Expanding scope of Kirkpatrick model from training effectiveness review to evidence-informed prioritization management for cricothyroidotomy simulation.

Modified Kirkpatrick model has been adopted to evaluate training effectiveness by 6 categories, including activity accounting (training objectives/success in organization change) at Level-0, reaction (satisfaction) at Level-1, learning (acquisition of surgical airway skills) at Level-2, behavior (post-training change in personal strengths) at Level-3, result (organizational or clinical outcomes) at Level-4, and Return on Investment (ROI) or Expectation (ROE) (monetary and societal values following training and other quality and safety related measures) at Level-5. The purpose of this hospital-based prospective observational study was twofold: i) To evaluate potential impacts on monetary and societal values and successful organization change following implementation of advanced Cricothyroidotomy simulator and standardized curriculum in healthcare simulation training, ii) To inform decisions of resource allocation by reviewing overall values and prioritization strategies for i) general surgeon/emergency physician ii) with seniority >5 years and iii) prior porcine training experience based on findings at Kirkpatrick Level-0, Level-4, and Level-5. Seventy doctors and 10 nurses completed Cricothyroidotomy training and follow-up questionnaires within 2021/22. All training usability scoring measured by Scales of Emergency Surgical Airway Simulator (SESAS-17) achieved over 4 out of 5 (Level-4) with effects in favor of emergency physicians or general surgeons (p < .5), regardless of seniority and prior training experience. Success in organization change (Level-0) and cost-effectiveness (Level-5) were hypothetically established using theoretical framework of Gleicher's formula and Roger's Diffusion of Innovation Theory. Overall training effectiveness, in terms of advantage in usability, cost-benefits and successful organizational changes, provided sound evidence to support continuous investment of new curriculum and innovative simulator and "Surgeon-and-emergency-physician-first" policy when it comes to resources allocation strategies for Cricothyroidotomy training. [ACGME competencies: Practice Based Learning and Improvement, Systems Based Practice.].

Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis.

BACKGROUND: Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity. METHODS: We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data. RESULTS: A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)]. CONCLUSIONS: No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery. TRIAL REGISTRATION: 10.17605/OSF.IO/3DJ6C.

Harnessing power of simulation training effectiveness with Kirkpatrick model in emergency surgical airway procedures.

Objectives: Training effectiveness indicates how good a program has met pre-set training objectives or organizational goals for the best benefit of healthcare professionals and service users in the community. The study aimed to evaluate training effectiveness following implementation of new training curriculum of emergency surgical airway procedures (Cricothyroidotomy) organized by the Queen Elizabeth Hospital. Design: This training evaluation relied on observational descriptive study design. Timed task on Cricothyroidotomy procedures and standardized post-training questionnaire were applied to assess the first 3 levels of Kirkpatrick's model: (Level-1) Reaction by training satisfaction; (Level-2) Learning by acquisition of knowledge and skills assessment passing rate; (Level-3) Behavior by personal strengths. Setting: This program was operated in the Multi-Disciplinary Simulation and Skills Centre, a hospital-based high-fidelity simulation training center accredited by the Society for Simulation in Healthcare. Participants: The study recruited 80 trauma service providers, including 35 general surgeons, 15 emergency physicians, 10 anesthesiologists or intensivists, 6 neurosurgeons, 4 orthopedic surgeons, and 10 emergency nurses from five trauma centers under the Hospital Authority. All underwent the Advanced Trauma Life Support training in advance. Results: Compared with reference score from previous training sessions, the result of program using new training curriculum and simulator demonstrated significant training satisfaction of participants (Level-1), and high level of assertiveness, mental preparedness, self-efficacy, and internal locus of control and responsibility (p < .01, for all in Level-3). All participants (N = 80) completed entire Cricothyroidotomy procedure in 2 min without technical errors (Assessment passing rate = 100%) (Level-2). Conclusions: Under Kirkpatrick model, simulation training in Cricothyroidotomy procedure using new curriculum and simulators has been proven to be useful for healthcare professionals involved in trauma service management. The result suggests that application of a state-of-the-art training tools to advanced surgical skills training could improve training satisfaction, knowledge and skills acquisition, and personal strengths transferable to clinical practice. ACGME competencies: Practice Based Learning and Improvement.

Investigating effects of healthcare simulation on personal strengths and organizational impacts for healthcare workers during COVID-19 pandemic: A cross-sectional study.

INTRODUCTION: This cross-sectional study aimed at evaluating impacts of healthcare simulation training, either in-situ or lab-based, on personal strengths of healthcare workers (HCWs) and organizational outcomes during the COVID-19 pandemic. METHODS: COVID-19 Taskforce was established to formulate standardized scenario-based simulation training materials in late-January 2020. Post-training questionnaires made up of 5-point Likert scales were distributed to all participants to evaluate their personal strengths, in terms of i) assertiveness, ii) mental preparedness, iii) self-efficacy, iv) internal locus of control, and v) internal locus of responsibility. Independent sample t-tests were used to analyze between-group difference in "In-situ" and "Lab-based" group; and one-sample t-tests were used to compare change in personal strengths with reference point of 3 (Neutral). Kirkpatrick's Model served as the analytical framework for overall training effects. RESULTS: Between 05 February and 18 March 2020, 101 sessions of simulation training were conducted in "In-Situ" at either Accident & Emergency Department (20, 20%) or Intensive Care Unit (15, 14%) and "Lab-based" for Isolation (30, 30%) and General Wards (36, 36%). 1,415 hospital staff members, including 1,167 nurses (82%), 163 doctors (12%) and 85 patient care assistants (6%), were trained. All domains of personal strengths were scored 4.24 or above and statistically significantly increased when comparing with reference population (p < .001). However, no significant differences between in-situ and lab-based simulation were found (p > .05), for all domains of personal strengths. CONCLUSION: Healthcare simulation training enhanced healthcare workers' personal strengths critical to operational and clinical outcomes during the COVID-19 pandemic.

Pre-operative intravenous steroid improves pain and joint mobility after total knee arthroplasty in Chinese population: a double-blind randomized controlled trial.

INTRODUCTION: This study aims to investigate the effect of pre-operative intravenous methylprednisolone on post-operative pain control and joint mobility in Chinese patients undergoing single primary total knee arthroplasty. METHODS: This is a prospective, randomized, double-blinded, placebo-controlled single-centre trial. Sixty subjects were randomized into intervention and control group. The peri-operative anaesthetic and analgesic regimes were standardized. The intervention group received 125 mg methylprednisolone intravenously on the induction of anaesthesia. Subjects were assessed at 24, 30 and 48 h after surgery and upon discharge for pain scores and range of movement from the operated knee. Change in C-reactive protein level was calculated. Patient's satisfaction was recorded. Adverse reactions were documented. Subjects were followed up at 6 weeks, 4 months and 1 year. RESULTS: Rest pain and pain on movement were significantly reduced in the methylprednisolone group at 24 and 30 h after surgery (ANOVA p = 0.030, p = 0.003, p = 0.032, p = 0.010). The methylprednisolone group demonstrated a greater range of movement from the operated knee up to 30 h after surgery (ANOVA p = 0.031). Post-operative C-reactive protein level was significantly less in the methylprednisolone group (p < 0.001). Methylprednisolone group had a higher patient's satisfaction than the control group (p < 0.01). No adverse effects were noted at the 1-year follow-up. CONCLUSION: Pre-operative intravenous methylprednisolone improves post-operative pain and joint mobility after total knee arthroplasty up to 30 h after operation. It results in a higher patients' satisfaction. It can act as an effective adjunct in the multimodal analgesic regime. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03082092.

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses.

OBJECTIVES: Despite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU) context. This study explored the communication openness perceptions of Chinese doctors and nurses and identified their perceptions of issues in ICU communication, their reasons for speaking up and the possible factors and strategies involved in promoting the practice of speaking up. DESIGN: A mixed-methods design with quantitative and sequential qualitative components was used. SETTING AND PARTICIPANTS: Eighty ICU staff members from a large public hospital in Hong Kong completed a questionnaire regarding their perceptions of communication openness. Ten clinicians whose survey responses indicated support for open communication were then interviewed about their speak-up practices. RESULTS: The participating ICU staff members had similar perceptions of their openness to communication. However, the doctors responded more positively than the nurses to many aspects of communication openness. The two groups also had different perceptions of speaking up. The interviewed ICU staff members who indicated a high level of communication openness reported that their primary reasons for speaking up were to seek and clarify information, which was achieved by asking questions. Other factors perceived to influence the motivation to speak up included seniority, relationships and familiarity with patient cases. CONCLUSIONS: Creating an atmosphere of safety and equality in which team members feel confident in expressing their personal views without fear of reprisal or embarrassment is necessary to encourage ICU staff members, regardless of their position, to speak up. Because harmony and saving face is valued in Chinese culture, training nurses and doctors to speak up by focusing on human factors and values rather than simply addressing conflict management is desirable in this context.