Learning with our peers: peer-led versus instructor-led debriefing for simulated crises, a randomized controlled trial.

BACKGROUND: Although peer-assisted learning is known to be effective for reciprocal learning in medical education, it has been understudied in simulation. We aimed to assess the effectiveness of peer-led compared to instructor-led debriefing for non-technical skill development in simulated crisis scenarios. METHODS: Sixty-one undergraduate medical students were randomized into the control group (instructor-led debriefing) or an intervention group (peer debriefer or peer debriefee group). After the pre-test simulation, the participants underwent two more simulation scenarios, each followed by a debriefing session. After the second debriefing session, the participants underwent an immediate post-test simulation on the same day and a retention post-test simulation two months later. Non-technical skills for the pre-test, immediate post-test, and retention tests were assessed by two blinded raters using the Ottawa Global Rating Scale (OGRS). RESULTS: The participants' non-technical skill performance significantly improved in all groups from the pre-test to the immediate post-test, with changes in the OGRS scores of 15.0 (95% CI [11.4, 18.7]) in the instructor-led group, 15.3 (11.5, 19.0) in the peer-debriefer group, and 17.6 (13.9, 21.4) in the peer-debriefee group. No significant differences in performance were found, after adjusting for the year of medical school training, among debriefing modalities (P = 0.147) or between the immediate post-test and retention test (P = 0.358). CONCLUSIONS: Peer-led debriefing was as effective as instructor-led debriefing at improving undergraduate medical students' non-technical skill performance in simulated crisis situations. Peer debriefers also improved their simulated clinical skills. The peer debriefing model is a feasible alternative to the traditional, costlier instructor model.

Debriefing for the Transfer of Learning: The Importance of Context.

The advent of simulation-based education has caused a renewed interest in feedback and debriefing. However, little attention has been given to the issue of transfer of learning from the simulation environment to real-life and novel situations. In this article, the authors discuss the importance of context in learning, based on the frameworks of analogical transfer and situated cognition, and the limitations that context imposes on transfer. They suggest debriefing strategies to improve transfer of learning: positioning the lived situation within its family of situations and implementing the metacognitive strategies of contextualizing, decontextualizing, and recontextualizing. In contextualization, the learners' actions, cognitive processes, and frames of reference are discussed within the context of the lived experience, and their mental representation of the situation and context is explored. In decontextualization, the underlying abstract principles are extracted without reference to the situation, and in recontextualization, those principles are adapted and applied to new situations and to the real-life counterpart. This requires that the surface and deep features that characterize the lived situation be previously compared and contrasted with those of the same situation with hypothetical scenarios ("what if"), of new situations within the same family of situations, of the prototype situation, and of real-life situations. These strategies are integrated into a cyclical contextualization, decontextualization, and recontextualization model to enhance debriefing.

Does the unexpected death of the manikin in a simulation maintain the participants' perceived self-efficacy? An observational prospective study with medical students.

BACKGROUND: The death of a simulated patient is controversial. Some educators feel that having a manikin die is prejudicial to learning; others feel it is a way of better preparing students for these situations. Perceived self-efficacy (PSE) reflects a person's perception of their ability to carry out a task. A high PSE is necessary to manage a task efficiently. In this study, we measured the impact of the death of a simulated patient on medical students' perceived self-efficacy concerning their ability to cope with a situation of cardiac arrest. METHODS: We carried out a single-centre, observational, prospective study. In group 1 (n = 27), pre-graduate medical students were warned of the possible death of the manikin; group 2 students were not warned (n = 29). The students' PSE was measured at the end of the simulated situation and after the debriefing. RESULTS: The PSE of the two groups was similar before the debriefing (p = 0.41). It had significantly progressed at the end of the debriefing (p < 0,001). No significant difference was noted between the 2 groups (p = 0.382). CONCLUSIONS: The simulated death of the manikin did not have a negative impact on the students' PSE, whether or not they had been warned of the possible occurrence of such an event. Our study helps defend the position which supports the inclusion of unexpected death of the manikin in a simulation setting.

Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.

IMPORTANCE: D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE: To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS: A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS: All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES: The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS: Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE: Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01134068.

Evaluation of manual and automatic manually triggered ventilation performance and ergonomics using a simulation model.

BACKGROUND: In the absence of endotracheal intubation, the manual bag-valve-mask (BVM) is the most frequently used ventilation technique during resuscitation. The efficiency of other devices has been poorly studied. The bench-test study described here was designed to evaluate the effectiveness of an automatic, manually triggered system, and to compare it with manual BVM ventilation. METHODS: A respiratory system bench model was assembled using a lung simulator connected to a manikin to simulate a patient with unprotected airways. Fifty health-care providers from different professional groups (emergency physicians, residents, advanced paramedics, nurses, and paramedics; n = 10 per group) evaluated manual BVM ventilation, and compared it with an automatic manually triggered device (EasyCPR). Three pathological situations were simulated (restrictive, obstructive, normal). Standard ventilation parameters were recorded; the ergonomics of the system were assessed by the health-care professionals using a standard numerical scale once the recordings were completed. RESULTS: The tidal volume fell within the standard range (400-600 mL) for 25.6% of breaths (0.6-45 breaths) using manual BVM ventilation, and for 28.6% of breaths (0.3-80 breaths) using the automatic manually triggered device (EasyCPR) (P < .0002). Peak inspiratory airway pressure was lower using the automatic manually triggered device (EasyCPR) (10.6 ± 5 vs 15.9 ± 10 cm H2O, P < .001). The ventilation rate fell consistently within the guidelines, in the case of the automatic manually triggered device (EasyCPR) only (10.3 ± 2 vs 17.6 ± 6, P < .001). Significant pulmonary overdistention was observed when using the manual BVM device during the normal and obstructive sequences. The nurses and paramedics considered the ergonomics of the automatic manually triggered device (EasyCPR) to be better than those of the manual device. CONCLUSIONS: The use of an automatic manually triggered device may improve ventilation efficiency and decrease the risk of pulmonary overdistention, while decreasing the ventilation rate.

[Training in emergency situations through medical simulation]. / La formation à l'urgence par la simulation en santé.

Alongside conventional teaching, simulation is an effective training technique. It comprises a series of techniques enabling experiences in real situations to be replaced by those in equivalent situations in an immersive and interactive way This type of training does not enable errors to be totally avoided, but helps to reduce the consequences.

Predicting deep venous thrombosis in pregnancy: external validation of the LEFT clinical prediction rule.

The assessment of clinical probability represents an important step in the diagnostic strategy of patients with suspected deep vein thrombosis. The recently derived LEFt clinical prediction rule for pregnant women combines three variables: symptoms in the left leg (L), calf circumference difference of 2 centimeters or over (E for edema) and first trimester presentation (Ft) but is lacking an external validation. The LEFt rule was computed among pregnant women with suspected deep vein thrombosis who were included in a multicenter prospective diagnostic management outcome study. We calculated the proportion of women and the prevalence of deep vein thrombosis in each probability group, along with the diagnostic performances of the LEFt rule. All variables needed to compute the rule could be retrieved in 157 of the 167 pregnant women with suspected deep vein thrombosis. The prevalence of confirmed deep vein thrombosis was 13 of 157 (8.3%). The LEFt rule was negative in 46 (29%) women. A deep vein thrombosis was diagnosed in 13 of 111 (11.7%, 95% Confidence Interval (CI): 8.3-20.9%) of women with at least one of the LEFt criteria, as compared with none of 46 (0.0%, 95%CI: 0.0-7.9%) of women with none of the LEFt criteria. These results suggest that a negative LEFt rule accurately identifies pregnant women in whom the proportion of confirmed deep vein thrombosis appears to be very low. The rule should not be used as stand-alone test for excluding DVT during pregnancy, but might rather be implemented in a diagnostic strategy in association with D-dimer measurement and compression ultrasonography.

[From emergency services to neurosurgical intensive care, the role of the nurse in neurosurgery]. / Des urgences à la réanimation neurochirurgicale, le rôle de l'infirmière en neurochirurgie.

Treating a patient with a head injury requires a full general assessment, a rigorous evaluation of the severity of the trauma and the prevention of brain insults of systemic origin. Monitoring by the nurse is essential and determines the carrying out of additional tests. She must look out for neurological deterioration and prepare the patient and his or her family for potential sequelae.