Crisis Resource Management in the Delivery Room: Development of Behavioral Markers for Team Performance in Emergency Simulation.
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ABSTRACT:
SUBMITTER: Bracco F
PROVIDER: S-EPMC5876984 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:In today's team-oriented healthcare environment, high-quality patient care requires physicians to possess not only medical knowledge and technical skills but also crisis resource management (CRM) skills. In emergency medicine (EM), the high acuity and dynamic environment makes CRM skills of physicians particularly critical to healthcare team success. The Accreditation Council of Graduate Medicine Education Core Competencies that guide residency program curriculums include CRM skills; however, EM residency programs are not given specific instructions as to how to teach these skills to their trainees. This article describes a simulation-based CRM course designed specifically for novice EM residents.The CRM course includes an introductory didactic presentation followed by a series of simulation scenarios and structured debriefs. The course is designed to use observational learning within simulation education to decrease the time and resources required for implementation. To assess the effectiveness in improving team CRM skills, two independent raters use a validated CRM global rating scale to measure the CRM skills displayed by teams of EM interns in a pretest and posttest during the course.The CRM course improved leadership, problem solving, communication, situational awareness, teamwork, resource utilization and overall CRM skills displayed by teams of EM interns. While the improvement from pretest to posttest did not reach statistical significance for this pilot study, the large effect sizes suggest that statistical significance may be achieved with a larger sample size.This course can feasibly be incorporated into existing EM residency curriculums to provide EM trainees with basic CRM skills required of successful emergency physicians. We believe integrating CRM training early into existing EM education encourages continued deliberate practice, discussion, and improvement of essential CRM skills.
| S-EPMC5785195 | biostudies-literature
Project description:While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design.Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs.One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training.A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.
| S-EPMC4651583 | biostudies-other
Project description:IntroductionOperating room (OR) fire can be a devastating and costly event to patients and health care providers. Prevention and effective management of such fires may present difficulties even for experienced OR staff.MethodsThis simulation involved a 52-year-old man presenting for excisional biopsy of a cervical lymph node to be performed under sedation. Participants were expected to identify and manage both contained and uncontained fires resulting from ignition by electrosurgical cautery. We conducted weekly multidisciplinary simulations in the mock OR at Massachusetts General Hospital. Participants included surgery and anesthesiology residents, certified registered nurse anesthetists, registered nurses, and surgical technicians. Participants were unaware of the scenario content. Each 90-minute session was divided into three parts: an orientation (10 minutes), the case with rapid cycle debriefing (65 minutes), and a final debriefing with course evaluations (15 minutes). Equipment consisted of a simulation OR with general surgery supplies, general anesthesia equipment, a high-fidelity Laerdal SimMan 3G simulator, a code cart, a defibrillator, dry ice for smoke effects, and a projector with a fire image.ResultsFrom April to June 2015, 86 participants completed this simulation. Participants reported that the simulation scenario was realistic (80%), was relevant to their clinical practice (93%), changed their practice (82%), and promoted teamwork (80%).DiscussionPrevention and management of OR fire require collaboration and prompt coordination between anesthesiologists, surgeons, and nurses. This simulation case scenario was implemented to train multidisciplinary learners in the identification and crisis management of such an event.
| S-EPMC7012309 | biostudies-literature
Project description:ObjectiveEmergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.MethodsThis was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T0), 1-month-old with hypoglycemia (T1), and 4-year-old clonidine ingestion (T2). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T0 to T2.ResultsA total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T0, T1, and T2, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T0 to T2 (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).ConclusionSerial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.
| S-EPMC8166302 | biostudies-literature
Project description:AimTo assess visual attention of neonatal team leaders during delivery room resuscitation of preterm infants using eye tracking glasses.MethodsProspective observational eye tracking study. Gaze fixations and sequences were captured, categorized, and mapped during the first 5?min of the resuscitations. Gaze fixation metrics of total gaze duration, visit count, and visit duration were summarized and compared based on interventions performed and provider training level. Fixation sequences were compared between attending neonatologists and fellows.ResultsDuring 18 eye tracking recordings, practitioners focused most of their cumulative visual attention on the infant (median total gaze duration 57%, interquartile range [IQR] 38-61%), followed by monitors (24%, IQR 13-46%), clinical staff (5%, IQR 1-8%), other physical objects (4%, IQR 3-6%), T-piece resuscitator (2%, IQR 0-4%) and the Apgar timer (1%, IQR 0-2%). Visual attention parameters varied according to intervention, with higher visit counts on the infant during corrective ventilation steps than during Continuous Positive Airway Pressure (CPAP) or Positive Pressure Ventilation (PPV), and longer visit durations on monitors during PPV. Time and frequency-based measures of visual attention did not significantly differ by provider training level, but patterned fixation sequences were identified among attending neonatologists that were not observed in fellows.ConclusionTeam leaders predominantly gazed upon the infant and monitors during resuscitation, and visual attention parameters varied depending on the respiratory interventions performed. Attending neonatologists exhibited patterned fixation sequences that were not observed in fellows. Study results may have implications for optimizing delivery room design and training novice providers.
| S-EPMC6995430 | biostudies-literature
Project description:IntroductionResuscitation of a critically ill patient is challenging for both novice learners and experienced health care providers. During a critical event, not only is it important to identify the correct underlying diagnosis, it is equally crucial that the appropriate Advance Cardiac Life Support algorithm, medications, and defibrillator modality are implemented. This scenario features a 56-year-old female who presents for excisional biopsy of an inguinal lymph node to evaluate lymphadenopathy concerning for lymphoma. Intraoperatively, she goes into cardiopulmonary arrest. Participants must identify and manage three different scenarios: (1) ventricular fibrillation, (2) unstable ventricular tachycardia, and (3) bradycardia, including the use of the defibrillator.MethodWeekly simulation sessions were conducted in the in situ simulation operating room at Massachusetts General Hospital. Surgical residents, anesthesiology residents, nurses, and surgical technicians participated in a multidisciplinary operating room team. Each approximately 60-minute session included an orientation, the case, and the debriefing. Equipment included a simulation operating room with general surgery supplies, general anesthesia equipment, a high-fidelity SimMan patient simulator, a code cart, and a defibrillator.ResultsNinety-one multidisciplinary participants completed this scenario from September to December 2015. Participants reported that the scenario was applicable to their clinical practice (96%), promoted teamwork skills (88%), and encouraged interprofessional learning (94%).DiscussionIntraoperative cardiac arrest is a devastating event that can result in poor patient outcomes if the care team is not thoroughly prepared for crisis management. This simulation case scenario was implemented to train multidisciplinary learners in the identification and management of such an event.
| S-EPMC6342395 | biostudies-literature
Project description:Checklists can improve adherence to standardized procedures and minimize human error. We aimed to test if implementation of a checklist was feasible and effective in enhancing patient care in an emergency department handling internal medicine cases. We developed four critical event checklists and confronted volunteer teams with a series of four simulated emergency scenarios. In two scenarios, the teams were provided access to the crisis checklists in a randomized cross-over design. Simulated patient outcome plus statement of the underlying diagnosis defined the primary endpoint and adherence to key processes such as time to commence CPR represented the secondary endpoints. A questionnaire was used to capture participants' perception of clinical relevance and manageability of the checklists. Six teams of four volunteers completed a total of 24 crisis sequences. The primary endpoint was reached in 8 out of 12 sequences with and in 2 out of 12 sequences without a checklist (Odds ratio, 10; CI 1.11, 123.43; p = 0.03607, Fisher's exact test). Adherence to critical steps was significantly higher in all scenarios for which a checklist was available (performance score of 56.3% without checklist, 81.9% with checklist, p = 0.00284, linear regression model). All participants rated the checklist as useful and 22 of 24 participants would use the checklist in real life. Checklist use had no influence on CPR quality. The use of context-specific checklists showed a statistically significant influence on team performance and simulated patient outcome and contributed to adherence to standard clinical practices in emergency situations.
| S-EPMC8563565 | biostudies-literature
Project description:In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This article, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This article discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo simulation, system dynamics modeling, discrete-event simulation, and agent-based simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this article, our goal is to enhance adoption of computer simulation, a set of methods that hold great promise in addressing emergency care organization and design challenges.
| S-EPMC5805575 | biostudies-literature
Project description:Introduction:High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods:We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results:All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion:Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potentially play a supportive role in developing an emergency medicine curriculum.
| S-EPMC7373349 | biostudies-literature
Project description:BackgroundAlthough robotic surgery has gained popularity, safety concerns remain due to potential delay in addressing intraoperative hemorrhages since the surgeon is not at the bedside. This study aimed to test whether a training program for emergency robotic undocking protocols improved the performance of thoracic operating room (OR) teams.MethodsAn emergency undocking protocol and checklists were created for massive hemorrhage during robotic thoracic surgery. In phase I, two OR teams participated in in-situ simulations of the scenarios in the OR without knowledge of the protocols. In phase II, the protocol and checklists were introduced to four different OR teams by either high-fidelity lab simulation or video-based didactic sessions. The teams' performances were tested with in-situ OR simulations. Performance assessments included the number of missed critical steps, participant-reported feedback, and timeliness of crucial steps.ResultsAll teams successfully converted from robot-assisted to open, with the attending at bedside within five minutes from the decision to convert, regardless of phase or education type. Phase I (control) teams had an average of 2.55 critical misses per team while the average was 0.25 for phase II teams (P=0.08). There was no significant difference between phases in time required for the surgeon to be at the bedside (average 132.2 seconds, P=0.64).ConclusionsTargeted education can lead to improved team performance. This study shows that high-fidelity simulation and didactic sessions can both be used to effectively teach emergency undocking protocols.
| S-EPMC11320252 | biostudies-literature