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.

SP safety, autonomy and healthcare simulation practice in the COVID-19 era.

This letter expands upon the three tenets of the Healthcare Simulation Manifesto-comprehensive safety, collaborative advocacy, and ethical leadership. To do this, we will discuss two key terms: 'essential' and 'autonomy' in relation to safety for standardized/simulated patients (SPs). In this time of crisis, simulationists must move the boundary of skills training previously accepted as safe for human beings, and leverage technology to ensure the highest level of safety achievable for our SPs.

Manifesto for healthcare simulation practice.

A pandemic has sent the world into chaos. It has not only upended our lives; hundreds of thousands of lives have already been tragically lost. The global crisis has been disruptive, even a threat, to healthcare simulation, affecting all aspects of operations from education to employment. While simulationists around the world have responded to this crisis, it has also provided a stimulus for the continued evolution of simulation. We have crafted a manifesto for action, incorporating a more comprehensive understanding of healthcare simulation, beyond tool, technique or experience, to understanding it now as a professional practice. Healthcare simulation as a practice forms the foundation for the three tenets comprising the manifesto: safety, advocacy and leadership. Using these three tenets, we can powerfully shape the resilience of healthcare simulation practice for now and for the future. Our call to action for all simulationists is to adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.

An institution-wide approach to submission, review, and funding of simulation-based curricula.

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.

A pilot study to assess the construct and face validity of the Northwestern Objective Microanastomosis Assessment Tool.

OBJECT: Microsurgical skills remain an integral component of neurosurgical education. There is a need for an objective scale to assess microsurgical skills. The objective of this study was to assess the face and construct validity of a bench training microanastomosis module and an objective assessment scale, i.e., the Northwestern Objective Microanastomosis Assessment Tool (NOMAT). METHODS: Medical students, neurosurgical residents, and postdoctoral research fellows at Northwestern University were enrolled in the study. Trainees were divided into 3 groups based on microsurgical experience: 1) experienced, 2) exposed, and 3) novices. Each trainee completed two end-to-end microanastomoses using a 1-mm and a 3-mm synthetic vessel. Two cameras were installed to capture procedural footage. One neurosurgeon blindly graded the performance of trainees using both objective and subjective methods to assess construct validity. Two neurosurgeons reviewed the contents of the simulation module to assess face validity. RESULTS: Twenty-one trainees participated in the study, including 6 experienced, 6 exposed, and 9 novices. The mean NOMAT score for experienced trainees on the 1-mm module was 47.3/70 compared with 26.0/70 and 25.8/70 for exposed and novice trainees, respectively (p = 0.02). Using subjective grading, experienced trainees performed significantly better on the 1-mm module (64.2/100) compared with exposed or novice trainees (23.3/100 and 25.0/100, respectively; p = 0.02). No statistical difference between groups was noted for the 3-mm module with both NOMAT and subjective grading. Experienced trainees took less time to perform both tasks compared with the others. CONCLUSIONS: Face and construct validities of the microanastomosis module were established. The scale and the microanastomosis module could help assess the microsurgical skills of neurosurgical trainees and serve as a basis for the creation of a microsurgical curriculum.

Training induces cognitive bias: the case of a simulation-based emergency airway curriculum.

INTRODUCTION: Training-induced cognitive bias may affect performance. Using a simulation-based emergency airway curriculum, we tested the hypothesis that curriculum design would induce bias and affect decision making. METHODS: Twenty-three novice anesthesiology residents were randomized into 2 groups. The primary outcome measure was the initiation of supraglottic airway and cricothyroidotomy techniques in a simulated cannot-ventilate, cannot-intubate scenario during 3 evaluation sessions. Secondary outcomes were response times for device initiation. After a baseline evaluation and didactic lecture, residents received an initial practical training in either surgical cricothyroidotomy (CRIC group) or supraglottic airway (SGA group). After the midtest, the groups switched to receive the alternate training. RESULTS: From baseline to midtest, the SGA group increased initiation of supraglottic airway but not cricothyroidotomy. The CRIC group increased initiation of cricothyroidotomy but not supraglottic airway. After completion of training in both techniques, the SGA group increased initiation of both supraglottic airway and cricothyroidotomy. In contrast, the CRIC group increased initiation of cricothyroidotomy but failed to change practice in supraglottic airway. Final test response times showed that the CRIC group was slower to initiate supraglottic airway and faster to initiate cricothyroidotomy. DISCUSSION: Practical training in only 1 technique caused bias in both groups despite a preceding didactic lecture. The chief finding was an asymmetrical effect of training sequence even after training in both techniques. Initial training in cricothyroidotomy caused bias that did not correct despite subsequent supraglottic airway training. Educators must be alert to the risk of inducing cognitive bias when designing curricula.

Simulation and quality improvement in anesthesiology.

Simulation, a strategy for improving the quality and safety of patient care, is used for the training of technical and nontechnical skills and for training in teamwork and communication. This article reviews simulation-based research, with a focus on anesthesiology, at 3 different levels of outcome: (1) as measured in the simulation laboratory, (2) as measured in clinical performance, and (3) as measured in patient outcomes. It concludes with a discussion of some current uses of simulation, which include the identification of latent failures and the role of simulation in continuing professional practice assessment for anesthesiologists.

Acquisition of critical intraoperative event management skills in novice anesthesiology residents by using high-fidelity simulation-based training.

BACKGROUND: Early acquisition of critical competencies by novice anesthesiology residents is essential for patient safety, but traditional training methods may be insufficient. The purpose of this study was to determine the effectiveness of high-fidelity simulation training of novice residents in the initial management of critical intraoperative events. METHODS: Twenty-one novice residents participated in this 6-week study. Three hypoxemia and three hypotension scenarios were developed and corresponding checklists were validated. Residents were tested in all scenarios at baseline (0 weeks) and divided into two groups, using a randomized crossover study design. Group 1 received simulation-based training in hypoxemic events, whereas Group 2 was trained in hypotensive events. After intermediate (3 weeks) testing in all scenarios, the groups switched to receive training in the other critical event. Final testing occurred at 6 weeks. Raters blinded to subject identity, group assignment, and test date scored videotaped performances by using checklists. The primary outcome measure was composite scores for hypoxemia and hypotension scenarios, which were compared within and between groups. RESULTS: Baseline performance between groups was similar. At the intermediate evaluation, the mean hypoxemia score was higher in Group 1 compared with Group 2 (65.5% vs. 52.4%, 95% CI of difference 6.3-19.9, P < 0.003). Conversely, Group 2 had a higher mean hypotension score (67.4% vs. 45.5%, 95% CI of difference 14.6-29.2, P < 0.003). At Week 6, the scores between groups did not differ. CONCLUSIONS: Event-specific, simulation-based training resulted in superior performance in scenarios compared with traditional training and simulation-based training in an alternate event.

Surgical team training: the Northwestern Memorial Hospital experience.

OBJECTIVES: To develop and implement a team-training curriculum. We hypothesized that better interactions between personnel would lead to improved patient safety, increased efficiency, and better staff satisfaction. DESIGN: Prospective assessment of a team-training program. SETTING: University-affiliated hospital. PARTICIPANTS: Operating room physicians, nurses, technicians, and other personnel. INTERVENTIONS: Four-hour classroom curriculum, intraoperative coaching on team-related behaviors, and follow-up feedback sessions. MAIN OUTCOME MEASURES: Baseline metrics and observational data were collected for 3 months before implementing the team-training program and 6 months after a designated implementation date. A questionnaire regarding perceptions of teamwork was completed at the beginning of and 6 weeks following the team-training classroom session. RESULTS: Six months after implementation of team training, compliance with preoperative briefings was 66%. No changes in hospital metrics were observed. An improved perception of teamwork among the participants was demonstrated in pretraining and posttraining surveys. Perceptions of teamwork and the utility of a preoperative briefing differed among nurses, surgeons, and anesthesiologists. CONCLUSIONS: Our team-training program resulted in moderate compliance with behaviors taught in the curriculum. Even with only moderate compliance, we demonstrated improved perceptions of teamwork.

Two-photon confocal microscopy: a nondestructive method for studying wound healing.

Two-photon confocal microscopy is a new technology useful in nondestructive analysis of tissue. The pattern generated from laser-excited autofluorescence and second harmonic signals can be analyzed to construct a three-dimensional, microanatomical, structural image. The healing of full-thickness guinea pig skin wounds was studied over a period of 28 days using two-photon confocal microscopy. Three-dimensional data were rendered from two-dimensional images and compared with conventional, en face, histologic sections. Two-photon confocal microscopy images show resolution of muscle, fascia fibers, collagen fibers, inflammatory cells, blood vessels, and hair. Although these images do not currently have the resolution of standard histology, the ability to noninvasively acquire three-dimensional images of skin promises to be an important tool in wound-healing studies.

Regeneration of neomucosa using cell-seeded collagen-GAG matrices in athymic mice.

Tissue engineering of oral mucosa could allow improved reconstructive options for intraoral tissue defects. Porous collagen-glycosaminoglycan (CG) matrices coated with a silicone elastomer were seeded by centrifugation with cultured human oral mucosal epithelial cells (strain OKG4 gingival keratinocytes) at a density of 250,000 cells per square centimeter. Full-thickness dorsal wounds (1.5 x 1.5 cm) were created surgically on each athymic mouse and were treated with either a seeded matrix or an unseeded matrix, or they were left open as a control. The CG matrices reduced the degree of wound contraction at day 14 compared with open wounds. The epithelial thickness of seeded matrices at day 14 was significantly greater (p = 0.0001) than that of unseeded matrices. Seeded matrices had more rapid degradation at 14 days compared with unseeded matrices. Human oral mucosal cells seeded into CG matrices contribute to form a stratified and differentiated epithelial layer during revascularization, cellular infiltration, and degradation of the CG matrix.