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.

Learner reflections on a postgraduate emergency medicine simulation curriculum: a qualitative exploration based on focus group interviews.

OBJECTIVES: To describe postgraduate emergency medicine (EM) residents' perceptions of simulation-based curriculum immediately post-simulation training. METHODS: This interpretive qualitative study explores residents' reflections on a city-wide, adult EM simulation-based curriculum. Focus group interviews gather residents' insights immediately post-simulation. Postgraduate trainees from the University of Toronto EM residency program were eligible to participate. We explored participants' perceptions of how well learning objectives were addressed, helpful/challenging aspects of the simulations, feelings during sessions, debriefing/pre-briefing, simulation integration into the broader EM curriculum, and anticipated changes in practice after the session. RESULTS: Our findings indicate that EM residents' learning goals for the simulation sessions evolve as they progress through residency training. Junior trainees report performance-oriented goals while senior trainees report learning-oriented goals. Differing motivations may affect residents' perceptions of the quality of the simulation experience. Junior residents want to feel prepared for the scenario and primed with the appropriate knowledge to manage the case. Senior residents focus on developing teamwork competencies and on mastering new clinical skills in the simulation environment. CONCLUSIONS: Junior and senior emergency medicine residents differ in their goal orientation during simulation-based training. Educators who develop simulation-based curricula should be mindful that junior residents may benefit from preparatory materials while senior residents prefer to be challenged. Resident reflections may significantly contribute to improvement of simulation-based curricula.

RéSUMé: OBJECTIF: Décrire la perception du programme de formation par simulation des résidents en médecine d'urgence (MU) immédiatement après un entraînement par simulation. MéTHODES: Cette étude qualitative interprétative explore les réflexions des résidents au sujet d'un programme axé sur la simulation en MU pour adultes à travers la ville. Les entretiens des groupes de discussion recueillent les aperçus des résidents immédiatement après la simulation. Les stagiaires de troisième cycle du programme de résidence en MU de l'Université de Toronto étaient admissibles à participer. Nous avons examiné les perceptions des participants sur la manière dont les objectifs d'apprentissage étaient abordés, les aspects utiles / exigeants des simulations, les sentiments pendant les sessions, le débriefing / pré-briefing, l'intégration de la simulation dans le programme plus large de la MU et les changements anticipés dans la pratique après la session. RéSULTATS: Nos résultats indiquent que les objectifs d'apprentissage des résidents en MU pour les séances de simulation évoluent au fur et à mesure qu'ils progressent dans la formation en résidence. Les stagiaires juniors rapportent des objectifs axés sur la performance tandis que les stagiaires avec plus d'ancienneté rapportent des objectifs axés sur l'apprentissage. Des motivations différentes peuvent affecter la perception qu'ont les résidents de la qualité de l'expérience de simulation. Les résidents assistants veulent se sentir préparés pour le scénario et équipés des connaissances appropriées pour gérer le cas. Les résidents avec plus d'ancienneté se concentrent sur le développement des compétences de travail d'équipe et sur la maîtrise de nouvelles compétences cliniques dans l'environnement de simulation. CONCLUSIONS: Les résidents assistants et ceux avec plus d'ancienneté en médecine d'urgence diffèrent dans leur orientation vers les objectifs au cours de la formation par simulation. Les éducateurs qui développent des programmes axés sur la simulation doivent être conscients que les résidents assistants peuvent bénéficier des matériels préparatoires tandis que les résidents avec plus d'ancienneté préfèrent être mis au défi. Les réflexions des résidents peuvent contribuer de manière significative à l'amélioration des programmes axés sur la simulation.

[Simulation curricular content in postgraduate emergency medicine: A multicentre Delphi study].

OBJECTIVES: There is increasing evidence to support integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum exists. Using Delphi methodology, we aimed to identify and establish content validity for adult EM curricular content best suited for simulation-based training, to inform national postgraduate EM training. METHODS: A national panel of experts in EM simulation iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed. Topics scoring <2/4 were removed and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥ 3.5/4 were considered "core" curricular topics, while those rated 3.0-3.5 were considered "extended" curricular topics. RESULTS: Forty-five experts from 13 Canadian centres participated. Two hundred eighty potential curricular topics, in 29 domains, were generated from a systematic literature review, relevant educational documents and Delphi panellists. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in eight domains, reached consensus as "core" curricular topics. Thirty-five additional topics, in 14 domains, reached consensus as "extended" curricular topics. CONCLUSIONS: Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.

OBJECTIF: De plus en plus d'études étayent l'intégration de la simulation dans la formation médicale; toutefois, il n'existe aucun programme national de simulation en médecine d'urgence (MU). Aussi l'étude menée selon la méthode Delphi visait-elle à dégager des sujets d'intérêt et à valider le contenu du programme convenant le mieux à l'apprentissage par simulation en MU de l'adulte, en vue de l'élaboration d'une formation postdoctorale, à l'échelle du pays. MÉTHODE: Un groupe national d'experts en simulation en MU a évalué par itération, sur une échelle de 4 points, des sujets d'intérêt en vue de déterminer ceux qui convenaient le mieux à une formation axée sur la simulation. Il y a eu analyse des réponses à chaque tour. Les sujets qui avaient recueilli une cote < 2/4 étaient retirés et les autres étaient soumis de nouveau au groupe pour évaluation, et ce, jusqu'à l'atteinte d'un consensus, défini comme une valeur alpha de Cronbach ≥ 0,95. À la fin du processus Delphi, les sujets ayant obtenu une cote ≥ 3,5/4 étaient considérés comme des matières majeures, et ceux ayant obtenu une cote 3,0-3,5, comme des matières mineures. RÉSULTATS: Ont participé à l'exercice 45 experts provenant de 13 centres canadiens de formation. Une revue systématique de la documentation, un examen du matériel didactique pertinent et l'avis des experts en méthode Delphi ont permis de dégager 280 sujets d'intérêt, dans 29 domaines. Il y a eu atteinte d'un consensus après trois tours d'évaluation, et les taux de réponse variaient de 93 à 100%. À la fin du processus, 28 sujets, dans 8 domaines, ont été classés majeurs, et 35 autres, dans 14 domaines, mineurs. CONCLUSION: L'étude menée selon la méthode Delphi a permis de valider, après l'atteinte d'un consensus par les experts, le contenu du programme convenant le mieux à une formation axée sur la simulation en MU. Les résultats pourront servir d'assises à une meilleure intégration de l'apprentissage par simulation dans la formation postdoctorale en MU et, par suite, à l'élaboration d'un programme national de simulation visant à enrichir la formation clinique et à maximiser l'apprentissage.

Does the age of acute care physicians impact their (1) crisis management performance and (2) learning after simulation-based education? A protocol for a multicentre prospective cohort study in Toronto and Ottawa, Canada.

INTRODUCTION: The proportion of older acute care physicians (ACPs) has been steadily increasing. Ageing is associated with physiological changes and prospective research investigating how such age-related physiological changes affect clinical performance, including crisis resource management (CRM) skills, is lacking. There is a gap in the literature on whether physician's age influences baseline CRM performance and also learning from simulation. We aim to investigate whether ageing is associated with baseline CRM skills of ACPs (emergency, critical care and anaesthesia) using simulated crisis scenarios and to assess whether ageing influences learning from simulation-based education. METHODS AND ANALYSIS: This is a prospective cohort multicentre study recruiting ACPs from the Universities of Toronto and Ottawa, Canada. Each participant will manage an advanced cardiovascular life support crisis-simulated scenario (pretest) and then be debriefed on their CRM skills. They will then manage another simulated crisis scenario (immediate post-test). Three months after, participants will return to manage a third simulated crisis scenario (retention post-test). The relationship between biological age and chronological age will be assessed by measuring the participants CRM skills and their ability to learn from high-fidelity simulation. ETHICS AND DISSEMINATION: This protocol was approved by Sunnybrook Health Sciences Centre Research Ethics Board (REB Number 140-2015) and the Ottawa Health Science Network Research Ethics Board (#20150173-01H). The results will be disseminated in a peer-reviewed journal and at scientific meetings. TRIAL REGISTRATION NUMBER: NCT02683447; Pre-results.

Preparedness of urban, general emergency department staff for neonatal resuscitation in a Canadian setting.

OBJECTIVES: The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort. METHODS: Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort. RESULTS: The response rate was 67.3% (n  =  107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR  =  22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR  =  3.1, 95% CI 1.4-7.0). CONCLUSIONS: Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.

Patients with atrial fibrillation and an alternative primary diagnosis in the emergency department: a description of their characteristics and outcomes.

OBJECTIVES: Atrial fibrillation is common in the emergency department (ED). Mortality rates at 30, 90, and 365 days for ED patients with a main diagnosis of atrial fibrillation are 4, 6, and 11%, respectively; there are no data on the characteristics and outcomes of ED patients with atrial fibrillation who have alternative primary ED diagnoses. METHODS: In this single-site, retrospective cohort study, all electrocardiograms (ECGs) with confirmed atrial fibrillation performed in the ED from April 2007 to March 2008 were identified. Repeat ED visits were excluded. ECGs associated with a primary ED diagnosis of atrial fibrillation were excluded, and from the remaining ECGs of patients with a different primary ED diagnosis, half were randomly selected for abstraction. The main outcome measure was all-cause mortality at 30, 90, and 365 days post-ED visit, derived from linkage to a provincewide mortality database. As a secondary analysis, logistic regression was used to compare 90-day mortality of these patients to those with primary ED diagnoses of atrial fibrillation seen during the same time period. RESULTS: Of 768 qualifying index ED visits, 416 charts were abstracted. Mean (± standard deviation [SD]) age was 80.3 (± 11.8) years, and 50.7% were female. Two-thirds had a previous history of atrial fibrillation/flutter, 300 (72.1%) had a CHADS2 score ≥ 2, one died in the ED, and 275 (66.1%) were admitted. The most common primary ED diagnoses were congestive heart failure (12%), pneumonia (6%), and chest pain not yet diagnosed (6%), while most common in-hospital diagnoses were congestive heart failure (15%), chronic obstructive pulmonary disease exacerbation (6%), atrial fibrillation (5%), and pneumonia (5%). Mortalities at 30, 90, and 365 days were 10.6% (95% confidence interval [CI] = 7.8% to 14.0%), 17.4% (95% CI = 13.9% to 21.5%), and 34.2% (95% CI = 29.6% to 39.0%), respectively. In the adjusted analysis, an alternative primary ED diagnosis was associated with an increased risk of death (odds ratio [OR] = 2.75; p = 0.01). CONCLUSIONS: Patients seen in the ED with atrial fibrillation and different primary ED diagnoses are older and have high short- and long-term mortality rates: mortality was three times higher than in patients with primary ED diagnoses of atrial fibrillation. Future studies of atrial fibrillation in the ED should distinguish between these two populations and the potential contribution of atrial fibrillation to mortality in the setting of other primary ED diagnoses.