In situ medical simulation investigation of emergency department procedural sedation with randomized trial of experimental bedside clinical process guidance intervention.

INTRODUCTION: Patient safety during emergency department procedural sedation (EDPS) can be difficult to study. Investigators sought to delineate and experimentally assess EDPS performance and safety practices of senior-level emergency medicine residents through in situ simulation. METHODS: Study sessions used 2 pilot-tested EDPS scenarios with critical action checklists, institutional forms, embedded probes, and situational awareness questionnaires. An experimental informatics system was separately developed for bedside EDPS process guidance. Postgraduate year 3 and 4 subjects completed both scenarios in randomized order; only experimental subjects were provided with the experimental system during second scenarios. RESULTS: Twenty-four residents were recruited into a control group (n = 12; 6.2 ± 7.4 live EDPS experience) and experimental group (n = 12; 11.3 ± 8.2 live EDPS experience [P = 0.10]). Critical actions for EDPS medication selection, induction, and adverse event recognition with resuscitation were correctly performed by most subjects. Presedation evaluations, sedation rescue preparation, equipment checks, time-outs, and documentation were frequently missed. Time-outs and postsedation assessments increased during second scenarios in the experimental group. Emergency department procedural sedation safety probe detection did not change across scenarios in either group. Situational awareness scores were 51% ± 7% for control group and 58% ± 12% for experimental group. Subjects using the experimental system completed more time-outs and scored higher Simulation EDPS Safety Composite Scores, although without comprehensive improvements in EDPS practice or safety. CONCLUSIONS: Study simulations delineated EDPS and assessed safety behaviors in senior emergency medicine residents, who exhibited the requisite medical knowledge base and procedural skill set but lacked some nontechnical skills that pertain to emergency department microsystem functions and patient safety. The experimental system exhibited limited impact only on in-simulation time-out compliance.

Simulation intervention with manikin-based objective metrics improves CPR instructor chest compression performance skills without improvement in chest compression assessment skills.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) instructor/coordinator (CPR-I/C) adherence to published guidelines during resuscitation and learner assessment for basic life support (BLS)/CPR skills has not been experimentally studied. Investigators sought to (1) determine the quality of CPR-I/C chest compression and the accuracy of CPR-I/C chest compression assessment, and (2) improve CPR-I/C compression and assessment skills through cardiac arrest simulations with objective in-scenario performance feedback. METHODS: Thirty CPR-I/Cs (median, 20 years [range, 4-40 years] of BLS provider experience; 6 years [range 1-40 years] of BLS instructor experience) were randomized to control or experimental group. Each subject performed compressions during a 2-minute simulation, then reviewed 6 videos of simulated CPR performances (featuring prespecified chest compression parameters) for scoring as "pass" or "needs remediation." Subjects participated in a second simulation with or without real-time manikin compression feedback, then reviewed 6 additional videos. Primary outcome variables were the proportion of subjects with more than 80% (American Heart Association regional criteria) or more than 23 of 30 (ie, 77%; American Heart Association instructor manual criteria) correct compressions and subjects' accuracy of "pass"/"needs remediation" assessment for videos. The secondary outcome variable was correlation between subjects' correctness of chest compressions and their assessment accuracy for simulated CPR compression performance. RESULTS: All CPR-I/C subjects compressed suboptimally at baseline; real-time manikin feedback improved the proportion of subjects with more than 77% correct compressions to 0.53 (P < 0.01). Video review data revealed persistently low CPR-I/C assessment accuracy. Correlation between subjects' correctness of compressions and their assessment accuracy remained poor regardless of interventions. CONCLUSIONS: Real-time compression feedback during simulation improved CPR-I/C's chest compression performance skills without comparable improvement in chest compression assessment skills.

Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias.

BACKGROUND AND OBJECTIVES: Medical simulation and human factors engineering (HFE) may help investigate and improve clinical telemetry systems. Investigators sought to (1) determine the baseline performance characteristics of an Emergency Department (ED) telemetry system implementation at detecting simulated arrhythmias and (2) improve system performance through HFE-based intervention. METHODS: The prospective study was conducted in a regional referral ED over three 2-week periods from 2010 to 2012. Subjects were clinical providers working at the time of unannounced simulation sessions. Three-minute episodes of sinus bradycardia (SB) and of ventricular tachycardia (VT) were simulated. An experimental HFE-based multi-element intervention was developed to (1) improve system accessibility, (2) increase system relevance and utility for ED clinical practice and (3) establish organisational processes for system maintenance and user base cultivation. The primary outcome variable was overall simulated arrhythmia detection. Pre-intervention system characterisation, post-intervention end-user feedback and real-world correlates of system performance were secondary outcome measures. RESULTS: Baseline HFE assessment revealed limited accessibility, suboptimal usability, poor utility and general neglect of the telemetry system; one simulated VT episode (5%) was detected during 20 pre-intervention sessions. Systems testing during intervention implementation recorded detection of 4 out of 10 arrhythmia simulations (p=0.03). Twenty post-intervention sessions revealed more VT detections (8 of 10) than SB detections (3 of 10) for a 55% overall simulated arrhythmia detection rate (p=0.001). CONCLUSIONS: Experimental investigations helped reveal and mitigate weaknesses in an ED clinical telemetry system implementation. In situ simulation and HFE methodologies can facilitate the assessment and abatement of patient safety hazards in healthcare environments.

Development of simulated chest compression videos for objective evaluation of CPR instructors.

The goal of the development phase of the CPR Instructor Real-time Review through Use of Simulation (CIRRUS) research program was to create a video library portraying a spectrum of objectively verified simulation chest compression performances. Investigators scripted and recorded 12 two-person cardiopulmonary resuscitation (CPR) videos with specific chest compression parameters encompassing a range of hand positions, rates, depths, and chest releases in combinations that proportionately reflected typical learner cohort performances. Six videos were designated to portray adequate chest compressions, whereas the other six videos were to feature inadequate compressions. All 12 final 2-minute videos showed chest compression parameters as originally specified within tolerances to comply with American Heart Association recommendations. Deviations from specification were 1 to 10 cpm (mode = 4 cpm) for compression rate and -1.4 to 1.3 cm (mode = 0.9 cm) for depth. The program's collection of simulated CPR videos with objectively verified chest compression performances may help researchers and educators study and improve CPR instruction and provider preparation for the effective delivery of optimal patient care.

Pilot-phase findings from high-fidelity In Situ medical simulation investigation of emergency department procedural sedation.

INTRODUCTION: Emergency department procedural sedation (EDPS) is becoming widespread. Simulation may enhance patient safety through evidence-based training, effective assessment, and research of EDPS operators in pertinent knowledge, skills, processes, and teamwork. METHODS: Investigators developed a 2-scenario in situ simulation-based methodology and research tool kit for objective examination of EDPS practice. The emphasis was on protocol-driven presedation preparation, intrasedation vigilance and readiness for adverse events, and postsedation reassessment. Pilot sessions were conducted to test the methodology at an academic 719-bed hospital, with Institutional Review Board approval. RESULTS: Five interns and 5 attending emergency physicians completed pilot sessions resulting in protocol revisions to optimize simulation consistency, research tool sets, data acquisition, and operational conditions. Pilot data sets demonstrated interscenario consistency and intersubject reproducibility for timing, progression, and duration of critical EDPS events; high levels of perceived realism and relevance; and utility and suggested validity of the study methodology as an EDPS research mechanism. Small sample sizes limited the study methodology's ability to distinguish between the subject groups' clinical performances (critical action completion, probe detection, and situational awareness) except with composite scoring of presedation and postsedation assessments. Key EDPS preparation, adverse event management, and reassessment actions were selected to derive a Simulation EDPS Safety Composite Score that differentiated inexperienced [4.60 ± 0.8 on a 10-point score (n = 3)] and experienced EDPS operators [8.95 ± 1.03 (n = 5); P = 0.0007]. CONCLUSIONS: In situ simulation is a useful and relevant means to investigate EDPS patient safety. Pilot sessions have cleared the way for further experimental safety intervention research and development with the simulation-based methodology.

In situ simulation comparing in-hospital first responder sudden cardiac arrest resuscitation using semiautomated defibrillators and automated external defibrillators.

INTRODUCTION: Multifaceted approaches using simulation and human factors methods may optimize in-hospital sudden cardiac arrest (SCA) response. The Arrhythmia Simulation/Cardiac Event Nursing Training-Automated External Defibrillator phase (ASCENT-AED) study used in situ medical simulation to compare traditional and AED-supplemented SCA first-responder models. METHODS: The study was conducted at an academic 719-bed hospital with institutional review board approval. Two simulation scenarios were developed and featured either respiratory arrest with perfusing bradycardia or ventricular fibrillation (VF) arrest. Study floors were equipped with either a semiautomated defibrillator (SD) only (control) or with both SD and AED (experimental); subjects functioned as solitary first responders and did not receive resuscitation training. RESULTS: Fifty nurses were enrolled on control (n=25) and experimental (n=25) floors. The groups' nonblinded performances exhibited the following differences during VF scenario: slower calls for help by the control group [mean time to completion of 25+/-17 seconds versus 18+/-11 seconds for the experimental group (P<0.05)] and fewer subjects in the control group performing chest compressions [44.0% versus experimental group's 95.8% (P<0.001)]. Eighty-eight percent of the control group defibrillated the manikin at an average of 155+/-59 seconds, with 32.0% of those subjects using semiautomated rhythm analysis; 100% (not significant [NS]) of experimental group defibrillated at 154+/-72 seconds (NS) with 100% AED analysis (P<0.001). Fewer control group subjects (28.0%) were observed during the bradycardia scenarios to perform inappropriate chest compressions than the AED-supplemented subjects [69.6% (P=0.01)]; nonindicated defibrillation was delivered during these scenarios by a single subject in the control group. Twenty-eight percent and 72% of VF scenarios were managed appropriately by control and experimental groups, respectively; bradycardia scenarios were managed without severe adverse event by 64% of control group and 28% of experimental group. CONCLUSIONS: In situ simulation can provide useful information, both anticipated and unexpected, to guide decisions about proposed defibrillation technologies and SCA response models for in-hospital resuscitation system design and education before implementation.