Age and its impact on crisis management performance and learning after simulation-based education by acute care physicians: a multicentre prospective cohort study.

BACKGROUND: Physiological changes associated with ageing could negatively impact the crisis resource management skills of acute care physicians. This study was designed to determine whether physician age impacts crisis resource management skills, and crisis resource management skills learning and retention using full-body manikin simulation training in acute care physicians. METHODS: Acute care physicians at two Canadian universities participated in three 8-min simulated crisis (pulseless electrical activity) scenarios. An initial crisis scenario (pre-test) was followed by debriefing with a trained facilitator and a second crisis scenario (immediate post-test). Participants returned for a third crisis scenario 3-6 months later (retention post-test). RESULTS: For the 48 participants included in the final analysis, age negatively correlated with baseline Global Rating Scale (GRS; r=-0.30, P<0.05) and technical checklist scores (r=-0.44, P<0.01). However, only years in practice and prior simulation experience, but not age, were significant in a subsequent stepwise regression analysis. Learning from simulation-based education was shown with a mean difference in scores from pre-test to immediate post-test of 2.28 for GRS score (P<0.001) and 1.69 for technical checklist correct score (P<0.001); learning was retained for 3-6 months. Only prior simulation experience was significantly correlated with a decreased change in learning (r=-0.30, P<0.05). CONCLUSIONS: A reduced amount of prior simulation training and increased years in practice, but not age on its own, were significant predictors of low baseline crisis resource management performance. Simulation-based education leads to crisis resource management learning that is well retained for 3-6 months, regardless of age or years in practice.

Improving Ad Hoc Medical Team Performance with an Innovative "I START-END" Communication Tool.

Purpose: To study the effect of a communication tool entitled: "I START-END" (I-Identify; S-Story; T-Task; A-Accomplish/Adjust; R-Resources; T-Timely Updates; E-Exit; N-Next; D-Document and Debrief) in simulated urgent scenarios in non-operating room settings (referred to as "Ad Hoc") with anesthesia residents. The "I START-END" tool was created by incorporating Crisis Resource Management (CRM) principles into a practical and user-friendly format. Methods: This was a mixed methods pre/post observational study with 47 anesthesia resident volunteers participating from July 2014 to June 2016. Each resident served as their own control, and participated in three simulated Ad Hoc scenarios. The first simulation served as a baseline. The second simulation occurred 1-2 weeks after I START-END training. The third simulation occurred 3-6 months later. Simulation performance was videotaped and reviewed by trained experts using technical skill checklists and Anesthesia Non-Technical Skills (ANTS) score. Residents filled out questionnaires, pre-simulation, 1-2 weeks after I START-END training and 3-6 months later. Concurrently, resident performance at actual Code Blue events was scored by trained observers using the Mayo High Performance Teamwork Scale. Results: 80-90% of residents stated the tool provided an organized approach to Ad Hoc scenarios - specifically, information helpful to care of the patient was obtained more readily and better resource planning occurred as communication with the team improved. Residents stated they would continue to use the tool and apply it to other clinical settings. Resident video performance scores of technical skills showed significant improvement at the "late" session (3-6 months post exposure to the I START-END). ANTS scores were satisfactory and remained unchanged throughout. There was no difference between residents with and without I START-END training as measured by the Mayo High Performance Teamwork Scale, however, debriefing at Code Blues occurred twice as often when residents had I START-END training. Conclusion: Non-operating room settings are fraught with unfamiliarity that create many challenges. The I START-END tool operationalizes key CRM elements. The tool was well received by residents; it enabled them to speak up more readily, obtain vital information and continually update each other by anticipating, planning, and debriefing in an organized and collaborative way.

Using a situational awareness global assessment technique for interprofessional obstetrical team training with high fidelity simulation.

Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

Determination of the psychometric properties of a behavioural marking system for obstetrical team training using high-fidelity simulation.

BACKGROUND: To determine the effectiveness of high-fidelity simulation for team training, a valid and reliable tool is required. This study investigated the internal consistency, inter-rater reliability and test-retest reliability of two newly developed tools to assess obstetrical team performance. METHODS: After research ethics board approval, multidisciplinary obstetrical teams participated in three sessions separated by 5-9 months and managed four high-fidelity simulation scenarios. Two tools, an 18-item Assessment of Obstetric Team Performance (AOTP) and a six-item Global Assessment of Obstetric Team Performance (GAOTP) were used.(5) Eight reviewers rated the DVDs of all teams' performances. RESULTS: Two AOTP items were consistently incomplete and omitted from the analyses. Cronbach's α for the 16-item AOTP was 0.96, and 0.91 for the six-item GAOTP. The eight-rater α for the GAOTP was 0.81 (single-rater intra-class correlation coefficient, 0.34) indicating acceptable inter-rater reliability. The 'four-scenario' α for the 12 teams was 0.79 for session 1, 0.88 for session 2, and 0.86 for session 3, suggesting that performance is not being strongly affected by the context specificity of the cases. Pearson's correlation of team performance scores for the four scenarios were 0.59, 0.35, 0.40 and 0.33, and for the total score across scenarios it was 0.47, indicating moderate test-retest reliability. CONCLUSIONS: The results from this study indicate that the GAOTP would be a sufficient assessment tool for obstetrical team performance using simulation provided that it is used to assess teams with at least eight raters to ensure a sufficiently stable score. This could allow the quantitative evaluation of an educational intervention.

Human factors in action: getting "pumped" at a nursing usability laboratory.

We describe our experience with a Nursing Usability Laboratory, where human factors design principles were applied to common nursing procedures. Our first step was to develop a human factors usability checklist. We then used this checklist while observing 11 nurses completing two standardized tasks on a simulated patient: (1) programming an insulin infusion and (2) programming a heparin infusion. We found that a usability checklist can help to uncover systematic error-provoking conditions in nursing tasks, that immediate improvements can be made in nursing training and practice and that participant nurses found the process useful. This paper will be of interest to any hospital seeking to enhance safety by applying human factors design principles.

Applying theory to practice in undergraduate education using high fidelity simulation.

High-fidelity patient simulation allows students to apply their theoretical knowledge of pharmacology and physiology to practice. The purpose of this study was to determine if experiential education using high-fidelity simulation improves undergraduate performance scores on simulation-based and written examinations. After receiving research ethics board approval, students completed a consent form and then answered a ten question multiple-choice quiz to identify their knowledge regarding the management of cardiac arrhythmias. Four simulation scenarios were presented and students worked through each scenario as a team. Faculty facilitated the sessions and feedback was given using students' videotaped performances as a template for discussion. Performance evaluation scores using predetermined checklists and global rating scales were completed. Students then reviewed the American Heart Association guidelines for the management of unstable cardiac arrhythmias. The afternoon session involved repetition of the four case scenarios with the same teams involved but different team leaders. Students then repeated the quiz they received in the morning. Descriptive statistics, paired t-test and repeated measures analysis of variance (ANOVA) were used to analyse results. Two hundred and ninety-nine students completed the study. There was a statistically significant improvement in performance on the pharmacology written test. Simulation team performance also statistically improved and a good correlation between checklist and global rating scores were demonstrated in all but one scenario. Student evaluation of the experience was extremely positive. High-fidelity simulation can be used to allow students to apply theoretical knowledge to practice in a safe and realistic environment. Results of this study indicate that simulation is a valuable learning experience and bridges the gap between theory and practice. Simulation technology has the potential to provide an enriching venue to examine the role of communication and dynamics of novice learners in team environments.

Identification of gaps in the achievement of undergraduate anesthesia educational objectives using high-fidelity patient simulation.

UNLABELLED: In this study we sought to identify educational gaps in medical students' knowledge using human patient simulation. The Undergraduate Committee developed 10 scenarios based on anesthesia curriculum objectives. Checklists were designed by asking 15 faculty members involved in undergraduate education to propose expected performance items at a level appropriate for medical students. These items consisted of essential performance items as well as critical management omissions. Checklists were used to score students' videotaped performances. Checklist items common to more than one scenario were grouped for data analysis and identification of gaps in achievement of educational objectives. Eighteen groupings of expected performance criteria and 8 groupings of critical management omissions were established. Performance data of 165 students were analyzed. Common management omissions were lack of adequate airway management, failure to check blood pressure, and failure to stop the anesthetic. Students reliably performed defibrillation, notation of vital signs, auscultation of lung fields, and administration of IV fluids. The most common critical omissions were failing to a). call for help, b). take a history/do physical examination, and c). prepare airway equipment. Management and critical omissions noted during performance assessments provide information regarding students' educational needs, enabling faculty to focus attention on demonstrated areas of weakness. IMPLICATIONS: This study involved the use of high-fidelity patient simulation that offers standardized clinical experiences that can detect gaps in medical students' knowledge base and clinical performance. This information can be used by faculty to focus their teaching efforts to ensure competency in important educational areas.