Measuring the impact of simulation debriefing on the practices of interprofessional trauma teams using natural language processing.

BACKGROUND: Natural language processing (NLP) may be a tool for automating trauma teamwork assessment in simulated scenarios. METHODS: Using the Trauma Nontechnical Skills Assessment (T-NOTECHS), raters assessed video recordings of trauma teams in simulated pre-debrief (Sim1) and post-debrief (Sim2) trauma resuscitations. We developed codes through directed content analysis and created algorithms capturing teamwork-related discourse through NLP. Using a within subjects pre-post design (n = 150), we compared changes in teams' Sim1 versus Sim2 T-NOTECHS scores and automatically coded discourse to identify which NLP algorithms could identify skills assessed by the T-NOTECHS. RESULTS: Automatically coded behaviors revealed significant post-debrief increases in teams' simulation discourse: Verbalizing Findings, Acknowledging Communication, Directed Communication, Directing Assessment and Role Assignment, and Leader as Hub for Information. CONCLUSIONS: Our results suggest NLP can capture changes in trauma team discourse. These findings have implications for the expedition of team assessment and innovations in real-time feedback when paired with speech-to-text technology.

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study.

INTRODUCTION: Emesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% - 0.11% in fasted patients undergoing general anesthesia and 0% - 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy and airway decontamination (SALAD) involves maneuvering a suction catheter into the hypopharynx, while performing laryngoscopy and endotracheal intubation. Intentional esophageal intubation (IEI) involves blindly intubating the esophagus to control emesis before endotracheal intubation. Both are previously described techniques for endotracheal intubation in the setting of massive emesis. This study compares the SALAD and IEI techniques with the traditional approach of ad hoc, rigid suction catheter airway decontamination and endotracheal intubation in the setting of massive simulated emesis. METHODS: Senior anesthesiology and emergency medicine (EM) residents were randomized into three trial arms: the traditional, IEI, or SALAD. Each resident watched an instructional video on the assigned technique, performed the technique on a manikin, and completed the trial simulation with the SALAD simulation manikin. The primary trial outcome was aspirate volume collected in the manikin's lower airway. Secondary outcomes included successful intubation, intubation attempts, and time to successful intubation. We also collected pre- and post-simulation demographics and confidence questionnaire data. RESULTS: Thirty-one residents (21 anesthesiology and 10 EM residents) were randomized. Baseline group characteristics were similar. The mean aspirate volumes collected in the lower airway (standard deviation [SD]) in the traditional, IEI, and SALAD arms were 72 (45) milliliters per liter (mL), 100 (45) mL, and 83 (42) mL, respectively (p = 0.392). Intubation success was 100% in all groups. Times (SD) to successful intubation in the traditional, IEI, and SALAD groups were 1.69 (1.31) minutes, 1.74 (1.09) minutes, and 1.74 (0.93) minutes, respectively (p = 0.805). Overall, residents reported increased confidence (1.0 [0.0-1.0]; P = 0.002) and skill (1.0 [0.0-1.0]; P < 0.001) in airway management after completion of the study. CONCLUSION: The intubation techniques provided similar performance results in our study, suggesting any one of the three can be employed in the setting of massive emesis; although this conclusion deserves further study. Residents reported increased confidence and skill in airway management following the experience, suggesting use of the manikin provides a learning impact.

Field Emission Measurements of Solid Fuel Stoves in Yunnan, China Demonstrate Dominant Causes of Uncertainty in Household Emission Inventories.

Emission factors of carbon monoxide (CO), particulate matter (PM2.5), organic carbon (OC), and elemental carbon (EC), as well as combustion efficiency and particle optical properties were measured during 37 uncontrolled cooking tests of residential stoves in Yunnan Province, China. Fuel mixtures included coal, woody biomass, and agricultural waste. Compared to previously published emission measurements of similar stoves, these measurements have higher CO and PM2.5 emission factors. Real-time data show two distinct burn phases: a devolatilization phase after fuel addition with high PM2.5 emissions and a solid-fuel combustion phase with low PM2.5 emissions. The average emission factors depend on the relative contributions of these phases, which are affected by the services provided by the stoves. Differences in stove and fuel characteristics that are not represented in emission inventories affect the variability of emission factors much more than do the type of solid fuel or stove. In developing inventories with highly variable sources such as residential solid-fuel combustion, we suggest that (1) all fuels should be accounted for, not just the primary fuel; (2) the household service provided should be emphasized rather than specific combinations of solid fuels and devices; and (3) the devolatilization phase should be explicitly measured and represented.

Using epistemic network analysis to identify targets for educational interventions in trauma team communication.

BACKGROUND: Epistemic Network Analysis (ENA) is a technique for modeling and comparing the structure of connections between elements in coded data. We hypothesized that connections among team discourse elements as modeled by ENA would predict the quality of team performance in trauma simulation. METHODS: The Modified Non-technical Skills Scale for Trauma (T-NOTECHS) was used to score a simulation-based trauma team resuscitation. Sixteen teams of 5 trainees participated. Dialogue was coded using Verbal Response Modes (VRM), a speech classification system. ENA was used to model the connections between VRM codes. ENA models of teams with lesser T-NOTECHS scores (n = 9, mean = 16.98, standard deviation [SD] = 1.45) were compared with models of teams with greater T-NOTECHS scores (n = 7, mean = 21.02, SD = 1.09). RESULTS: Teams had different patterns of connections among VRM speech form codes with regard to connections among questions and edifications (meanHIGH = 0.115, meanLOW = -0.089; t = 2.21; P = .046, Cohen d = 1.021). Greater-scoring groups had stronger connections between stating information and providing acknowledgments, confirmation, or advising. Lesser-scoring groups had a stronger connection between asking questions and stating information. Discourse data suggest that this pattern reflected increased uncertainty. Lesser-scoring groups also had stronger connections from edifications to disclosures (revealing thoughts, feelings, and intentions) and interpretations (explaining, judging, and evaluating the behavior of others). CONCLUSION: ENA is a novel and valid method to assess communication among trauma teams. Differences in communication among higher- and lower-performing teams appear to result from the ways teams use questions. ENA allowed us to identify targets for improvement related to the use of questions and stating information by team members.

Pardon the Interruption(s)-Enabling a Safer Emergency Department Sign Out.

INTRODUCTION: Patient "handoffs" or "sign outs" in medicine are widely recognized as highly vulnerable times for medical errors to occur. The Emergency Department (ED) has been identified as an environment where these transitions of care at shift changes are particularly high-risk due to a variety of factors, including frequent interruptions, which can further lead to errors in transfer of information. Our primary objective was to evaluate whether simple interventions could minimize interruptions during the sign out period in an attempt to improve patient safety. METHODS: Multiple low-cost interventions were implemented, including an overhead chime, clerical staff diversion of phone calls and electrocardiograms, and prominent positioning of a movable pedestal sign. Utilizing a before-and-after study design, we directly observed team sign outs at various shift changes throughout the day over 2-month periods before and after implementation. Our primary outcome measure was the number of interruptions that occurred during designated sign out times. We also assessed total time spent in sign out, and a survey was sent to clinicians to assess their perception of sign out safety. RESULTS: Total sign out interruptions were significantly decreased as a result of the above-noted interventions (average 6.1 vs 1.1; P < 0.01). Total time spent during sign out was reduced (14.1 vs 11.4 minutes; P < 0.04), and clinicians' perception of safety improved significantly, with Likert scores of 4 or 5 on a 5 point scale increasing from 47.4% before to 91.7% after implementation. CONCLUSION: Patient sign out at shift change is a vulnerable time for patient safety and transition of care with interruptions further compromising the safe transfer of information. Simple interventions significantly decreased interruptions and were associated with shorter sign out periods and improved provider perception of sign out safety.

Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System.

INTRODUCTION: We present a novel airway simulation tool that recreates the dynamic challenges associated with emergency airways. The Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) simulation system trains providers to use suction to manage emesis and bleeding complicating intubation. METHODS: We modified a standard difficult-airway mannequin head (Nasco, Ft. Atkinson, WI) with hardware-store equipment to enable simulation of vomiting or hemorrhage during intubation. A pre- and post-survey was used to assess the effectiveness of the SALAD simulator. We used a 1-5 Likert scale to assess confidence in managing the airway of a vomiting patient and comfort with suction techniques before and after the training exercise. RESULTS: Forty learners participated in the simulation, including emergency physicians, anesthesiologists, paramedics, respiratory therapists, and registered nurses. The average Likert score of confidence in managing the airway of a vomiting or hemorrhaging patient pre-session was 3.10±0.49, and post-session 4.13±0.22. The average score of self-perceived skill with suction techniques in the airway scenario pre-session was 3.30±0.43, and post-session 4.03±0.26. The average score for usefulness of the session was 4.68±0.15, and the score for realism of the simulator was 4.65±0.17. CONCLUSION: A training session with the SALAD simulator improved trainee's confidence in managing the airway of a vomiting or hemorrhaging patient. The SALAD simulation system recreates the dynamic challenges associated with emergency airways and holds promise as an airway training tool.

Posterior reversible encephalopathy syndrome in the emergency department: case series and literature review.

INTRODUCTION: Posterior Reversible Encephalopathy Syndrome (PRES) often has variable presentations and causes, with common radiographic features-namely posterior white matter changes on magnetic resonance (MRI). As MRI becomes a more frequently utilized imaging modality in the Emergency Department, PRES will become an entity that the Emergency Physician must be aware of and be able to diagnose. CASE REPORT: We report three cases of PRES, all of which presented to the emergency department of a single academic medical center over a short period of time, including a 53-year-old woman with only relative hypertension, a 69-year-old woman who ultimately died, and a 46-year-old woman who had a subsequent intraparenchymal hemorrhage. CONCLUSION: PRES is likely much more common than previously thought and is a diagnosis that should be considered in a wide variety of emergency department patient presentations.

Incidental Findings on CT Scans in the Emergency Department.

Objectives. Incidental findings on computed tomography (CT) scans are common. We sought to examine rates of findings and disclosure among discharged patients who received a CT scan in the ED. Methods. Retrospective chart review (Aug-Oct 2009) of 600 patients age 18 and older discharged home from an urban Level 1 trauma center. CT reports were used to identify incidental findings and discharge paperwork was used to determine whether the patient was informed of these findings. Results. There were 682 CT scans among 600 patients: 199 Abdomen & Pelvis, 405 Head, and 78 Thorax. A total of 348 incidental findings were documented in 228/682 (33.4%) of the scans, of which 34 (9.8%) were reported to patients in discharge paperwork. Patients with 1 incidental finding were less likely to receive disclosure than patients with 2 or more (P = .010). Patients age <60 were less likely to have incidental findings (P < .001). There was no significant disclosure or incidental finding difference by gender. Conclusions. While previous research suggests that CT incidental findings are often benign, reporting to patients is recommended but this is rarely happening.