Early intranasal medication administration in out-of-hospital cardiac arrest: Two randomized simulation trials.

Objective: Intranasal medications have been proposed as adjuncts to out-of-hospital cardiac arrest (OHCA) care. We sought to quantify the effects of intranasal medication administration (INMA) in OHCA workflows. Methods: We conducted separate randomized OHCA simulation trials with lay rescuers (LRs) and first responders (FRs). Participants were randomized to groups performing hands-only cardiopulmonary resuscitation (CPR)/automated external defibrillator with or without INMA during the second analysis phase. Time to compression following the second shock (CPR2) was the primary outcome and compression quality (chest compression rate (CCR) and fraction (CCF)) was the secondary outcome. We fit linear regression models adjusted for CPR training in the LR group and service years in the FR group. Results: Among LRs, INMA was associated with a significant increase in CPR2 (mean diff. 44.1 s, 95% CI: 14.9, 73.3), which persisted after adjustment (p = 0.005). We observed a significant decrease in CCR (INMA 95.1 compressions per min (cpm) vs control 104.2 cpm, mean diff. -9.1 cpm, 95% CI -16.6, -1.6) and CCF (INMA 62.4% vs control 69.8%, mean diff. -7.5%, 95% CI -12.0, -2.9). Among FRs, we found no significant CPR2 delays (mean diff. -2.1 s, 95% CI -15.9, 11.7), which persisted after adjustment (p = 0.704), or difference in quality (CCR INMA 115.5 cpm vs control 120.8 cpm, mean diff. -5.3 cpm, 95% CI -12.6, 2.0; CCF INMA 79.6% vs control 81.2% mean diff. -1.6%, 95% CI -7.4, 4.3%). Conclusions: INMA in LR resuscitation was associated with diminished resuscitation performance. INMA by FR did not impede key times or quality.

Using Artificial Intelligence to Gauge Competency on a Novel Laparoscopic Training System.

OBJECTIVE: Laparoscopic surgical skill assessment and machine learning are often inaccessible to low-and-middle-income countries (LMIC). Our team developed a low-cost laparoscopic training system to teach and assess psychomotor skills required in laparoscopic salpingostomy in LMICs. We performed video review using AI to assess global surgical techniques. The objective of this study was to assess the validity of artificial intelligence (AI) generated scoring measures of laparoscopic simulation videos by comparing the accuracy of AI results to human-generated scores. DESIGN: Seventy-four surgical simulation videos were collected and graded by human participants using a modified OSATS (Objective Structured Assessment of Technical Skills). The videos were then analyzed via AI using 3 different time and distance-based calculations of the laparoscopic instruments including path length, dimensionless jerk, and standard deviation of tool position. Predicted scores were generated using 5-fold cross validation and K-Nearest-Neighbors to train classifiers. SETTING: Surgical novices and experts from a variety of hospitals in Ethiopia, Cameroon, Kenya, and the United States contributed 74 laparoscopic salpingostomy simulation videos. RESULTS: Complete accuracy of AI compared to human assessment ranged from 65-77%. There were no statistical differences in rank mean scores for 3 domains, Flow of Operation, Respect for Tissue, and Economy of Motion, while there were significant differences in ratings for Instrument Handling, Overall Performance, and the total summed score of all 5 domains (Summed). Estimated effect sizes were all less than 0.11, indicating very small practical effect. Estimated intraclass correlation coefficient (ICC) of Summed was 0.72 indicating moderate correlation between AI and Human scores. CONCLUSIONS: Video review using AI technology of global characteristics was similar to that of human review in our laparoscopic training system. Machine learning may help fill an educational gap in LMICs where direct apprenticeship may not be feasible.

Evidence supporting performance measures of laparoscopic appendectomy through a novel surgical proficiency assessment tool and low-cost laparoscopic training system.

BACKGROUND: Laparoscopic training remains inaccessible for surgeons in low- and middle-income countries, limiting its widespread adoption. We developed a novel tool for assessment of laparoscopic appendectomy skills through ALL-SAFE, a low-cost laparoscopy training system. METHODS: This pilot study in Ethiopia, Cameroon, and the USA assessed appendectomy skills using the ALL-SAFE training system. Performance measures were captured using the ALL-SAFE verification of proficiency tool (APPY-VOP), consisting of a checklist, modified Objective Structured Assessment of Technical Skills (m-OSATS), and final rating. Twenty participants, including novice (n = 11), intermediate (n = 8), and expert (n = 1), completed an online module covering appendicitis management and psychomotor skills in laparoscopic appendectomy. After viewing an expert skills demonstration video, participants recorded their performance within ALL-SAFE. Using the APPY-VOP, participants rated their own and three peer videos. We used the Kruskal-Wallis test and a Many-Facet Rasch Model to evaluate (i) capacity of APPY-VOP to differentiate performance levels, (ii) correlation among three APPY-VOP components, and (iii) rating differences across groups. RESULTS: Checklist scores increased from novice (M = 21.02) to intermediate (M = 23.64) and expert (M = 28.25), with differentiation between experts and novices, P = 0.005. All five m-OSATS domains and global summed, total summed, and final rating discriminated across all performance levels (P < 0.001). APPY-VOP final ratings adequately discriminated Competent (M = 2.0), Borderline (N = 1.8), and Not Competent (M = 1.4) performances, Χ2 (2,85) = 32.3, P = 0.001. There was a positive correlation between ALL-SAFE checklist and m-OSATS summed scores, r(83) = 0.63, P < 0.001. Comparison of ratings suggested no differences across expertise levels (P = 0.69) or location (P = 0.66). CONCLUSION: APPY-VOP effectively discriminated between novice and expert performance in laparoscopic appendectomy skills in a simulated setting. Scoring alignment across raters suggests consistent evaluation, independent of expertise. These results support the use of APPY-VOP among all skill levels inside a peer rating system. Future studies will focus on correlating proficiency to clinical practice and scaling ALL-SAFE to other settings.

Effectiveness of Lay Bystander Hands-Only Cardiopulmonary Resuscitation on a Mattress versus the Floor: A Randomized Cross-Over Trial.

STUDY OBJECTIVE: Bystander cardiopulmonary resuscitation increases the likelihood of out-of-hospital cardiac arrest survival by more than two-fold. A common barrier to the prompt initiation of compressions is moving victims to the floor, but compression quality on a "floor" versus a "mattress" has not been tested among lay bystanders. METHODS: We conducted a prospective, randomized, cross-over trial comparing lay bystander compression quality using a manikin on a bed versus the floor. Participants included adults without professional health care training. We randomized participants to the order of manikin placement, either on a mattress or on the floor. For both, participants were instructed to perform 2 minutes of chest compressions on a cardiopulmonary resuscitation Simon manikin Gaumard (Gaumard Scientific, Miami, FL). The primary outcome was mean compression depth (cm) over 2 minutes. We fit a linear regression model adjusted for scenario order, age, sex, and body mass index with robust standard errors to account for repeated measures and reported mean differences with 95% confidence intervals (CIs). RESULTS: Our sample of 80 adults was 66% female with a mean age of 50.5 years (SD 18.2). The mean compression depth on the mattress was 2.9 cm (SD 2.3) and 3.5 cm (SD 2.2) on the floor, a mean difference of 0.58 cm (95% CI 0.18, 0.98). Compression depth fell below the 5 to 6 cm depth recommended by the American Heart Association on both surfaces. In the adjusted model, the mean depth was greater when the manikin was on the floor than the mattress (adjusted mean difference 0.62 cm; 95% CI 0.23 to 1.01), and mean depth was less for females than males (adjusted mean difference -1.42 cm, 95% CI -2.59, -0.25). In addition, the difference in compression depth was larger for female participants (mean difference 0.94 cm; 95% CI 0.54, 1.34) than for male participants (mean difference -0.01 cm; 95% CI -0.80, 0.78), and the interaction was statistically significant (P = .04). CONCLUSION: The mean compression depth was significantly smaller on the mattress and with female bystanders. Further research is needed to understand the benefit of moving out-of-hospital cardiac arrest victims to the floor relative to the detrimental effect of delaying chest compressions.

Impact of the COVID-19 pandemic on American College of Surgeons-Accredited Education Institutes & American Society of Anesthesiologists-Simulation Education Network: Opportunities for interdisciplinary collaboration.

BACKGROUND: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation. METHODS: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported. RESULTS: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work." CONCLUSION: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation.

To Pack a Nose: High-Fidelity Epistaxis Simulation Using 3D Printing Technology.

BACKGROUND: Initial management and stabilization of epistaxis is managed by a diverse offset of clinical providers with variable levels of training. OBJECTIVE: To determine the anatomic and clinical fidelity and ease of use of a novel simulator for the training and assessment of epistaxis management skills. STUDY DESIGN: Qualitative Research Study using expert questionnaire's for validation of a newly developed simulator. METHODS: We performed a quasi-experimental intervention with 22 otolaryngology faculty and 10 trainees who independently evaluated the simulator. Data were collected in three phases: phase 1 (preliminary evaluation), phase 2 (final expert evaluation), and phase 3 (trainee evaluation). We designed a three-dimensional (3D) printed model from a de-identified patient computed tomography scan. Artificial blood was circulated through catheters to simulate bleeding from three distinct sites (sphenopalatine, Kiesselbach's plexus, and anterior ethmoid). Four domains were assessed: "Physical and anatomic attributes," "Realism of experience," "Ability to perform tasks," and "Value and clinical relevance." Internal structure and validity were measured with Cronbach's alpha and item outfit mean-square statistics. RESULTS: Results from otolaryngology faculty showed very high median ratings for "Value of the simulator as a training tool" (4.0/4) and high ratings for "Relevance to practice" (4.0/4), and realism of experience (4.0/4). Responses from otolaryngology trainees demonstrated high value for clinical training (4.0/4) and high likelihood to recommend use for future trainees (4.0/4). Confidence in managing epistaxis before (1.0/4) and after (3.0/4) simulator use was statistically improved (P = .03). CONCLUSIONS: Using 3D printing technology, we created a novel simulator for epistaxis management. Preliminary evidence suggests the model is cost-effective, anatomically realistic, relevant to trainees' educational needs, and valuable as a training tool. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:747-753, 2022.

The Fundamentals of Vaginal Surgery pilot study: developing, validating, and setting proficiency scores for a vaginal surgical skills simulation system.

BACKGROUND: Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery. OBJECTIVE: Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance. STUDY DESIGN: In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance. RESULTS: A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P>.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P<.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it. CONCLUSION: We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.

Meeting the New Joint Commission's Maternal Safety Requirements: A Quantitative Blood Loss Train-the-Trainer Program for Improved Process and Outcomes.

INTRODUCTION: Recently, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice encouraged the use of quantitative and cumulative assessment of maternal blood loss (QBL) as part of safety bundles for prevention of postpartum hemorrhage. The aim of this study was to determine whether our train-the-trainer QBL program improved process and patient outcomes. METHODS: In this pre-post interventional study, 26 "champions" participated in the QBL train-the-trainer program in preparation for patient safety bundle rollout. The multipart program included at least 3 simulated C-section hemorrhage scenarios and rapid-cycle debriefing. Champions used the curriculum for broad staff training for 2 months before safety bundle implementation.Six months each of preintervention and postintervention data were collected from medical records of all qualified cases (N = 4413). Process outcomes were evaluated by comparing number of women who received QBL. Patient outcomes were evaluated by comparing blood transfusion rates and number of morbid cases (≥4 packed red blood cell units). χ2 test was used for analyses. RESULTS: Review of medical records indicated that 99.8% of 2218 women received QBL posttraining compared with 16.6% of 2195 women receiving QBL before training (P = 0.0001.) Transfusion rates increased from 54.47 to 69.25 units/1000 mothers. The rate of morbid cases (≥4 red blood cell units) dropped from 2.13 to 0.48 cases/1000 mothers. CONCLUSIONS: Our findings suggest the train-the-trainer QBL program was associated with improved process and decreased morbidity when implemented with a hemorrhage safety bundle. Further research is required to examine components of simulation-based QBL training methods and implementation to evaluate their impact on clinical outcomes.

Learning and Collaboration during Crisis: A Novel University-Community Partnership to Manufacture Medical Personal Protective Equipment.

Research on crisis management focuses on pre-planning for disasters in order to understand potential barriers. However, one significant barrier to crisis response is that organizations may come together in unplanned configurations during crisis response. This means that significant opportunities exist for understanding the process by which individuals learn, collaborate, and create new systems during crises. In this case report, we present the case of face shield production by a university, academic medical center, and community partners during the supply chain collapse of the early COVID-19 pandemic with the aim of identifying the relationships that formed during the COVID-19 response, so that this case of relationship formation and participant experiences might inform similar disaster response challenges in the future. Thirteen participants responded to an in-depth questionnaire designed to simulate an asynchronous in-depth interview. Respondents reported on the activities of 80 individuals from 38 units/organizations, providing insight into communication challenges and resolutions. Responses were analyzed using thematic analysis, highlighting roles and relationships among participants. The findings grant insight into the experience of learning from crisis response efforts, responding to recent calls for social scientific work on COVID-19 responses.

Development of a novel mandibular distraction osteogenesis simulator using Computer Aided Design and 3D printing.

INTRODUCTION: Micrognathia, a component of Robin Sequence, can cause glossoptosis, failure of palatal fusion, and critical obstruction of the airway. Mandibular distraction osteogenesis (MDO) is at times offered to anteriorly translate the mandible and tongue, relieving airway obstruction. MDO is an intricate reconstructive procedure that may be ideal for teaching using a high-fidelity educational simulator, allowing early hands-on experience in a zero-risk environment. OBJECTIVES: To design a novel, low-cost, high-fidelity neonatal MDO simulator that can be used for trainee education and refinement of surgical technique. METHODS: A novel MDO simulator was developed using additive manufacturing techniques. Three experts in MDO surgery completed a 20-item survey, rating the simulator's physical attributes, the realism of experience, the simulator's value, its relevance to practice and the surgeon's ability to perform tasks on a 4-point Likert scale. RESULTS: Computer Aided Design (CAD) and 3D printing allowed for the production of a realistic surgical simulator that emulates important aspects of MDO surgery. This preliminary evaluation indicated adequate means across the five domains relevant to the simulator's fidelity and usability (M = 3.33 to 3.75) out of a maximum of 4 points. Lowest rated items were consistent with expert comments allowing future refinement on subsequent iterations. Consumable material costs per model were $9.39 USD. CONCLUSIONS: The MDO model demonstrated adequate fidelity and holds promise as a skill-development tool for surgeons in training. Further studies are planned to determine its utility as a training and assessment tool.

A Cognitive Aid for Neonatal Epinephrine Dosing.

OBJECTIVES: Errors are common when preparing epinephrine for neonatal resuscitation. Epinephrine is available in two concentrations (1 mg/mL and 1 mg/10 mL) and requires weight-based calculations, which increases the risk of dosing errors. We developed a printed cognitive aid to assist with dose preparation. We hypothesized that the cognitive aid would result in a 25% difference in errors in preparing the dose of epinephrine during simulated neonatal resuscitation. METHODS: Nurses (N = 100) in a large academic and community hospital were randomly assigned to calculate the intended dose and prepare epinephrine for neonatal resuscitation with or without the cognitive aid. Scenarios were video recorded and timed. Secondary outcomes included errors in the written intended dose, errors in choosing the correct epinephrine concentration, and time required to prepare the final dose. Proportions were compared by using Fisher's exact test. Variables influencing dosing errors were investigated by using logistic regression. RESULTS: Using the cognitive aid significantly decreased the proportion of doses prepared incorrectly (24% vs 50%; P = .01). The aid also decreased errors in choosing the correct epinephrine concentration (12% vs 44%; P < .001), but there was no difference in the written intended dose or the time to prepare the dose. Years of experience, self-perceived math comfort, and anxiety were not predictive of dosing errors. CONCLUSIONS: A simple cognitive aid decreased epinephrine dosing errors during simulated neonatal resuscitation but did not improve efficiency. Despite the effectiveness of the cognitive aid, errors were not completely eliminated. This is a serious safety risk for newborns and requires additional interventions.

Overarching themes from ACS-AEI accreditation survey best practices 2011-2019.

The American College of Surgeons launched the Accredited Education Institutes (ACS-AEIs) in 2005 to create a network of simulation centers to offer the highest-quality surgical education and training and to pursue cutting-edge scholarship. Specific standards and criteria were developed to accredit simulation centers, and decisions made based on the application, site surveyor visit, and ACS-AEI Accreditation Committee review. In addition to granting accreditation and providing recommendations for improvement, site surveyors and the Accreditation Committee identified best practices defined as areas far exceeding the accreditation standards or novel methods of advancing high-quality, impactful education. Best practices were compiled into a list starting in 2011 for dissemination to all members of the ACS-AEI Consortium through on-line videos, newsletters, and workshops at the Annual ACS Surgical Simulation Summit. Using thematic analysis, the authors classified common themes from the 337 best practices identified during 247 accreditation reviews between June 2011 and June 2019. As best practices were extracted, the authors compiled them into a single database. Eight overarching themes were identified, including approaches to faculty development, scholarly activity, development of curricula, use of resources, delivery of educational content, assessment of learners, and collaboration between centers. The authors discuss themes in the context of their practical relevance and highlight strategies used at different centers, with an emphasis on the importance of each theme in developing a successful simulation program.

A novel cervical esophagogastric anastomosis simulator.

OBJECTIVES: At least partially technically related, a cervical esophagogastric anastomosis has a 12% to 14% leak rate, which is theoretically reducible with simulator practice. Preliminary development and testing of a cervical esophagogastric anastomosis simulator are described. METHODS: A portable, low-cost, scale reproduction of the cervical esophagogastric anastomosis operative site was engineered around a 19 × 11 × 6-cm plastic box. Silicone "esophageal" and "gastric tip" castings permitted construction of a stapled side-to-side cervical esophagogastric anastomosis guided by an illustrated curriculum. In a 2-phase pilot study, the simulator and curriculum were evaluated. Phase 1: Seven faculty evaluated fidelity using a 5-point, 24-item survey of (1) physical attributes, (2) realism of materials, (3) realism of experience, (4) value, and (5) relevance, and (6) ability to perform tasks. Overall impression of the simulator was also measured. Phase 2: Eight thoracic surgical trainees similarly evaluated the simulator and the quality of the curriculum. Faculty and trainee ratings were compared using a Rasch model, and inter-rater agreement was estimated. RESULTS: There were no overall fidelity differences across faculty and resident ratings. Combined observed averages ranged from 4.52 (Realism of Materials) to 5.00 (Relevance). Lifelike feel of esophagus had the lowest ratings (observed average = 4.40). Residents rated interrupted outer layer of anterior closure to be more difficult (observed average = 4.13) than faculty (observed average = 4.86; P = .016, d = 1.99). Global ratings (observed average = 3.33/4.00) indicated participants believed the simulator could be used for cervical esophagogastric anastomosis training now, but could be improved slightly. CONCLUSIONS: Preliminary evidence suggests the novel cervical esophagogastric anastomosis simulator is valuable as a surgical training tool.

Development and Multidisciplinary Preliminary Validation of a 3-Dimensional-Printed Pediatric Airway Model for Emergency Airway Front-of-Neck Access Procedures.

BACKGROUND: Pediatric-specific difficult airway guidelines include algorithms for 3 scenarios: unanticipated difficult tracheal intubation, difficult mask ventilation, and cannot intubate/cannot ventilate. While rare, these instances may require front-of-neck access (FONA) to secure an airway until a definitive airway can be established. The aim of this study was to develop a pediatric FONA simulator evaluated by both anesthesiology and otolaryngology providers, promoting multidisciplinary airway management. METHODS: A 3-dimensional-printed tracheal model was developed using rescaled, anatomically accurate dimensions from a computerized tomography scan using computer-aided design software. The medical grade silicone model was incorporated into a mannequin to create a low-cost, high-fidelity simulator. A multidisciplinary team of anesthesiology, otolaryngology, and simulation experts refined the model. Experts in airway management were recruited to rate the realism of the model's characteristics and features and their own ability to complete specific FONA-related tasks. RESULTS: Six expert raters (3 anesthesiology and 3 otolaryngology) were identified for multidisciplinary evaluation of model test content validity. Analysis of response data shows null variance within 1 or both specialties for a majority of the content validity tool elements. High and consistent absolute ratings for each domain indicate that the tested experts perceived this trainer as a realistic and highly valuable tool in its current state. CONCLUSIONS: The ability to practice front-of-neck emergency airway procedures safely and subsequently demonstrate proficiency on a child model has great implications regarding both quality of physician training and patient outcomes. This model may be incorporated into curricula to teach needle cricothyroidotomy and other FONA procedures to providers across disciplines.

Data Collection for Adverse Events Reporting by US Dental Schools.

OBJECTIVES: Accreditation of US dental schools requires a formal system of quality assessment of clinical adverse events (AE). There is no universal system to collect, record, interpret, or release findings or trends pertaining to AEs. The objective of this study was to compare similarities and differences among the AE reporting forms used at US dental schools. METHODS: Sixteen (24%) dental schools responded to a query to provide copies of their AE forms. The forms were analyzed to identify unique AE items. A total of 69 unique AE items were identified, grouped, and ranked according to frequency. Methods of AE data collection were also noted. RESULTS: The forms were different in organization, form, and content. The 69 AE items represented a wide variety of information, with no standardization of the type of information, how it was collected, or by whom. We identified 9 most requested AE items and 4 least requested AE items. The schools differed in how the information was obtained: 2 schools used a menu, 8 schools used free response, and 6 schools used a hybrid of both methods. CONCLUSIONS: We found that dental school clinic AE reporting forms are not standardized in structure, organization, or content. We conclude that a hybrid form containing both guided responses and free responses would ensure that proper information is being reported to fully understand why/how an AE occurred. In addition, dental schools need to develop a standardized method of collecting and assessing AE data which will allow for quality improvement and increased patient safety.

Volume Versus Mass Dosing of Epinephrine for Neonatal Resuscitation: A Randomized Trial.

BACKGROUND: Intravenous epinephrine for neonatal resuscitation requires weight-based calculations. Epinephrine is available in 2 different concentrations, increasing the risk of dosing errors. Expert panels have conflicting recommendations for the ordering method. The Neonatal Resuscitation Program recommends the volume (milliliters per kilogram) method, whereas the Institute for Safe Medication Practices recommends the mass (milligrams per kilogram) method. In this study, we aim to determine if the mass method is more accurate and efficient than the volume method. METHODS: In a randomized crossover simulation study, 70 NICU and pediatric emergency department nurses calculated the intended dose then prepared epinephrine using both the mass and volume methods. Both epinephrine concentrations were available. Scenarios were video recorded and timed. The primary outcome was the proportion of epinephrine doses prepared correctly. Variables associated with correct dosing were analyzed by using logistic regression. RESULTS: Of 136 total doses, 77 (57%) were prepared correctly. The correct intended dose was calculated more frequently by using the mass method (82% vs 68%; risk difference 15%; 95% confidence interval 3% to 26%), but there was no difference in the proportion of doses that were actually prepared correctly (53% of mass method doses versus 60% of volume method doses; risk difference -7%; 95% confidence interval -24% to 9%). There was no difference between methods in the time required to prepare the dose. Selecting the correct epinephrine concentration was the only variable associated with correct dosing. CONCLUSIONS: The mass method was neither more accurate nor more efficient. Nurses made frequent errors when using both methods. This is a serious patient safety risk. Additional educational and medication safety interventions are urgently needed.

Development of a high fidelity subglottic stenosis simulator for laryngotracheal reconstruction rehearsal using 3D printing.

INTRODUCTION: Laryngotracheal reconstruction (LTR) with cartilage graft augmentation is an effective treatment for subglottic stenosis and a critical advanced procedure for Pediatric Otolaryngologists. Trainees almost exclusively learn this procedure intraoperatively on children due to the lack of adequate pediatric training models. An enhanced and accelerated educational experience may be possible if trainees can rehearse the key portions of the procedure on a simulation model. OBJECTIVE: To design and manufacture a low-cost, high fidelity surgical simulation model of subglottic stenosis for LTR. METHODS: This simulator is composed of two component models: rib cartilage and trachea. Additive manufacturing techniques, including Computer Aided Design and Three Dimensional (3D) printing, were utilized to create the simulator. Three expert Pediatric Otolaryngologists rated the functionality and realism of the simulator using Likert scale survey data. RESULTS: The use of CAD and 3D printing techniques allowed for realistic, reproducible surgical simulation of key aspects of LTR. The validation evidence indicated good to excellent means across the five domains relevant to the simulator's fidelity and usability (M = 3.47 to 4.00) out of a maximum of 4 points. Lowest rated items were consistent with expert comments suggesting minor simulator improvements. Time of production is approximately 20 h from print to post-processing, and consumable material costs per model are $2.60 USD. CONCLUSIONS: This subglottic stenosis airway simulator facilitated Laryngotracheal Reconstruction rehearsal and is a promising training tool for pediatric otolaryngologists. Our methods allow patient-specific, pre-surgical rehearsal for complex airway scenarios that could benefit the experienced airway surgeon and trainees alike. Future research aims to validate this device's utility for accelerating attainment of proficiency and improving surgical outcomes.

Simulation-Based Medical Emergencies Education for Dental Students: A Three-Year Evaluation.

This aim of this study was to develop and evaluate a simulation program for dental students to supplement a lecture-based medical emergencies course. Students' self-reported knowledge, experience, confidence, and ability regarding medical emergencies were assessed as program outcomes. For three years (in 2014, 2015, and 2016), all second-year students (N=333) at one U.S. dental school were randomly assigned to groups of 15 and participated in 15 simulated clinical scenarios. All students completed a 21-item pre-post survey and rated their knowledge, experience, and confidence using simulated emergencies. Following the intervention, students' ability to complete critical actions was also peer-assessed using a ten-item checklist. Four open-ended questions were included on the post-intervention survey for acquisition of additional data. For all years, students' self-reported measurements significantly improved with high practical impact (p≤0.001, g=|0.62, 3.93|), with the exception of calling 911 (knowledge). Peer-rated performance indicated the students were deficient (<75% success) in the following: inhaler use, dose of local anesthetic, dose of epinephrine, and EpiPen use. Content analysis of students' comments pointed to areas that need improvement but found high satisfaction with the program. These findings indicate that this program improved students' knowledge, experience, and confidence using simulated medical emergencies.

Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario.

BACKGROUND: Extracorporeal cardiopulmonaryresuscitation (ECPR) is emerging as a viable rescue strategy for refractory out-of-hospital cardiac arrest. In the U.S., limited training of emergency medicine providers is a barrier to widespread implementation. AIMS: Test the hypothesis that emergency medicine physicians and nurses can acquire and retain the skills to rapidly and safely initiate ECPR using high-fidelity simulation. STUDY DESIGN: Prospective interventional study. SETTING: U.S. tertiary academic medical center. SUBJECTS: Emergency medicine physicians and nurses with no prior ECPR/ECMO experience. METHODS: Teams of three physicians and three nurses underwent a two-day ECPR training course including didactics, hands-on training, and simulation. Teams were videotaped initiating ECPR in a high-fidelity simulation scenario before and after simulation training. The primary outcome was the proportion of simulations in which full ECPR support was achieved within 30 min of patient arrival. RESULTS: Five teams completed the entire study. Full ECPR support was achieved within 30 min of patient arrival in 11/15, 15/15, and 15/15 attempts at baseline (B), post-testing (PT) and 3-month post-testing (3-PT), respectively (p = 0.06). Intervals (mean ± sd) required to achieve full ECPR support at B, PT, and 3-PT were 25.8±5.3, 17.2±4.6, and 19.2±1.9 min respectively (p < 0.05 for B vs. PT and 3-PT). CONCLUSION: High fidelity simulation training is effective in preparing emergency medicine physicians and nurses to rapidly and safely initiate ECPR in a simulated cardiac arrest scenario, and should be considered when implementing an ED-based ECPR program.

Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study.

BACKGROUND: The FlexDex® (FD) is a solely mechanical articulating device that combines the functionality of robotic surgery with the relative low cost and simplicity of laparoscopy. We sought to evaluate the performance of first-time FD users while performing a simple suture task at locations of varying degrees of difficulty. STUDY DESIGN: A prospective, randomized crossover study was performed comparing the FD to standard laparoscopy (SL). Two specific groups were evaluated; Group 1 consisted of complete novices, and Group 2 consisted of surgical trainees. Participants performed a simple suture with both FD and SL locations of varying degrees of difficulty (Easy, Moderate, and Hard). The following outcomes were evaluated: Instrument Function and Ergonomics (Comfort/Ergonomics survey), Task Difficulty (National Aeronautics and Space Administration Task Load Index [NASA-TLX]), Task Performance Quality (Objective Structured Assessment of Technical Skills [OSATS]), and Time (seconds). RESULTS: Twenty-two participants were enrolled with 12 participants in Group 1 and 10 participants in Group 2. Group 1-FD participants experienced overall less shoulder strain (1.2 ± 0.40 versus 1.9 ± 0.90, P = .01), and Group 2-FD participants experienced less shoulder (2.5 ± 0.66 versus 4.0 ± 0.50, P = .01), back (1.1 ± 0.32 versus 1.9 ± 0.74, P = .01), and forearm strain (1.9 ± 0.88 versus 2.5 ± 1.1, P = .04). Group 1 participants using the FD experienced higher mental demand (73 ± 17 versus 48 ± 27, P < .01) and perceived effort (70 ± 20 versus 54 ± 23, P < .001). Both Group 1 and Group 2 FD participants performed tasks at the Hard location more effectively. Both Group 1 (70 versus 87, P = .21) and Group 2 (53 versus 60, P = .55) performed tasks at the Hard location in similar times, while Group 1 (80 versus 177, P = .03) and Group 2 (33 versus 70, P = .001) performed tasks at the Easy location in shorter times using SL. CONCLUSIONS: This study demonstrates the first assessment of the FD, a mechanically articulating laparoscopic tool. First-time FD users demonstrated improved ergonomics and effectiveness suturing at difficult locations. Future studies will focus on comparison to robotic surgery and translation into clinical applications.