Debriefing in Simulation and Beyond.

Debriefing, with its roots in military and aviation, is critically important to effective application of simulation education. With its widespread implementation and strong underpinnings in a variety of educational theories, debriefing is a central pillar of essentially all health care simulation centers. Even anesthesiologists who have completed training and practice outside of teaching centers will encounter debriefing when they participate in Part IV of Maintenance of Certification in Anesthesiology in endorsed simulation centers. Beyond this well-established presence, debriefing offers exciting opportunities for improvement of health care education and quality. First, debriefing practices should not be limited to the simulation setting. It is applicable to reflecting upon the crisis situations that are often faced by anesthesiologists, as well as a powerful tool for feedback on a daily basis. The improvement of feedback in both quality and quantity is considered by many educators to be a fundamental step in improving educational and training programs. The principles of debriefing, and probably more importantly the value of debriefing, are invaluable concepts for the clinical environment and amplify the impact of simulation in patient care. It can be reasonably argued that helping health care practitioners develop the habitual practice of giving and receiving feedback could become one of simulation educators' greatest contributions to patient safety. Another important role of debriefing should be in the area of IPE and practice. The challenges of IPE in simulation have been described; it is important for health care educators to be aware of these IPE experiences. These experiences have created a cadre of facilitators ready to participate in meaningful clinical debriefings across specialties and disciplines. Debriefing has played a central role in medical simulation since early implementation. This role is well founded in both history and in educational theory. Various techniques of debriefing have evolved according to learner types, personal preference, and the scenario objectives. Regardless of technique, debriefing offers the opportunity for meaningful change within participants by providing genuine reflection upon authentic experiences. These changes, when applied to clinical practice, are an important part of the claim that simulation can improve patient safety.

Designing and evaluating an effective theory-based continuing interprofessional education program to improve sepsis care by enhancing healthcare team collaboration.

Continuing interprofessional education (CIPE) differs from traditional continuing education (CE) in both the learning process and content, especially when it occurs in the workplace. Applying theories to underpin the development, implementation, and evaluation of CIPE activities informs educational design, encourages reflection, and enhances our understanding of CIPE and collaborative practice. The purpose of this article is to describe a process of design, implementation, and evaluation of CIPE through the application of explicit theories related to CIPE and workplace learning. A description of an effective theory-based program delivered to faculty and clinicians to enhance healthcare team collaboration is provided. Results demonstrated that positive changes in provider perceptions of and commitment to team-based care were achieved using this theory-based approach. Following this program, participants demonstrated a greater appreciation for the roles of other team members by indicating that more responsibility for implementing the Surviving Sepsis guideline should be given to nurses and respiratory therapists and less to physicians. Furthermore, a majority (86%) of the participants made commitments to demonstrate specific collaborative behaviors in their own practice. The article concludes with a discussion of our enhanced understanding of CIPE and a reinterpretation of the learning process which has implications for future CIPE workplace learning activities.

High-fidelity simulation is superior to case-based discussion in teaching the management of shock.

BACKGROUND: Case-based discussion (CBD) is an established method for active learning in medical education. High-fidelity simulation has emerged as an important new educational technology. There is limited data from direct comparisons of these modalities. AIMS: The primary purpose of this study was to compare the effectiveness of high-fidelity medical simulation with CBD in an undergraduate medical curriculum for shock. METHODS: The subjects were 85 third-year medical students in their required surgery rotation. Scheduling circumstances created two equal groups. One group managed a case of septic shock in simulation and discussed a case of cardiogenic shock, the other group discussed septic shock and experienced cardiogenic shock through simulation. Student comprehension of the assessment and management of shock was then evaluated by oral examination (OE). RESULTS: Examination scores were superior in all comparisons for the type of shock experienced through simulation. This was true regardless of the shock type. Scores associated with patient evaluation and invasive monitoring, however, showed no difference between groups or in crossover comparison. CONCLUSIONS: In this study, students demonstrated better understanding of shock following simulation than after CBD. The secondary finding was the effectiveness of an OE with just-in-time deployment in curriculum assessment.

Recreating simulation scenarios for interprofessional education: an example of educational interprofessional practice.

High-fidelity simulation has proliferated in healthcare education. Once a novelty, simulation is now a mainstay of many curricula and even required by some accrediting bodies. Interprofessional behaviors, manifested through interprofessional education and practice are believed to improve patients' lives. The exciting potential of simulation-interprofessional education (SIM-IPE) is now being explored. This report details a SIM-IPE experience from a university medical simulation center and Schools of Nursing and Medicine. Circumstances required an existing scenario to be "retrofitted" for interprofessional education. Key decision points, challenges and practices are highlighted in the hope that they may be of use to other simulation educators.

Perioperative management of the adult with cystic fibrosis.

Since cystic fibrosis (CF) was first differentiated from celiac disease in 1938, the medical care of patients with CF has substantially improved. These improvements have resulted in a significant increase in median survival and the quality of life experienced by patients. The resultant increase in survival has caused the "average" CF patient to be a young adult and not a child. The gene that causes CF was first identified in 1989 and is the first gene discovered by positional cloning. Unfortunately, gene therapy for CF has not been successful, although it continues to hold great promise for future patient care. Although pulmonary disease is responsible for more than 90% of the morbidity and mortality in patients with CF, they also experience pancreatic disease, including diabetes mellitus, bone disease, hepatobiliary disease, and genitourinary disease. The optimal perioperative management of patients with CF requires an understanding of the relevant pathophysiology and the unique challenges presented by these patients. We reviewed these concepts, including special considerations such as liver and lung transplantation and pregnancy.

Delayed Anaphylaxis to Mammalian Meat Following Tick Exposure and Its Impact on Anesthetic Management for Cardiac Surgery: A Case Report.

Hypersensitivity reactions to mammalian meat following tick exposure are increasing in prevalence and provide a unique challenge to anesthesiologists. The reactions, including anaphylaxis, are delayed and therefore may not be easily recognized and treated. The risk is especially high in cardiac surgery, where several potential triggers, including biological valves as well as heparin, are used frequently. In the presence of such hypersensitivity, prophylactic measures including preoperative testing and pharmacologic prophylaxis may be useful in modulating the immune response such that triggering agents may be used relatively safely. We present 3 patients with previous sensitization to meat protein following a tick bite with known allergic reactions to mammalian meat who presented for cardiac surgery involving exposure to potential allergens and discuss the perioperative management including possible prevention.

Evidence-based management of tracheostomies in hospitalized patients.

There is little evidence-based literature on the management of tracheostomized patients. The existing data relate to the role of tracheostomy in specific disease states, the timing of tracheostomy, and comparison of open surgical to percutaneous tracheostomy. Tracheostomy protocols are under development. A recent series of 1,130 patients who underwent tracheostomy had a combined procedural, early, and late complication rate of approximately 4%, which is an improvement from the earlier complication rate. In the recent series, tracheal stenosis overtook hemorrhage as the leading complication, by 2 to 1. Tracheal stenosis accounted for nearly half of the complications. Half of the tracheal stenoses required surgical correction. All the patients who developed tracheal stenosis had endotracheal tubes for > 12 days before tracheostomy.

High fidelity simulation as a research tool.

Medical simulation has grown explosively over the last decade. Simulation is becoming commonplace in clinical education but can also be used as an investigative clinical tool in its own right. There are thus two arms of simulation in clinical research. The first is investigation of the clinical impact of simulation as an educational tool and the second as an instrument to assess the function of clinical practitioners and systems. This article reviews the terminology, current practice and current research in simulation. The use of simulation in assessment of the clinical performance of devices, people and systems will then be discussed and some current work in these areas presented. Finally, medical simulation will be discussed within the paradigm of translational research. Early examples of this 'tool-bench to bedside' model will be presented as possible prototypes for future work directed towards patient safety.

The effect of the intrathoracic pressure regulator on hemodynamics and cardiac output.

The intrathoracic pressure regulator (ITPR) (CirQLator; Advanced Circulatory Systems Inc, Roseville, Minn) is a novel, noninvasive device intended to increase cardiac output and blood pressure in hypovolemic or cardiogenic shock by generating a continuous low-level intrathoracic vacuum in between positive pressure ventilations. Although there are robust data supporting the benefit of the ITPR in multiple animal models of shock, the device has not been used in humans.The goals of this study were to evaluate both the safety and efficacy of the ITPR in humans. Twenty patients undergoing coronary artery bypass graft surgery were enrolled in this phase 1 study. Intraoperative use of both pulmonary artery pressure monitoring and transesophageal echocardiography (TEE) was required for study inclusion. Hemodynamic variables as well as TEE measurements of left ventricular performance were collected at baseline and after the ITPR device was activated, before surgical incision. Thermodilution cardiac output increased significantly with the application of the ITPR (4.9 vs. 5.5 L/min; P = 0.017). Similarly, cardiac output was measured by TEE (5.1 vs. 5.7 L/min; P = 0.001).There were significant increases in pulmonary artery systolic blood pressures (35 vs. 38 mmHg; P G 0.001) and mean pulmonary artery pressures (24 vs. 26 mmHg; P = 0.008). There were no significant differences in systemic blood pressures, left ventricular volumes, stroke volume, or ejection fraction as measured by TEE. Using two different measurement techniques, application of the ITPR increased cardiac output in normovolemic anesthetized patients who underwent coronary artery bypass graft before sternotomy. These data suggest that the ITPR has the potential to safely and effectively increase cardiac output in humans.

Model for end-stage liver disease predicts mortality for tricuspid valve surgery.

BACKGROUND: Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models. METHODS: From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses. RESULTS: Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96). CONCLUSIONS: The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.

The immunocompromised adult patient and surgery.

The perioperative management of immunosuppressed patients remains relatively unsophisticated. Rational management involves understanding the normal immune response to injury as modified by the preexisting or imposed abnormalities that immunosuppressed patients manifest on the basis of their disease and/or treatment. Patients with cancer, infected with human immunodeficiency virus, and having had an organ transplant are extreme examples of disordered immunity and it is important to understand the effects of their diseases and treatments. In the future, however, more appropriate management will require anticipation and appreciation of frequent preoperative immunotherapy, a more complete understanding of the immunological response to anesthesia and surgery, the ability to assess immune reserve and stratify risk within the context of that profile, and a better knowledge of the immunological effect of anesthetic agents.