A new tool for assessing short debriefings after immersive simulation: validity of the SHORT scale.

BACKGROUND: Simulation is being increasingly used worldwide in healthcare education. However, it is costly both in terms of finances and human resources. As a consequence, several institutions have designed programs offering several short immersive simulation sessions, each followed by short debriefings. Although debriefing is recommended, no tool exists to assess appropriateness of short debriefings after such simulation sessions. We have developed the Simulation in Healthcare retrOaction Rating Tool (SHORT) to assess short debriefings, and provide some validity evidence for its use. METHODS: We designed this scale based on our experience and previously published instruments, and tested it by assessing short debriefings of simulation sessions offered to emergency medicine residents at Laval University (Canada) from 2015 to 2016. Analysis of its reliability and validity was done using Standards for educational and psychological testing. Generalizability theory was used for testing internal structure evidence for validity. RESULTS: Two raters independently assessed 22 filmed short debriefings. Mean debriefing length was 10:35 (min 7:21; max 14:32). Calculated generalizability (reliability) coefficients are φ = 0.80 and φ-λ3 = 0.82. The generalizability coefficient for a single rater assessing three debriefings is φ = 0.84. CONCLUSIONS: The G study shows a high generalizability coefficient (φ ≥ 0.80), which demonstrates a high reliability. The response process evidence for validity provides evidence that no errors were associated with using the instrument. Further studies should be done to demonstrate validity of the English version of the instrument and to validate its use by novice raters trained in the use of the SHORT.

Portrait of trauma care in Quebec's rural emergency departments and identification of priority intervention needs to improve the quality of care: a study protocol.

INTRODUCTION: Trauma remains the primary cause of death in individuals under 40 years of age in Canada. In Quebec, the Trauma Care Continuum (TCC) has been demonstrated to be effective in decreasing the mortality rate among trauma victims. Although rural citizens are at greater risk for trauma and trauma death, no empirical data concerning the effectiveness of the TCC for the rural population in Quebec are available. The emergency departments (EDs) are important safety nets for rural citizens. However, our data indicate that access to diagnostic support services, such as intensive care units and CT is limited in rural areas. The objectives are to (1) draw a portrait of trauma services in rural EDs; (2) explore geographical variations in trauma care in Quebec; (3) identify adaptable factors that could reduce variation; and (4) establish consensus solutions for improving the quality of care. METHODS AND ANALYSIS: The study will take place from November 2015 to November 2018. A mixed methodology (qualitative and quantitative) will be used. We will include data (2009-2013) from all trauma victims treated in the 26 rural EDs and tertiary/secondary care centres in Quebec. To meet objectives 1 and 2, data will be gathered from the Ministry's Database of the Quebec Trauma Registry Information System. For objectives 3 and 4, the project will use the Delphi method to develop consensus solutions for improving the quality of trauma care in rural areas. Data will be analysed using a Poisson regression to compare mortality rate during hospital stay or death on ED arrival (objectives 1 and 2). Average scores and 95% CI will be calculated for the Delphi questionnaire (objectives 3 and 4). ETHICS AND DISSEMINATION: This protocol has been approved by CSSS Alphonse-Desjardins research ethics committee (Project MP-HDL-2016-003). The results will be published in peer-reviewed journals.

Investigation of myocardial contusion with sternal fracture in the emergency department: multicentre review.

OBJECTIVE: To describe the use of initial electrocardiogram (ECG), follow-up ECG or equivalent monitoring, and troponin I in patients presenting with sternal fracture who are assessed in emergency departments or by front-line physicians. DESIGN: Multicentre descriptive retrospective study. SETTING: Two traumatology teaching centres in Quebec city, Que. PARTICIPANTS: Fifty-four trauma patients presenting with sternal fracture. INTERVENTIONS: Assessment of the use of initial ECG, ECG or equivalent monitoring 6 hours after trauma, and troponin administration. MAIN OUTCOME MEASURES: In terms of ECG use, quality comparison criteria were selected on the basis of expert opinions in 4 studies. An initial ECG and a follow-up ECG 6 hours after trauma or cardiac monitoring 6 hours after trauma were recommended by most authors for diagnosing myocardial contusion in cases of sternal fracture. Serum troponin I administered 4 to 8 hours after chest trauma was also recommended by some as an effective means of detecting substantial arrhythmia secondary to myocardial contusion. Descriptive univariate analyses and tests were performed. A P < .05 was considered significant. RESULTS: Thirty-nine patients (72%) were assessed initially with ECGs; after 6 hours in the emergency department, 18 of these patients (33%) had follow-up ECGs or equivalent cardiac monitoring. Sixteen patients (30%) were assessed by means of troponin I dosage. Two patients (4%) presented with ECG abnormalities and only 1 patient (2%) presented with an elevated troponin I level. CONCLUSION: Emergency physicians must increase their use of ECG in initial or follow-up diagnosis for trauma patients presenting with sternal fracture to detect myocardial contusion and arrhythmia. The use of troponin in conjunction with ECG is also suggested for this population in order to identify patients at risk of complications secondary to myocardial contusion.

Adrenal inhibition following a single dose of etomidate in intubated traumatic brain injury victims.

BACKGROUND: Etomidate is frequently used to intubate traumatic brain injury (TBI) victims, even though it has been linked to adrenal insufficiency (AI) in some populations. Few studies have explored the risk of prolonged etomidate-induced AI among TBI victims. OBJECTIVE: To determine the risk and the length of AI induced by etomidate in patients intubated for moderate and severe TBI. METHODS: Participants in this observational study were moderate to severe intubated TBI victims aged ≥ 16 years. The anesthetic used (etomidate versus others) was determined solely by the treating emergency physician. Adrenocorticotropic hormone (ACTH) stimulation tests (250 µg) were performed 24, 48, and 168 hours after intubation. AI was defined as an increase in serum cortisol 1 hour post-ACTH test (delta cortisol) of less than 248.4 nmol/L. RESULTS: Forty subjects (participation 42.6%) underwent ACTH testing. Fifteen received etomidate, and 25 received another anesthetic. There were no statistically significant differences between groups as to the cumulative incidence of AI at any measurement time. However, at 24 hours, exploratory post hoc analyses showed a significant decrease in delta cortisol (adjusted means: etomidate group: 305.1 nmol/L, 95% CI 214.7-384.8 versus other anesthetics: 500.5 nmol/L, 95% CI 441.8-565.7). This decrease was not present at 48 and 168 hours. CONCLUSION: In TBI victims, although a single dose of etomidate does not increase the cumulative incidence of AI as defined, it seems to decrease the adrenal response to an ACTH test for 24 hours. The clinical impacts of this finding remain to be determined.

Glycogen depletion of human skeletal muscle fibers in response to high-frequency electrical stimulation.

The purpose of the present study was to evaluate the pattern of change in muscular glycogen content in response to high-frequency electrical stimulation (HFES). Muscle biopsies were taken from the vastus lateralis muscle of 7 healthy young men before, 15 min after, and 30 min after electrical stimulation delivered at a 50-Hz frequency (15 s on, 45 s off) at an intensity of 100 mA. The glycogen content of type I, IIA, and IIB muscle fibres was evaluated using microphotometry of periodic acid Schiff (PAS) stained fibres. After 15 min of electrical stimulation, the glycogen content in type I, IIA, and IIB muscle fibres significantly decreased from 113 +/- 10 (mean +/- SE) to 103 +/- 10 (p < or = 0.05), 129 +/- 9 to 102 +/- 12 (p < or = 0.01), and 118 +/- 8 to 90 +/- 13 (p < or = 0.01) arbitrary relative units, respectively. No further decrement in glycogen content was observed in all three fibre types following an additional 15 min of HFES. In addition, isometric force decreased by approximately 50%, from 125.9 +/- 20.0 N to 64.2 +/- 7.7 N (p < or = 0.01), during the first 15 contractions. No further decrease in isometric force was observed following an additional 15 contractions of HFES. These results reveal that significant reductions in isometric force of knee extensor muscles and glycogen content of all human skeletal muscle fibre types in vastus lateralis muscle are observable after 15 min of neuromuscular high-frequency transcutaneous electrical stimulation.