technical and nontechnical skills (NTSs). We sought to identify medical events with potential for rescue, range them according to the potential impact on crew health and mission success during LDEMs, and develop a list of NTSs to train for management of in-flight medical events. MATERIALS AND METHODS: Twenty-eight subject matter experts with specializations in surgery, medicine, trauma, spaceflight operations, NTS training, simulation, human factors, and organizational psychology completed online surveys followed by a 2-d in-person workshop. They identified and rated medical events for survivability, mission impact, and impact of crewmember NTSs on outcomes in space. RESULTS: Sudden cardiac arrest, smoke inhalation, toxic exposure, seizure, and penetrating eye injury emerged as events with the highest potential mission impact, greatest potential for survival, and that required excellent NTS for successful management. Key NTS identified to target in training included information exchange, supporting behavior, communication delivery, and team leadership/followership. CONCLUSIONS: With a planned Mars mission on the horizon, training countermeasures need to be developed in the next 3-5 y. These results may inform policy, selection, medical system design, and training scenarios for astronauts to manage in-flight medical events on LDEMs. Findings may extend to surgical and medical care in any rural and remote location.

Robotic Assistance Confers Ambidexterity to Laparoscopic Surgeons.

STUDY OBJECTIVE: To examine whether a robotic surgical platform can complement the fine motor skills of the nondominant hand, compensating for the innate difference in dexterity between surgeon's hands, thereby conferring virtual ambidexterity. DESIGN: Crossover intervention study (Canadian Task Force classification II-1). SETTING: Centers for medical simulation in 2 tertiary care hospitals of Harvard Medical School. PARTICIPANTS: Three groups of subjects were included: (1) surgical novices (medical graduates with no robotic/laparoscopic experience); (2) surgeons in training (postgraduate year 3-4 residents and fellows with intermediate robotic and laparoscopic experience); and (3) advanced surgeons (attending surgeons with extensive robotic and laparoscopic experience). INTERVENTIONS: Each study group completed 3 dry laboratory exercises based on exercises included in the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Each exercise was completed 4 times: using the dominant and nondominant hands, on a standard laparoscopic FLS box trainer, and in a robotic dry laboratory setup. Participants were randomized to the handedness and setting order in which they tackled the tasks. MEASUREMENTS AND MAIN RESULTS: Performance was primarily measured as time to completion, with adjustments based on errors. Means of performance for the dominant versus nondominant hand for each task were calculated and compared using repeated-measures analysis of variance. A total of 36 subjects were enrolled (12 per group). In the laparoscopic setting, the mean overall time to completion of all 3 tasks with the dominant hand differed significantly from that with the nondominant hand (439.4 seconds vs 568.4 seconds; p = .0008). The between-hand performance difference was nullified with the robotic system (374.4 seconds vs 399.7 seconds; p = .48). The evaluation of performance for each individual task also revealed a statistically significant disparate performance between hands for all 3 tasks when the laparoscopic approach was used (p = .003, .02, and .01, respectively); however, no between-hand difference was observed when the tasks were performed robotically. On analysis across the 3 surgeon experience groups, the performance advantage of robotic technology remained significant for the surgical novice and intermediate-level experience groups. CONCLUSION: Robot-assisted laparoscopy may eliminate the operative handedness observed in conventional laparoscopy, allowing for virtual ambidexterity. This ergonomic advantage is particularly evident in surgical trainees. Virtual ambidexterity may represent an additional aspect of surgical robotics that facilitates mastery of minimally invasive skills.

Attending Surgeons' Leadership Style in the Operating Room: Comparing Junior Residents' Experiences and Preferences.

PURPOSE: Recent studies have focused on surgeons' nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents' opinions about the OR leadership style of teaching faculty. METHODS: Overall, 20 interns and 20 mid-level residents completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis. RESULTS: Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p < 0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership. CONCLUSIONS: Junior resident preference of leadership style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees.

Expanding simulation-based education through institution-wide initiatives: A blueprint for success.

BACKGROUND: The Consortium of American College of Surgeons Accredited Education Institutes (ACS-AEIs) was created to promote patient safety through the use of simulation, develop innovative education and training, advance technologies, identify best practices, and encourage research and collaboration. METHODS: During the seventh annual meeting of the consortium, leaders from across the consortium who have developed institution-wide simulation centers were invited to participate in a panel to discuss their experiences and the lessons learned. CONCLUSION: These discussions resulted in definition of 5 key areas that need to be addressed effectively to support efforts of the ACS-AEIs.

Interprofessional simulation to improve safety in the epilepsy monitoring unit.

OBJECTIVE: Patient safety is critical for epilepsy monitoring units (EMUs). Effective training is important for educating all personnel, including residents and nurses who frequently cover these units. We performed a needs assessment and developed a simulation-based team training curriculum employing actual EMU sentinel events to train neurology resident-nurse interprofessional teams to maximize effective responses to high-acuity events. METHODS: A mixed-methods design was used. This included the development of a safe-practice checklist to assess team response to acute events in the EMU using expert review with consensus (a modified Delphi process). All nineteen incoming first-year neurology residents and 2 nurses completed a questionnaire assessing baseline knowledge and attitudes regarding seizure management prior to and following a team training program employing simulation and postscenario debriefing. Four resident-nurse teams were recorded while participating in two simulated scenarios. Employing retrospective video review, four trained raters used the newly developed safe-practice checklist to assess team performance. We calculated the interobserver reliability of the checklist for consistency among the raters. We attempted to ascertain whether the training led to improvement in performance in the actual EMU by comparing 10 videos of resident-nurse team responses to seizures 4-8months into the academic year preceding the curricular training to 10 that included those who received the training within 4-8months of the captured video. RESULTS: Knowledge in seizure management was significantly improved following the program, but confidence in seizure management was not. Interrater agreement was moderate to high for consistency of raters for the majority of individual checklist items. We were unable to demonstrate that the training led to sustainable improvement in performance in the actual EMU by the method we used. CONCLUSIONS: A simulated team training curriculum using a safe-practice checklist to improve the management of acute events in an EMU may be an effective method of training neurology residents. However, translating the results into sustainable benefits and confidence in management in the EMU requires further study.

Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study.

STUDY OBJECTIVE: To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN: In vitro study (Canadian Task Force classification: II-1). SETTING: Academic hospital simulation laboratory. INTERVENTION: Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS: Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION: CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Comparison of video, optical, and direct laryngoscopy by experienced tactical paramedics.

OBJECTIVES: While optical and video laryngoscopy have been studied in the emergency department, the operating room, and the routine prehospital setting, their efficacy in the tactical environment--in which operator safety is as important as intubation success--has not been evaluated. This study compared direct laryngoscopes to optical (AirTraq) and video (King Vision) laryngoscopes in a simulated tactical setting. METHODS: This prospective institutional review board-approved simulation study evaluated each of the laryngoscopes in the hands of seven experienced tactical paramedics. After a one-hour training session, each tactical paramedic used each of the laryngoscopes, in a random order, on each of four different airway manikins. A tactical environment was simulated using auditory and visual immersion, and the intubations occurred on the ground with the paramedics in full tactical gear. Outcomes included time to successful ventilation, first-pass success rate, Cormack-Lehane grade, and intubator head height during the intubation. Statistical analysis included chi-squared and Wilcoxon rank sum tests, and multivariate logistic regression was performed to determine contributing factors to outcomes with significant variation. RESULTS: A total of 84 intubations were performed by seven tactical paramedics. While there were no significant differences in time to successful ventilation or first-pass success rate, the optical and video laryngoscopes had significantly better Cormack-Lehane grades, defined as grade I or II (100% for both compared to 85.7%), while direct laryngoscopy resulted in significantly less maximum vertical exposure of the intubator (51.82 cm compared to AirTraq's 56.64 cm and King Vision's 56.13 cm). CONCLUSION: Video and optical laryngoscopes can be used successfully by experienced tactical paramedics in a simulated tactical setting. The King Vision and AirTraq resulted in improved Cormack-Lehane glottic views but similar times to ventilation and first-pass success compared to direct laryngoscopy. Intubator head height was lower with direct laryngoscopy. Clarifying the role of optical and video laryngoscopes in a tactical environment, especially in the hands of less experienced intubators, requires further research.

Using a medical simulation center as an electronic health record usability laboratory.

Usability testing is increasingly being recognized as a way to increase the usability and safety of health information technology (HIT). Medical simulation centers can serve as testing environments for HIT usability studies. We integrated the quality assurance version of our emergency department (ED) electronic health record (EHR) into our medical simulation center and piloted a clinical care scenario in which emergency medicine resident physicians evaluated a simulated ED patient and documented electronically using the ED EHR. Meticulous planning and close collaboration with expert simulation staff was important for designing test scenarios, pilot testing, and running the sessions. Similarly, working with information systems teams was important for integration of the EHR. Electronic tools are needed to facilitate entry of fictitious clinical results while the simulation scenario is unfolding. EHRs can be successfully integrated into existing simulation centers, which may provide realistic environments for usability testing, training, and evaluation of human-computer interactions.

Simulation-based trial of surgical-crisis checklists.

BACKGROUND: Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS: Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS: A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS: In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Using an Objective Structured Clinical Examination to test adherence to Joint Commission National Patient Safety Goal--associated behaviors.

BACKGROUND: A study was conducted at a tertiary care academic medical center to assess a simulation-based, single-station Objective Structured Clinical Examination (OSCE) designed to evaluate intern trainees' familiarity with and adherence to behaviors associated with Joint Commission National Patient Safety Goals and The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. METHOD: Subjects were interns, from all disciplines, completing basic skills training during intern orientation. The OSCE scenario was designed to assess 13 behaviors associated with four National Patient Safety Goals (1, 2, 3, and 7) from 2009 and 2010 and the Universal Protocol. Sessions were digitally recorded and independently reviewed by two observers, who scored behaviors using a standardized score sheet. Behaviors were assigned point values and tabulated for all trainees. Kappa coefficient was calculated to assess interrater reliability. RESULTS: One-hundred eleven (74.5%) of 149 interns completed the station. The average time to completion was 6.9 minutes (standard deviation [SD] 1.8; range, 3.5-12.6). Interns scored an average of 9.5 points (SD, 4.7; range, 2-20; mode, 8) of 26. The interrater reliability for the two reviewers was 0.9. Interns most frequently requested chlorhexidine to sterilize the patient's skin (98.2% of interns demonstrated); identifying an unlabeled medication vial as inappropriate for use was the most frequently missed item (8.1% of interns demonstrated). CONCLUSIONS: Behaviors related to tenets of patient safety and quality care can be assessed using a simple to design and execute OSCE. Using simulation to test behaviors associated with the National Patient Safety Goals may be a desirable adjunct to traditional simple knowledge-based tests.

Assessing physician leadership styles: application of the situational leadership model to transitions in patient acuity.

BACKGROUND: The situational leadership model suggests that an effective leader adapts leadership style depending on the followers' level of competency. PURPOSE: We assessed the applicability and reliability of the situational leadership model when observing residents in simulated hospital floor-based scenarios. METHODS: Resident teams engaged in clinical simulated scenarios. Video recordings were divided into clips based on Emergency Severity Index v4 acuity scores. Situational leadership styles were identified in clips by two physicians. Interrater reliability was determined through descriptive statistical data analysis. RESULTS: There were 114 participants recorded in 20 sessions, and 109 clips were reviewed and scored. There was a high level of interrater reliability (weighted kappa r = .81) supporting situational leadership model's applicability to medical teams. A suggestive correlation was found between frequency of changes in leadership style and the ability to effectively lead a medical team. CONCLUSIONS: The situational leadership model represents a unique tool to assess medical leadership performance in the context of acuity changes.

Technique for chest compressions in adult CPR.

Chest compressions have saved the lives of countless patients in cardiac arrest as they generate a small but critical amount of blood flow to the heart and brain. This is achieved by direct cardiac massage as well as a thoracic pump mechanism. In order to optimize blood flow excellent chest compression technique is critical. Thus, the quality of the delivered chest compressions is a pivotal determinant of successful resuscitation. If a patient is found unresponsive without a definite pulse or normal breathing then the responder should assume that this patient is in cardiac arrest, activate the emergency response system and immediately start chest compressions. Contra-indications to starting chest compressions include a valid Do Not Attempt Resuscitation Order. Optimal technique for adult chest compressions includes positioning the patient supine, and pushing hard and fast over the center of the chest with the outstretched arms perpendicular to the patient's chest. The rate should be at least 100 compressions per minute and any interruptions should be minimized to achieve a minimum of 60 actually delivered compressions per minute. Aggressive rotation of compressors prevents decline of chest compression quality due to fatigue. Chest compressions are terminated following return of spontaneous circulation. Unconscious patients with normal breathing are placed in the recovery position. If there is no return of spontaneous circulation, then the decision to terminate chest compressions is based on the clinical judgment that the patient's cardiac arrest is unresponsive to treatment. Finally, it is important that family and patients' loved ones who witness chest compressions be treated with consideration and sensitivity.