An observer tool to enhance learning of incoming anesthesia residents' skills during simulation training of central venous catheter insertion: a randomized controlled trial.

BACKGROUND: Central venous catheter (CVC) insertion using simulation is an essential skill for anesthesiologists. Simulation training is an effective mean to master this skill. Given the large number of residents and the limited duration of training sessions, the active practice time is limited and residents remain observers of their colleagues for much of the session. To improve learning during observation periods, the use of an observer tool (OT) has been advocated but its educational effectiveness is not well defined. METHODS: Incoming anesthesia residents were randomized to use an OT (i.e. procedural skill-based checklist) (OT+) or not (OT-) when observing other residents during a simulation bootcamp. The primary outcome was a composite score (total 60 points) evaluating CVC procedural skills rated immediately after the training. This score covers theoretical knowledge explored by multiple choice questions (MCQs) (/20), perceived improvement in knowledge and skills (/20), perceived impact on future professional life (/10) and satisfaction (/10). Measurements were repeated 1 month later. Residents in each group recorded the number of CVCs placed and their clinical outcomes (attempts, complications) during the first month of their clinical rotation using a logbook. RESULTS: Immediately after training, the composite score was similar between the two groups: 45.3 ± 4.2 (OT+, n = 49) and 44.4 ± 4.8 (OT-, n = 42) (p = 0.323). Analysis of sub-items also showed no difference. Results at 1 month were not different between groups. Analysis of the logbook showed no difference between groups. No serious complications were reported. CONCLUSIONS: The use of a procedural task-based OT by incoming anesthesia residents and used during CVC insertion simulation training was not associated with better learning outcomes, neither immediately after the session nor when re-evaluated 1 month later. The training at least once on simulator of all residents could limit the impact of OT. Further studies are necessary to define the place of OT in simulation training.

Guidelines on human factors in critical situations 2023.

OBJECTIVE: To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. DESIGN: A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS: We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS: The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions. CONCLUSION: Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Deconstructing forearm casting task by videos with step-by-step simulation teaching improved performance of medical students: is making working student's memory work better similar to a process of artificial intelligence or just an improvement of the prefrontal cortex homunculus?

PURPOSE: To compare two teaching methods of a forearm cast in medical students through simulation, the traditional method (Trad) based on a continuous demonstration of the procedure and the task deconstruction method (Decon) with the procedure fragmenting into its constituent parts using videos. METHODS: During simulation training of the below elbow casting technique, 64 medical students were randomized in two groups. Trad group demonstrated the entire procedure without pausing. Decon group received step-wise teaching with educational videos emphasizing key components of the procedure. Direct and video evaluations were performed immediately after training (day 0) and at six months. Performance in casting was assessed using a 25-item checklist, a seven item global rating scale (GRS Performance), and a one item GRS (GRS Final Product). RESULTS: Fifty-two students (Trad n = 24; Decon n = 28) underwent both day zero and six month assessments. At day zero, the Decon group showed higher performance via video evaluation for OSATS (p = 0.035); GRS performance (p < 0.001); GRS final product (p < 0.001), and for GRS performance (p < 0.001) and GRS final product (p = 0.011) via direct evaluation. After six months, performance was decreased in both groups with ultimately no difference in performance between groups via both direct and video evaluation. Having done a rotation in orthopaedic surgery was the only independent factor associated to higher performance. CONCLUSIONS: The modified video-based version simulation led to a higher performance than the traditional method immediately after the course and could be the preferred method for teaching complex skills.

Strategy to Develop a Common Simulation Training Program: Illustration with Anesthesia and Intensive Care Residency in France.

Phenomenon: The urgency of having fair and trustworthy competency-based assessment in medical training is growing. Simulation is increasingly recognized as a potent method for building and assessing applied competencies. The growing use of simulation and its application in summative assessment calls for comprehensive and rigorously designed programs. Defining the current baseline of what is available and feasible is a crucial first step. This paper uses anesthesia and intensive care (AIC) in France as a case study in how to document this baseline. Approach: An IRB-approved, online anonymous closed survey was submitted to AIC residency program directors and AIC simulation program directors in France from January to February 2021. The researcher-developed survey consisted of 65 questions across five sections: centers' characteristics, curricular characteristics, courses' characteristics, instructors' characteristics, and simulation perceptions and perspectives. Findings: The participation rate was 31/31 (100%) with 29 centers affiliated with a university hospital. All centers had AIC simulation activities. Resident training was structured in 94% of centers. Simulation uses were training (100%), research and development (61%), procedural or organizational testing (42%), and summative assessment (13%). Interprofessional full-scale simulation training existed in 90% of centers. Procedural training on simulators prior to clinical patients' care was performed "always" in 16%, "most often" in 45%, "sometimes" in 29% and "rarely" or "not" in 10% of centers. Simulated patients were used in 61% of centers. Main themes were identified for procedural skills, full-scale and simulated patient simulation training. Simulation activity was perceived as increasing in 68% of centers. Centers expressed a desire to participate in developing and using a national common AIC simulation program. Insights: Based on our findings in AIC, we demonstrated a baseline description of nationwide simulation activities. We now have a clearer perspective on a decentralized approach in which individual institutions or regional consortia conduct simulation for a discipline in a relatively homogeneous way, suggesting the feasibility for national guidelines. This approach provides useful clues for AIC and other disciplines to develop a comprehensive and meaningful program matching existing expectations and closing the identified gaps.

Change in Sleep Quality of Residents the Night Before High-Fidelity Simulation: Results From a Prospective 1-Year National Survey.

OBJECTIVE: The stress level of participants in high-fidelity simulation stems from various factors but may result in anticipatory anxiety causing sleep disturbances during the night prior to simulation. The objective of this survey was to determine the change in sleep quality of residents during the night prior to the simulation. METHODS: The survey was proposed for 1 year to all residents at the beginning of the simulation, in 10 simulation centres. The questionnaire combined demographics and the Leeds Sleep Evaluation Questionnaire using visual analogue scales divided into 4 sleep qualitative domains. The primary outcome was the prevalence of sleep disturbance (>10 mm on 1 domain). Secondary outcomes were the prevalence of severe sleep disturbance (>25 mm), as well as qualitatively and quantitatively reported explanatory sleep parameters. RESULTS: Among respondents, 66% [95% CI: 63 to 69] of residents had more than 10 mm and 27% [95% CI: 24 to 30] had more than 25 mm of sleep disturbance. Residents with a sleep disturbance of more than 10 mm had fewer hours of sleep (6.4 [standard deviation=1.8] vs 7.3 [standard deviation=1.3], difference: -0.9 [95% CI: -1.1 to -0.7]; P < .0001), with a higher number of night-time awakenings (1.3 [standard deviation=1.5] vs 0.7 [standard deviation=0.9], difference: 0.6 [95% CI: 0.4 to 0.8]; P < .0001). CONCLUSION: Among residents participating in the simulation, a high prevalence of change in sleep quality during the night before the simulation was noted. Strategies to help residents achieve better sleep prior to simulation should be explored.

Management of urgent invasive procedures in patients treated with direct oral anticoagulants: An observational registry analysis.

BACKGROUND: Patients treated with direct oral anticoagulants (DOACs) may require urgent procedures. Managing these patients is challenging due to different bleeding risks and may include laboratory testing, procedural delays, or haemostatic/reversal agent administration. OBJECTIVE: We evaluated management strategies and outcomes of urgent, non-haemostatic invasive procedures in patients treated with DOACs. METHODS AND RESULTS: In a descriptive cohort study, we prospectively evaluated 478 patients in the GIHP-NACO registry, from June 2013 to November 2015. Hospitalised patients receiving dabigatran (n = 160), rivaroxaban (n = 274), or apixaban (n = 44) requiring urgent, procedural interventions were evaluated, of which 384/478 (80 %) were surgical procedures. Orthopaedic surgery included 216/384 patients (56 %), while gastrointestinal surgery included 75/384 (20 %) patients. On admission, the median age was 79 (70-85), and creatinine clearance was <60 mL·min-1 in 316/478 (66 %) patients. DOAC concentration was determined in 277 (58 %) patients and was 85 ng·mL-1 (median; range 0-764), 61 ng·mL-1 (3-541), and 81 ng·mL-1 (26-354) for dabigatran, rivaroxaban, and apixaban, respectively. Procedures were delayed in 194/455 (43 %) of the cases. Excessive bleeding was observed in 62/478 (13 %) procedures, and haemostatic agents were administered in 76/478 (16 %) procedures. By day 30, major cerebral and cardiovascular events were observed in 38/478 (7.9 %) patients, and mortality was 28/478 (5.9 %). CONCLUSIONS: In the GIHP-NACO registry, before specific antidotes were available, DOAC treated patients undergoing urgent invasive procedures were delayed in nearly half of the cases, and showed a low rate of excessive bleeding, suggesting that most urgent procedures can be performed safely without DOAC reversal. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov. Identifier: NCT02185027.

Comparison of multimodal active learning and single-modality procedural simulation for central venous catheter insertion for incoming residents in anesthesiology: a prospective and randomized study.

BACKGROUND: Active learning methods, including low-fidelity simulation, are useful but the incremental learning effect of each method is however limited. We designed this study to assess if combining flipped classroom and the modified Peyton's « 4-steps¼ method during procedural simulation (intervention group [IG]) would provide better learning results than simulation alone (control group [CG]) in the context of central venous catheter insertion training. METHODS: This prospective, single-center, and randomized study took place in 2017 in a single simulation center. All first year Anesthesiology residents of Ile de France area at the start of their residency were randomly included either in the IG or CG during a seminar aimed at providing initial procedural skills with low-fidelity simulation. A composite learning score which included knowledge MCQ and a questionnaire assessing satisfaction and value of the training session was recorded after training (primary outcome, /100). A randomized sub-group of learners of each group were video-recorded during central venous catheter insertion at the end of training and their skills were evaluated with validated tools, including a specific checklist and a global rating scale (GRS). RESULTS: Among 89 anesthesiology residents, 48 and 41 learners were randomized in the intervention and control groups respectively. Of the IG residents, 40/48 (83%) had read the learning material prior to the session. There was no significant difference regarding the composite outcome ([IG]= 81.1 vs [CG] = 80.5 /100 (p = 0.68)). Results of the post-session MCQ knowledge questionnaire were also non-significantly different. Residents were similarly satisfied and described a significant improvement of their knowledge and skills after training. Learners highly valued the training session as a mean to improve their future practice. No significant differences regarding checklist and GRS scores were observed. CONCLUSIONS: A multimodal active learning strategy of procedural learning did not provide better learning outcomes when compared to a traditional simulation method. In both groups, satisfaction was high and perception of the acquired theoretical and practical knowledge was improved after training.

Characteristics and outcomes of patients undergoing anesthesia while SARS-CoV-2 infected or suspected: a multicenter register of consecutive patients.

BACKGROUND: There are limited data to detail the perioperative anesthetic management and the incidence of postoperative respiratory complications among patients requiring an anesthetic procedure while being SARS-CoV-2 positive or suspected. METHODS: An observational multicenter cohort study was performed including consecutive patients who were SARS-CoV-2 confirmed or suspected and who underwent scheduled and emergency anesthesia between March 17 and May 26, 2020. RESULTS: A total of 187 patients underwent anesthesia with SARS-CoV-2 confirmed or suspected, with ultimately 135 (72.2%) patients positive and 52 (27.8%) negative. The median SOFA score was 2 [0; 5], and the median ARISCAT score was 49 [36; 67]. The major respiratory complications rate was 48.7% (n = 91) with 40.4% (n = 21) and 51.9% (n = 70) in the SARS-CoV-2-negative and -positive groups, respectively (p = 0.21). Among both positive and negative groups, patients with a high ARISCAT risk score (> 44) had a higher risk of presenting major respiratory complications (p < 0.01 and p = 0.1, respectively). DISCUSSION: When comparing SARS-COV-2-positive and -negative patients, no significant difference was found regarding the rate of postoperative complications, while baseline characteristics strongly impact these outcomes. This finding suggests that patients should be scheduled for anesthetic procedures based on their overall risk of postoperative complication, and not just based on their SARS-CoV-2 status.

Use of an Observer Tool to Enhance Observers' Learning of Anesthesia Residents During High-Fidelity Simulation: A Randomized Controlled Trial.

INTRODUCTION: The growing number of learners implies that all of them cannot play an active role during high-fidelity scenarios. Studies suggest a positive educational value when learners are observers only, but it remains uncertain whether learning outcomes might be improved by using an observer tool (OT). METHODS: Eighty-nine anesthesia residents were randomized to use an OT (n = 44, OT+; based on a cognitive aid) or not (n = 45, OT-) when not role-playing. The main outcome parameter was the learning outcomes assessed by comparing the change (before-after) in the response score to a questionnaire dedicated to medical knowledge obtained in the OT+ and OT- groups. The impact of using the OT was also assessed by measuring the perceived stress level and the change of the Anesthetists' Non-Technical Skill items values. RESULTS: At the end of the session, the mean medical knowledge score (mean ± SD) was higher in the OT+ group than in the OT- group (11.4 ± 2.7 vs. 9.6 ± 2.4, respectively, P = 0.0008). The mean Anesthetists' Non-Technical Skill score and level of stress perceived did not differ between groups. Trainees rated similarly the learning value and satisfaction related to the simulation course. CONCLUSIONS: This study suggests that observing high-fidelity simulation scenarios using an OT based on a cognitive aid increases the medical knowledge gain when compared with that seen in passive observers. This study suggests that the use of an OT improves the educational value of simulation.

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication.

BACKGROUND: A serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses' ability to detect patient clinical deterioration. METHODS: The SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick's framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis). RESULTS: The content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups' high rating of the game's realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study. CONCLUSION: While it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03092440.

External Cardiac Massage Training of Medical Students: A Randomized Comparison of Two Feedback Methods to Standard Training.

BACKGROUND: The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices. OBJECTIVES: The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students. METHODS: This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention. RESULTS: Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p < 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups. CONCLUSION: The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.

Use of Cognitive Aids: Results from a National Survey among Anaesthesia Providers in France and Canada.

INTRODUCTION: The use of cognitive aids (CAs) during critical events is thought to be useful. However, whether CAs are known and used by French and Canadian anaesthesia providers is not clear. METHODS: A survey was emailed to French and Canadian anaesthesia providers in 2017 through their respective national societies. It consisted of 23 questions about the participants' demographics and their knowledge, use, and impact of CAs. A second survey was sent to French simulation centres. RESULTS: 912 responses were recorded in France and 278 in Canada (overall response rate: 7% and 11%, respectively). Among the respondents, 700/899 in France (78%) versus 249/273 (91%) in Canada were familiar with the concept of cognitive dysfunction during a crisis and 501/893 (56%) in France versus 250/271 (92%) in Canada knew the concept of CAs. Amongst those respondents who knew about CAs, 189/492 (38%) in France versus 108/244 (44%) in Canada stated that they had already used a CA in real life and 225/493 (45%) in France versus 126/245 (51%) in Canada had received training in their use. Simulation was the principal modality for training in 150/225 (67%) of cases in France versus 47/126 (37%) in Canada. Among the 28/50 French simulation centres which responded (2018 January), 27 organised sessions in anaesthesia and 22 used CAs. CONCLUSION: CAs were better known in Canada than in France, but their actual use in real life was low in both countries. Simulation appears to play a potentially important role training anaesthesia providers in the use of CAs.

Comparative value of a simulation by gaming and a traditional teaching method to improve clinical reasoning skills necessary to detect patient deterioration: a randomized study in nursing students.

BACKGROUND: Early detection and response to patient deterioration influence patient prognosis. Nursing education is therefore essential. The objective of this randomized controlled trial was to compare the respective educational value of simulation by gaming (SG) and a traditional teaching (TT) method to improve clinical reasoning (CR) skills necessary to detect patient deterioration. METHODS: In a prospective multicenter study, and after consent, 2nd year nursing students were randomized into two groups: Simulation by gaming "SG": the student played individually with a serious game consisting of 2 cases followed by a common debriefing with an instructor;Traditional Teaching "TT": the student worked on the same cases in text paper format followed by a traditional teaching course with a PowerPoint presentation by an instructor. CR skill was measured by script concordance tests (80 SCTs, score 0-100) immediately after the session (primary outcome) and on month later. Other outcomes included students' satisfaction, motivation and professional impact. RESULTS: One hundred forty-six students were randomized. Immediately after training, the SCTs scores were 59 ± 9 in SG group (n = 73) and 58 ± 8 in TT group (n = 73) (p = 0.43). One month later, the SCTs scores were 59 ± 10 in SG group (n = 65) and 58 ± 8 in TT group (n = 54) (p = 0.77). Global satisfaction and motivation were highly valued in both groups although significantly greater in the SG group (p < 0.05). The students declared that the training course would have a positive professional impact, with no difference between groups. CONCLUSIONS: In this study assessing nursing student CR to detect patient deterioration, no significant educational difference (SCT), neither immediate nor 1 month later, was observed between training by SG and the TT course. However, satisfaction and motivation were found to be greater with the use of SG. TRIAL REGISTRATION: ClinicalTrials.gov; NCT03428269. Registered 30 january 2018.

Impact of learners' role (active participant-observer or observer only) on learning outcomes during high-fidelity simulation sessions in anaesthesia: A single center, prospective and randomised study.

AIM: The increasing use of high-fidelity simulation is limited by the imbalance between the growing number of students and the human resources available in such a way that all residents cannot play a role during scenarios. The learning outcomes of observers need to be studied. METHODS: This prospective randomised study was approved by the institutional review board. Anaesthesia residents attending a one-day training session were enrolled. In each of the four scenarios, three residents played an active role while others observed in a separate room. All participants attended debriefing sessions. Residents were randomised between active participant-observer group (AP-O group) and observer group (O group). A similar questionnaire was distributed before, immediately after the session and after three months and included self-reported assessment of satisfaction, medical knowledge (noted 0-16), and non-technical skills. RESULTS: A hundred and four questionnaires were analysed. Immediately after the simulation, a significant increase in medical knowledge was recorded but was higher in the AP-O group (6 [5-8] to 10 [8-11]/16) than in the O group (7 [5-8] to 9 [7-10]/16). High scores for non-technical skills were similarly observed in both groups. Satisfaction was high in both groups but was higher in the AP-O group (9 [8-9] versus 8 [8-9]/10, P=0.019). Decay of knowledge was observed for most main outcomes at three months. CONCLUSION: This study suggests an immediate improvement of learning outcomes for both roles after immersive simulation but some learning outcomes may be better for residents engaged as players in scenarios.