Refining mass casualty plans with simulation-based iterative learning.

BACKGROUND: Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap. METHODS: We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents. RESULTS: Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared. CONCLUSION: Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff.

Evaluation and Effectiveness of a Two-Day Dementia Training Program for Hospital Staff Working in an Emergency Department.

BACKGROUND: Entering the hospital via an Emergency Department (ED) is a pivotal moment in the life of People with Dementia (PwD) and often starts an avoidable downward spiral. Therefore, it is required to further educate ED staff to raise awareness of the needs of PwD. Although there are many studies about existing dementia training programs for the hospital setting, empirical evidence for the ED setting and cross-level training evaluations are lacking. OBJECTIVE: The study aims to evaluate a two-day dementia training course for ED staff on the outcome levels of learning, individual performance, and organizational performance. Furthermore, the study examines whether the training fulfilled participants' expectations. METHODS: Mixed methods were used to assess data from head nurses, nursing, and administrative staff working in EDs. We conducted semi-structured interviews three weeks before (N = 18) and eight months after (N = 9) the training. Questionnaire data were assessed before the training, three months, and six months after the training (N = 44). A qualitative content analysis was conducted to analyze qualitative data; quantitative data was described descriptively. RESULTS: The intervention seems to be effective on both learning and individual performance levels. However, we did not observe any changes in the organizational performance. The training program met attendees' expectations only partly. The working environment of EDs needs to be taken more into account. CONCLUSION: Hospital staffs' expectations of a dementia training program depend on the work area in which they operate. Results support the implementation of intervention bundles to enable sustainable cross-level changes.

[Pre-hospital management of a psychiatric emergency]. / Prise en charge préhospitalière d'une urgence psychiatrique.

The pre-hospital care process of a patient presenting a psychiatric emergency involves many pre-hospital and hospital personnel. Identifying such high-risk situations, allowing an initial approach that is adjusted and authorises care are often very delicate moments. An adapted management, concerted within a network, allows the safety of the patient, his entourage and the interveners. These situations are characterised by their polymorphism with major constants: training, anticipation and knowledge of organisations.

Teaching acute hospital staff and students about patient flow.

Good patient flow in an acute hospital is concerned with ensuring patients experience minimal delays throughout the hospital journey, from the emergency department to the wards, outpatients and to a suitable discharge destination. Good flow requires effective processes, staff buy-in and staff education. This study aimed to explore ways in which this topic is currently taught in an Irish acute hospital group. Participants were recruited to engage in semi-structured interviews about their experience of teaching patient flow. Following qualitative data analysis using a structured analysis guide, five main themes were identified: current methods, unstructured nature of teaching, frustration with frequency, dissemination of teaching/learning and opportunities for improvement. Recommendations from this study could be used to support a formalised approach to teaching this topic in the future. The use of the Teaching for Understanding framework and Universal Design for Learning principles are strongly advocated to support the development of a nationwide module, to structure the topics to be taught and provide guidance on how to effectively and efficiently teach this topic in Ireland.

Patient Monitoring Alarms in an Intensive Care Unit: Observational Study With Do-It-Yourself Instructions.

BACKGROUND: As one of the most essential technical components of the intensive care unit (ICU), continuous monitoring of patients' vital parameters has significantly improved patient safety by alerting staff through an alarm when a parameter deviates from the normal range. However, the vast number of alarms regularly overwhelms staff and may induce alarm fatigue, a condition recently exacerbated by COVID-19 and potentially endangering patients. OBJECTIVE: This study focused on providing a complete and repeatable analysis of the alarm data of an ICU's patient monitoring system. We aimed to develop do-it-yourself (DIY) instructions for technically versed ICU staff to analyze their monitoring data themselves, which is an essential element for developing efficient and effective alarm optimization strategies. METHODS: This observational study was conducted using alarm log data extracted from the patient monitoring system of a 21-bed surgical ICU in 2019. DIY instructions were iteratively developed in informal interdisciplinary team meetings. The data analysis was grounded in a framework consisting of 5 dimensions, each with specific metrics: alarm load (eg, alarms per bed per day, alarm flood conditions, alarm per device and per criticality), avoidable alarms, (eg, the number of technical alarms), responsiveness and alarm handling (eg alarm duration), sensing (eg, usage of the alarm pause function), and exposure (eg, alarms per room type). Results were visualized using the R package ggplot2 to provide detailed insights into the ICU's alarm situation. RESULTS: We developed 6 DIY instructions that should be followed iteratively step by step. Alarm load metrics should be (re)defined before alarm log data are collected and analyzed. Intuitive visualizations of the alarm metrics should be created next and presented to staff in order to help identify patterns in the alarm data for designing and implementing effective alarm management interventions. We provide the script we used for the data preparation and an R-Markdown file to create comprehensive alarm reports. The alarm load in the respective ICU was quantified by 152.5 (SD 42.2) alarms per bed per day on average and alarm flood conditions with, on average, 69.55 (SD 31.12) per day that both occurred mostly in the morning shifts. Most alarms were issued by the ventilator, invasive blood pressure device, and electrocardiogram (ie, high and low blood pressure, high respiratory rate, low heart rate). The exposure to alarms per bed per day was higher in single rooms (26%, mean 172.9/137.2 alarms per day per bed). CONCLUSIONS: Analyzing ICU alarm log data provides valuable insights into the current alarm situation. Our results call for alarm management interventions that effectively reduce the number of alarms in order to ensure patient safety and ICU staff's work satisfaction. We hope our DIY instructions encourage others to follow suit in analyzing and publishing their ICU alarm data.

Healthcare stakeholders' perceptions and experiences of factors affecting the implementation of critical care telemedicine (CCT): qualitative evidence synthesis.

BACKGROUND: Critical care telemedicine (CCT) has long been advocated for enabling access to scarce critical care expertise in geographically-distant areas. Additional advantages of CCT include the potential for reduced variability in treatment and care through clinical decision support enabled by the analysis of large data sets and the use of predictive tools. Evidence points to health systems investing in telemedicine appearing better prepared to respond to sudden increases in demand, such as during pandemics. However, challenges with how new technologies such as CCT are implemented still remain, and must be carefully considered. OBJECTIVES: This synthesis links to and complements another Cochrane Review assessing the effects of interactive telemedicine in healthcare, by examining the implementation of telemedicine specifically in critical care. Our aim was to identify, appraise and synthesise qualitative research evidence on healthcare stakeholders' perceptions and experiences of factors affecting the implementation of CCT, and to identify factors that are more likely to ensure successful implementation of CCT for subsequent consideration and assessment in telemedicine effectiveness reviews. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, and Web of Science for eligible studies from inception to 14 October 2019; alongside 'grey' and other literature searches. There were no language, date or geographic restrictions. SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis. Studies included views from healthcare stakeholders including bedside and CCT hub critical care personnel, as well as administrative, technical, information technology, and managerial staff, and family members. DATA COLLECTION AND ANALYSIS: We extracted data using a predetermined extraction sheet. We used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess the methodological rigour of individual studies. We followed the Best-fit framework approach using the Consolidated Framework for Implementation Research (CFIR) to inform our data synthesis.  We classified additional themes not captured by CFIR under a separate theme. We used the GRADE CERQual approach to assess confidence in the findings. MAIN RESULTS: We found 13 relevant studies. Twelve were from the USA and one was from Canada. Where we judged the North American focus of the studies to be a concern for a finding's relevance, we have reflected this in our assessment of confidence in the finding. The studies explored the views and experiences of bedside and hub critical care personnel; administrative, technical, information technology, and managerial staff; and family members. The intensive care units (ICUs) were from tertiary hospitals in urban and rural areas. We identified several factors that could influence the implementation of CCT. We had high confidence in the following findings: Hospital staff and family members described several advantages of CCT. Bedside and hub staff strongly believed that the main advantage of CCT was having access to experts when bedside physicians were not available. Families also valued having access to critical care experts. In addition, hospital staff described how CCT could support clinical decision-making and mentoring of junior staff.  Hospital staff greatly valued the nature and quality of social networks between the bedside and CCT hub teams. Key issues for them were trust, acceptance, teamness, familiarity and effective communication between the two teams. Interactions between some bedside and CCT hub staff were featured with tension, frustration and conflict. Staff on both sides commonly described disrespect of their expertise, resistance and animosity. Hospital staff thought it was important to promote and offer training in the use of CCT before its implementation. This included rehearsing every step in the process, offering staff opportunities to ask questions and disseminating learning resources. Some also complained that experienced staff were taken away from bedside care and re-allocated to the CCT hub team. Hospital staff's attitudes towards, knowledge about and value placed on CCT influenced acceptance of CCT. Staff were positive towards CCT because of its several advantages. But some were concerned that the CCT hub staff were not able to understand the patient's situation through the camera. Some were also concerned about confidentiality of patient data. We also identified other factors that could influence the implementation of CCT, although our confidence in these findings is moderate or low. These factors included the extent to which telemedicine software was adaptable to local needs, and hub staff were aware of local norms; concerns about additional administrative work and cost; patients' and families' desire to stay close to their local community; the type of hospital setting; the extent to which there was support from senior leadership; staff access to information about policies and procedures; individuals' stage of change; staff motivation, competence and values; clear strategies for staff engagement; feedback about progress; and the impact of CCT on staffing levels. AUTHORS' CONCLUSIONS: Our review identified several factors that could influence the acceptance and use of telemedicine in critical care. These include the value that hospital staff and family members place on having access to critical care experts, staff access to sufficient training, and the extent to which healthcare providers at the bedside and the critical care experts supporting them from a distance acknowledge and respect each other's expertise. Further research, especially in contexts other than North America, with different cultures, norms and practices will strengthen the evidence base for the implementation of CCT internationally and our confidence in these findings. Implementation of CCT appears to be growing in importance in the context of global pandemic management, especially in countries with wide geographical dispersion and limited access to critical care expertise. For successful implementation, policymakers and other stakeholders should consider pre-empting and addressing factors that may affect implementation, including strengthening teamness between bedside and hub teams; engaging and supporting frontline staff; training ICU clinicians on the use of CCT prior to its implementation; and ensuring staff have access to information and knowledge about when, why and how to use CCT for maximum benefit.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness.

OBJECTIVE: We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States. METHODS: We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network. RESULTS: We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%). CONCLUSIONS: This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

Feasibility and impact of inverted classroom methodology for coronavirus disease 2019 (COVID-19) pandemic preparedness at an urban community hospital.

Strategies for pandemic preparedness and response are urgently needed for all settings. We describe our experience using inverted classroom methodology (ICM) for COVID-19 pandemic preparedness in a small hospital with limited infection prevention staff. ICM for pandemic preparedness was feasible and contributed to an increase in COVID-19 knowledge and comfort.

Implementation of Simulation Training During the COVID-19 Pandemic: A New York Hospital Experience.

SUMMARY STATEMENT: Simulation played a critical role in our institution's response to the COVID-19 pandemic in New York City. With the rapid influx of critically ill patients, resource limitations, and presented safety concerns, simulation became a vital tool that provided solutions to the many challenges we faced. In this article, we describe how simulation training was deployed at our institution throughout the course of the pandemic, which included the period of our medical surge. Simulation helped refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles. We also discuss the obstacles we encountered with implementing simulations during the pandemic, the measures we took to adapt to our limitations, and the simulation strategies and end products that were derived from these adaptations.

Development of a sterile compounding training and competency program at a large academic medical center.

PURPOSE: This article is one of the 5 articles describing steps taken to enhance sterile compounding compliance at a large, multisite academic medical center. This article focuses on the development of a comprehensive personnel training and assessment program for sterile compounding. SUMMARY: Increased regulatory oversight and the release of new United States Pharmacopeia chapters motivated the reenvisioning of the medical center's sterile compounding personnel training and assessment program. The main challenges facing any entity undertaking sterile compounding include identification of compounding staff, development of policies and procedures, and baseline and ongoing training including observational competency assessments and record keeping. These challenges are exacerbated by high work volumes and variation in compounding practices encountered within a large multisite institution. Our organization developed a team of specialized pharmacists and pharmacy technicians to implement and enforce changes promoting the safe production and use of compounded sterile products and meet rising regulatory requirements. This team worked within various operational areas to customize purchased policies and procedures and group compounding staff based on training needs. The team performs ongoing personnel monitoring and training of new compounders in a shared training space. Challenges encountered and future considerations for program enhancement are described. CONCLUSION: Implementation of standards and enforcement of staff behaviors in a large academic medical center is perhaps best completed by a team of highly trained experts working in collaboration with supervisors and using a dedicated training and testing space, as evidenced by the success of the described program in overecoming past challenges.

Experience on how to implement a preanalytical and POCT unit in Madrid's IFEMA field hospital during this unprecedented COVID-19 emergency.

To fight the virus SARS-CoV-2 spread to Europe from China and to give support to the collapsed public health system, the Spanish Health Authorities developed a field hospital located in the facilities of Madrid exhibition centre (IFEMA) to admit and treat patients diagnosed with SARS-CoV-2 infectious disease (COVID-19). The Department of Laboratory Medicine of La Paz University Hospital in Madrid (LMD-HULP) was designated to provide laboratory services. Due to the emergency, the IFEMA field hospital had to be prepared for patient admission in less than 1 week and the laboratory professionals had to collaborate in a multidisciplinary group to assure that resources were available to start on time. The LMD-HULP participated together with the managers in the design of the tests portfolio and the integration of the healthcare information systems (IS) (hospital IS, laboratory IS and POCT management system). Laboratorians developed a strategy to quickly train clinicians and nurses on test requests, sample collection procedures and management/handling of the POCT blood gas analyser both by written materials and training videos. The IFEMA´s preanalytical unit managed 3782 requests, and more than 11,000 samples from March 27th to April 30th. Furthermore, 1151 samples were measured by blood gas analysers. In conclusion, laboratory professionals must be resilient and have to respond timely in emergencies as this pandemic. The lab's personnel selection, design and monitoring indicators to maintain and further improve the quality and value of laboratory services is crucial to support medical decision making and provide better patient care.

Evaluation and Effectiveness of Dementia Staff Training Programs in General Hospital Settings: A Narrative Synthesis with Holton's Three-Level Model Applied.

BACKGROUND: People with Dementia (PwD) are frequently admitted to hospital settings. The lack of proper dementia knowledge, poor communication skills, negative attitudes toward dementia, and lack of confidence affects the quality of care, thus development of dementia trainings has increased. Nevertheless, literature regarding the effectiveness of training implementation is limited. OBJECTIVE: The aim of this narrative synthesis is to 1) identify the characteristics of training programs and 2) explore the effectiveness of these training programs in everyday clinical practice. METHODS: A systematic search in PubMed, PsycINFO, CINAHL, and Cochrane was conducted, including qualitative and quantitative peer-reviewed studies. Holton's evaluation model with its three outcome levels (learning, individual performance, and organizational results) was adopted. 14 studies were included. RESULTS: The synthesis of the results was divided into two parts: 1) to describe the characteristics and content of trainings 2) to evaluate the effectiveness of training programs according to the three outcome levels of Holton's model, taking into consideration its construct domains: ability, motivation, and environment. Learning outcomes were assessed in all selected studies: 13 studies observed changes in individual performance, four studies reported changes within the organizational level, and only five showed sustainable changes over time. CONCLUSION: Person-centered care (PCC) approaches, interactive and varied teaching methods, supporting conditions like champions, action plans, and setting care policies, are all characteristics of effective trainings. Successful programs should be sustainable over time, demonstrating positive outcomes across the organization. Based on current findings, there is a lack of adequate evaluation with regard to training programs on the organizational level.

Hospital Staff's Attitudes Toward and Knowledge About Dementia Before and After a Two-Day Dementia Training Program.

BACKGROUND: The outcomes of hospitalized People with Dementia (PwD) are likely to be negative due to, among other key causes, negative staff attitudes and limited staff knowledge regarding dementia. Targeted interventions have been shown to positively change the attitudes of the hospital staff while also increasing their overall knowledge of dementia. However, training effects are often short-lived and frequently long-term effects are not examined in studies. OBJECTIVE: To examine whether attending a dementia training program changes the attitudes of hospital staff toward PwD and/or increases their knowledge levels about dementia, and whether or not these changes are stable. METHODS: The training program lasted two days and N = 60 attending hospital staff members agreed to participate in the study. Data were assessed with questionnaires prior to the training, 3 months, and 6 months after the training. German versions of the Dementia Attitude Scale (DAS-D) and the Knowledge in Dementia (KIDE) scale were used. Additionally, data about perception of PwD and confidence in dealing with challenging behavior were collected and analyzed. RESULTS: After the training program, participants showed a significantly better attitude toward PwD as measured by DAS-D. These time-effects occurred in both DAS-D subscales ("dementia knowledge" and "social comfort"). Although a positive trend could be seen in the KIDE scale, no statistically significant increase occurred over time. CONCLUSION: Specialist training programs seem to be promising in positively changing attitudes toward and increasing knowledge about PwD with long-term effects. Further research should address the effects of attitude change in patient care.

Assessment of emergency trolley drugs in a children's hospital. Before and after study on an educational intervention. / Relevamiento de drogas en carros de emergencia de un hospital pediátrico. Estudio antes-después de una intervención educativa.

INTRODUCTION: The approach to pediatric emergencies requires specialized resources, and medication errors are common. OBJECTIVES: To describe the contents of emergency trolleys (ETs) in a children's hospital and compare them after an educational intervention. METHODS: The ETs from 9 hospitalization wards were included. A checklist of 30 drugs was developed. ETs were assessed by determining whether drugs were present or absent and their amount. An educational intervention was conducted and assessments were repeated 30 and 90 days after the intervention. RESULTS: The baseline measurement indicated an overall ratio of adequate drugs of 43.9 % (95 % confidence interval [Cl]: 38.4-49.4) with a variation among ETs from 29 % to 54.8 %, and from 15 % to 85 % among drug groups. At 30 days, the adequate ratio reached 70.3 % (95 % CI: 65.275.4), with a wide variation among the different ETs and drug groups (from 51.6 % to 93.5 % and from 50 % to 95 %, respectively). At 90 days, the percentages were similar. The comparison between the first and second measurement showed an improvement in all ETs (range: 3.2 %-45.1 %), odds ratio: 3.73 (95 % CI: 2.5-5.6), p < 0.001. Results were similar between the second and third measurement. CONCLUSIONS: The baseline measurement showed a low level of adequate ET drugs. After the intervention, this improved significantly and was maintained during the studied period.

Introducción. El abordaje de las emergencias pediátricas requiere recursos especializados y son frecuentes los errores relacionados con la medicación. Objetivos. Describir el contenido de los carros de emergencia (CE) en un hospital pediátrico y compararlo luego de una intervención educativa. Métodos. Se incluyeron CE de 9 salas de internación. Se elaboró una lista de cotejo con 30 drogas. Se relevaron los CE determinando presencia o ausencia de drogas y si las cantidades eran suficientes. Luego se realizó una intervención educativa y relevamientos 30 y 90 días posintervención. Resultados. La medición basal arrojó una proporción global de drogas adecuadas del 43,9 % (intervalo de confianza -IC- del 95 %: 38,449,4) con una variación entre CE del 29 % al 54,8 % y del 15 % al 85 % en los grupos de drogas. A los 30 días, la proporción correcta alcanzó el 70,3 % (IC 95 %: 65,2-75,4), con amplia variación entre los diferentes CE y grupos de drogas (del 51,6 % al 93,5 % y del 50 % al 95 %, respectivamente). A los 90 días, los porcentajes fueron similares. La comparación entre la primera y segunda medición mostró mejoría en todos los CE (rango: del 3,2 % al 45,1 %), odds ratio 3,73 (IC 95 %: 2,55,6), p < 0,001. Los resultados fueron similares entre la segunda y tercera medición. Conclusiones. En la medición inicial, se evidenció bajo nivel de adecuación de drogas de los CE. Luego de la intervención, mejoró significativamente y se mantuvo durante el período evaluado.

A Community Hospital's Response to the COVID-19 Pandemic.

The novel coronavirus 2019-nCoV (COVID-19) has disrupted and altered the way health care is delivered in the United States and across the world. Patient care guidelines and isolation recommendations continue to hastily change, demonstrating the key role of nursing professional development practitioners in educating and preparing frontline staff to provide safe patient care during the COVID-19 pandemic. This article describes a community hospital's strategic educational response to a highly contagious respiratory pandemic. Initiatives to increase staff education and conserve personal protective equipment are discussed.

Impact of multi-professional simulation-based training on perceptions of safety and preparedness among health workers caring for coronavirus disease 2019 patients in Pakistan

This study aimed to evaluate perceptions of safety and preparedness among health workers caring for coronavirus disease 2019 (COVID-19) patients before and after a multi-professional simulation-based course in Pakistan. Health workers' perceptions of preparedness, safety, and their willingness to care for COVID-19 patients were measured before and after they attended a simulation-based training course to prepare them to care for COVID-19 patients at Combined Military Hospital Landi Kotal Cantt, from March 1 to April 30, 2020. The participants' perceived level of safety and preparedness to care for COVID-19 patients before the simulation-based course was low, but increased after completing it (P<0.05). They felt confident and were significantly more willing to care for patients with COVID-19 or other infections requiring strict isolation. Simulation-based training is an effective tool to improve perceptions of risk and readiness to deal with COVID-19 among medical and non-medical health workers in Pakistan.