Team Physiological Dynamics: A Critical Review.

OBJECTIVE: Review the use of physiological measurement in team settings and propose recommendations to improve the state of the science. BACKGROUND: New sensor and analytical capabilities enable exploration of relationships between team members' physiological dynamics. We conducted a review of physiological measures used in research on teams to understand (1) how these measures are theoretically and operationally related to team constructs and (2) what types of validity evidence exist for physiological measurement in team settings. METHOD: We identified 32 articles that investigated task-performing teams using physiological data. Articles were coded on several dimensions, including team characteristics. Study findings were categorized by relationships tested between team physiological dynamics (TPD) and team inputs, mediators/processes, outputs, or psychometric properties. RESULTS: TPD researchers overwhelmingly measure single physiological systems. Although there is research linking TPD to inputs and outputs, the research on processes is underdeveloped. CONCLUSION: We recommend several theoretical, methodological, and statistical themes to expand the growth of the TPD field. APPLICATION: Physiological measures, once established as reliable indicators of team functioning, might be used to diagnose suboptimal team states and cue interventions to ameliorate these states.

Epinephrine Auto-Injector Versus Drawn Up Epinephrine for Anaphylaxis Management: A Scoping Review.

OBJECTIVE: Anaphylaxis is a life-threatening event. Most clinical symptoms of anaphylaxis can be reversed by prompt intramuscular administration of epinephrine using an auto-injector or epinephrine drawn up in a syringe and delays and errors may be fatal. The aim of this scoping review is to identify and compare errors associated with use of epinephrine drawn up in a syringe versus epinephrine auto-injectors in order to assist hospitals as they choose which approach minimizes risk of adverse events for their patients. DATA SOURCES: PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were searched using terms agreed to a priori. STUDY SELECTION: We reviewed human and simulation studies reporting errors associated with the use of epinephrine in anaphylaxis. There were multiple screening stages with evolving feedback. DATA EXTRACTION: Each study was independently assessed by two reviewers for eligibility. Data were extracted using an instrument modeled from the Zaza et al instrument and grouped into themes. DATA SYNTHESIS: Three main themes were noted: 1) ergonomics, 2) dosing errors, and 3) errors due to route of administration. Significant knowledge gaps in the operation of epinephrine auto-injectors among healthcare providers, patients, and caregivers were identified. For epinephrine in a syringe, there were more frequent reports of incorrect dosing and erroneous IV administration with associated adverse cardiac events. For the epinephrine auto-injector, unintentional administration to the digit was an error reported on multiple occasions. CONCLUSIONS: This scoping review highlights knowledge gaps and a diverse set of errors regardless of the approach to epinephrine preparation during management of anaphylaxis. There are more potentially life-threatening errors reported for epinephrine drawn up in a syringe than with the auto-injectors. The impact of these knowledge gaps and potentially fatal errors on patient outcomes, cost, and quality of care is worthy of further investigation.

Integration of in-hospital cardiac arrest contextual curriculum into a basic life support course: a randomized, controlled simulation study.

OBJECTIVE: The objective was to compare resuscitation performance on simulated in-hospital cardiac arrests after traditional American Heart Association (AHA) Healthcare Provider Basic Life Support course (TradBLS) versus revised course including in-hospital skills (HospBLS). DESIGN: This study is a prospective, randomized, controlled curriculum evaluation. SETTING: Johns Hopkins Medicine Simulation Center. SUBJECTS: One hundred twenty-two first year medical students were divided into fifty-nine teams. INTERVENTION: HospBLS course of identical length, containing additional content contextual to hospital environments, taught utilizing Rapid Cycle Deliberate Practice (RCDP). MEASUREMENTS: The primary outcome measure during simulated cardiac arrest scenarios was chest compression fraction (CCF) and secondary outcome measures included metrics of high quality resuscitation. MAIN RESULTS: Out-of-hospital cardiac arrest HospBLS teams had larger CCF: [69% (65-74) vs. 58% (53-62), p<0.001] and were faster than TradBLS at initiating compressions: [median (IQR): 9s (7-12) vs. 22s (17.5-30.5), p<0.001]. In-hospital cardiac arrest HospBLS teams had larger CCF: [73% (68-75) vs. 50% (43-54), p<0.001] and were faster to initiate compressions: [10s (6-11) vs. 36s (27-63), p<0.001]. All teams utilized the hospital AED to defibrillate within 180s per AHA guidelines [HospBLS: 122s (103-149) vs. TradBLS: 139s (117-172), p=0.09]. HospBLS teams performed more hospital-specific maneuvers to optimize compressions, i.e. utilized: CPR button to flatten bed: [7/30 (23%) vs. 0/29 (0%), p=0.006], backboard: [21/30 (70%) vs. 5/29 (17%), p<0.001], stepstool: [28/30 (93%) vs. 8/29 (28%), p<0.001], lowered bedrails: [28/30 (93%) vs. 10/29 (34%), p<0.001], connected oxygen appropriately: [26/30 (87%) vs. 1/29 (3%), p<0.001] and used oral airway and/or two-person bagging when traditional bag-mask-ventilation unsuccessful: [30/30 (100%) vs. 0/29 (0%), p<0.001]. CONCLUSION: A hospital focused BLS course utilizing RCDP was associated with improved performance on hospital-specific quality measures compared with the traditional AHA course.

Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review.

OBJECTIVE: Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs. METHODS: The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. RESULTS: Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. CONCLUSIONS: This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.

Building consensus for the future of paediatric simulation: a novel 'KJ Reverse-Merlin' methodology.

Objectives: This project aims to identify guiding strategic principles to optimise simulation-based educational impact on learning, patient safety and child health. Methods: Study participants included 39 simulation experts who used a novel 'KJ Reverse-Merlin' consensus process in the systematic identification of barriers to success in simulation, grouped them in themes and subsequently identified solutions for each theme. Results: 193 unique factors were identified and clustered into 6 affinity groups. 6 key consensus strategies were identified: (1) allocate limited resources by engaging health systems partners to define education and research priorities; (2) conduct and publish rigorous translational and cost-effectiveness research; (3) foster collaborative multidisciplinary research and education networks; (4) design simulation solutions with systems integration and sustainability in mind; (5) leverage partnerships with industry for simulation, medical and educational technology; (6) advocate to engage the education community, research funding agencies and regulatory bodies. Conclusions: Simulation can be used as a research, quality improvement and or educational tool aimed at improving the quality of care provided to children. However, without organisation, strategy, prioritisation and collaboration, the simulation community runs the risk of wasting resources, duplicating and misdirecting the efforts.

A survey demonstrating lack of consensus on the sequence of medications for treatment of hyperkalemia among pediatric critical care providers.

OBJECTIVE: Hyperkalemia is one of the reversible causes of cardiac arrest in children. The Advanced Cardiovascular Life Support guidelines have specific recommendations on the choice and sequence of medications for treatment of life-threatening hyperkalemia. However, the Pediatric Advanced Life Support guidelines have no specific treatment recommendations. The objective of this study was to measure the extent to which opinions diverge among pediatricians on the choice and sequence of medication administration in the management of hyperkalemia during cardiac arrest. DESIGN: Scenario-based survey. SETTING: A hypothetical hospital area covered by the pediatric rapid response team. PATIENTS: A hypothetical scenario of a 7-year old child receiving a blood transfusion who is suddenly unresponsive and found to be in pulseless ventricular tachycardia with stat labs revealing a potassium level of 8.3. INTERVENTIONS: A scenario-based survey of PICU fellows and attendings at a PICU Fellows Boot Camp. MEASUREMENT AND MAIN RESULTS: Eighty-four fellows and 24 attendings responded to the survey. The response rate was 89%. Calcium was chosen most frequently as the first drug to be administered (calcium chloride, 40/115 [34.8%]; calcium gluconate, 62/115 [53.9%]) while 38 of 115 respondents (33%) chose a drug other than calcium. Only 17 of 115 respondents (15%) would use calcium, sodium bicarbonate, insulin, and dextrose in the advanced cardiovascular life support-recommended sequence. PICU attendings were significantly more likely to administer the advanced cardiovascular life support-recommended sequence than fellows (attendings, 8/24 [33%] vs fellows, 9/84 [11%]; p = 0.007). CONCLUSION: This survey revealed notable variability in the choice and sequence of medications for treatment of life-threatening hyperkalemia with surprisingly few participants in compliance with the advanced cardiovascular life support hyperkalemia guidelines. A standardized approach for pediatric life-threatening hyperkalemia is recommended to improve resuscitation quality.