Andrew Goldberg

A Systematic Review of Serious Games in Training Health Care Professionals.

Summary Statement Serious games are computer-based games designed for training purposes. They are poised to expand their role in medical education. This systematic review, conducted in accordance with PRISMA guidelines, aimed to synthesize current serious gaming trends in health care training, especially those pertaining to developmental methodologies and game evaluation. PubMed, EMBASE, and Cochrane databases were queried for relevant documents published through December 2014. Of the 3737 publications identified, 48 of them, covering 42 serious games, were included. From 2007 to 2014, they demonstrate a growth from 2 games and 2 genres to 42 games and 8 genres. Overall, study design was heterogeneous and methodological quality by MERQSI score averaged 10.5/18, which is modest. Seventy-nine percent of serious games were evaluated for training outcomes. As the number of serious games for health care training continues to grow, having schemas that organize how educators approach their development and evaluation is essential for their success.

The impact of simulated patient death on medical students’ stress response and learning of ACLS

Abstract Introduction: There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills. Methods: Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested. Results: For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p < 0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115 μg/dL, p <0.01 and + 97 pg/mL, p < 0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p < 0.05. There was no difference on long-term knowledge or skills. Conclusions: Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.

Using Serious Gaming to Improve the Safety of Central Venous Catheter Placement: A Post-Mortem Analysis

Central venous catheter related complications are a large burden on our healthcare system. Many of these complications can be prevented by the use of proper technique. One methodology to aid in the teaching non-technical aspects of procedures, serious games, has not been utilized in our field. The authors therefore set out to design a serious game aimed at teaching proper central venous catheter placement. The objective of this manuscript is to examine the challenges encountered while designing and executing our serious gaming trial. Ultimately, they found their game to be an effective teaching tool, although the game development phase of our study was long. The authors therefore concluded that serious gaming is an effective tool for teaching proper technique for the placement of central venous catheters.

Transfusion-Related Acute Lung Injury (TRALI) and Transfusion-Associated Circulatory Overload (TACO) in Liver Transplantation: A Case Report and Focused Review

Liver transplantation (LT) is a complex procedure in a patient with multi-organ system dysfunction and coagulation defects. The surgical procedure involves dissection, major vessel manipulation, and pathophysiologic effects of graft storage and reperfusion. As a result, LT frequently involves significant hemorrhage. Subsequent massive transfusion carries high risk of transfusion-associated complications. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion associated mortality. In this case report and focused review, we present data that suggest that patients undergoing liver transplantation may be at higher risk for TRALI and TACO than the general population. Anesthesiologists can play a role in decreasing these risks by increasing recognition and reporting of TRALI and TACO, using point of care testing with thromboelastography to guide and decrease transfusion, and considering alternatives to traditional blood products like solvent/detergent plasma.

ASA physical status assignment by non-anesthesia providers: Do surgeons consistently downgrade the ASA score preoperatively?

OBJECTIVE The American Society of Anesthesiologists physical status (ASA-PS) is associated with increased morbidity and mortality in the perioperative period. When surgeries are scheduled by surgeons and their staff at our large institution a presumed ASA-PS is chosen. This is because our institution (and, anecdotally, others in our hospital system and elsewhere), recognizing the relationship between higher ASA-PS and poorer postoperative outcomes, requires all patients with higher ASA-PS levels (≥3) to undergo enhanced preoperative workup. The patients may not, however, necessarily be seen in the anesthesia clinic prior to surgery. As a result, patients are assigned a presumed ASA-PS by a non-anesthesia provider (e.g., surgeons and physician extenders) that may not reflect the ASA-PS chosen by the anesthesiologist on the day of surgery. Errors in the accuracy of the ASA-PS prior to surgery lead to unnecessary and costly preoperative testing, delays in operative procedures, and potential case cancellations. Our study aimed to determine whether there are significant differences in the assignment of ASA-PS by non-anesthesia providers when compared to anesthesia providers. DESIGN We administered an IRB-approved survey asking the ASA-PS of 20 hypothetical case vignettes to 229 clinicians in various departments. Responses by non-anesthesia providers were compared to the consensus of the department of anesthesiology. SETTING Faculty office spaces and conferences. PATIENTS No patients, physicians only. INTERVENTIONS Survey administration. MEASUREMENTS ASA-PS scores acquired from surveys. MAIN RESULTS Residents and faculty in the department of anesthesiology demonstrated no statistical difference in the median ASA score in 19/20 case scenarios. All other departments were statistically different when compared to the department of anesthesiology (p<0.05). The probability of a department either over- or under-rating the ASA-PS was calculated, and is summarized in Fig. 3. All departments, except anesthesiology, had a 30-40% chance of under-rating the ASA-PS of the patients in the clinical vignettes. CONCLUSIONS Non-anesthesia providers assign ASA-PS with significantly less accuracy than do anesthesia providers, even when adjusted for multiple comparisons. Surgical and procedural departments were found to consistently under-rate the ASA-PS of patients in our clinical vignettes.

Performance gaps and improvement plans from a 5-hospital simulation programme for anaesthesiology providers: a retrospective study

Background Simulation is increasingly employed in healthcare provider education, but usage as a means of identifying system-wide practitioner gaps has been limited. We sought to determine whether practice gaps could be identified, and if meaningful improvement plans could result from a simulation course for anaesthesiology providers. Methods Over a 2-year cycle, 288 anaesthesiologists and 67 certified registered nurse anaesthetists (CRNAs) participated in a 3.5 hour, malpractice insurer-mandated simulation course, encountering 4 scenarios. 5 anaesthesiology departments within 3 urban academic healthcare systems were represented. A real-time rater scored each individual on 12 critical performance items (CPIs) representing learning objectives for a given scenario. Participants completed a course satisfaction survey, a 1-month postcourse practice improvement plan (PIP) and a 6-month follow-up survey. Results All recorded course data were retrospectively reviewed. Course satisfaction was generally positive (88–97% positive rating by item). 4231 individual CPIs were recorded (of a possible 4260 rateable), with a majority of participants demonstrating remediable gaps in medical/technical and non-technical skills (97% of groups had at least one instance of a remediable gap in communication/non-technical skills during at least one of the scenarios). 6 months following the course, 91% of respondents reported successfully implementing 1 or more of their PIPs. Improvements in equipment/environmental resources or personal knowledge domains were most often successful, and several individual reports demonstrated a positive impact on actual practice. Conclusions This professional liability insurer-initiated simulation course for 5 anaesthesiology departments was feasible to deliver and well received. Practice gaps were identified during the course and remediation of gaps, and/or application of new knowledge, skills and resources was reported by participants.

High-stakes Simulation-based Assessment for Retraining and Returning Physicians to Practice.

Physician shortages, whether real or perceived, remain a constant reality of modern health care. Shortages may be attributed to increasing demand and decreasing supply of physicians due to economic and political pressures. However, there are a multitude of individual reasons why many physicians may leave the workforce. Retraining physicians who have left medicine to return to practice is one method proposed to overcome these shortages. There are multiple programs, both in the United States and abroad, describing methods by which attending physicians can accomplish this task. The American Medical Association (AMA) has emphasized the need for reentry programs, and has set forth guidelines that should be met when creating such curricula. Although guidelines provide a framework for curriculum design, the AMA intentionally left the teaching methods open-ended to allow for educational flexibility, and to permit programs to be tailored to local and specialized needs. Using high-stakes, highfidelity simulation-based assessment to both evaluate and specifically tailor the curriculum for the physician seeking reentry is 1 unique method described. Although simulation-based assessment is controversial and poses significant challenges, its utility has been illustrated in the reentry of physicians in multiple fields and represents a realistic method for returning to practice. In this article we will discuss the need for and use of simulation as a tool for physician reentry.

Serious Gaming for Orthotopic Liver Transplant Anesthesiology: A Randomized Control Trial

Anesthetic management of orthotopic liver transplantation (OLT) is complex. Given the unequal distributions of liver transplant surgeries performed at different centers, anesthesiology providers receive relatively uneven OLT training and exposure. One well‐suited modality for OLT training is the “serious game,” an interactive application created for the purpose of imparting knowledge or skills, while leveraging the self‐motivating elements of video games. We therefore developed a serious game designed to teach best practices for the anesthetic management of a standard OLT and determined if the game would improve resident performance in a simulated OLT. Forty‐four residents on the liver transplant rotation were randomized to either the gaming group (GG) or the control group (CG) prior to their introductory simulation. Both groups were given access to the same educational materials and literature during their rotation, but the GG also had access to the OLT Trainer. Performance on the simulations were recorded on a standardized grading rubric. Both groups experienced an increase in score relative to baseline that was statistically significant at every stage. The improvements in scores were greater for the GG participants than the CG participants. Overall score improvement between the GG and CG (mean [standard deviation]) was statistically significant (GG, 7.95 [3.65]; CG, 4.8 [4.48]; P = 0.02), as were scores for preoperative assessment (GG, 2.67 [2.09]; CG, 1.17 [1.43]; P = 0.01) and anhepatic phase (GG, 1.62 [1.01]; CG, 0.75 [1.28]; P = 0.02). Of the residents with game access, 81% were “very satisfied” or “satisfied” with the game overall. In conclusion, adding a serious game to an existing educational curriculum for liver transplant anesthesia resulted in significant learning gains for rotating anesthesia residents. The intervention was straightforward to implement and cost‐effective. Liver Transplantation 23 430–439 2017 AASLD.

Intraoperative Hemodynamic Instability and Diagnosis of Pheochromocytoma During Excision of Adrenal Incidentaloma With Incomplete Workup: A Case Report

Preoperative evaluation of incidentalomas for pheochromocytoma is imperative. This case report describes a scheduled adrenalectomy in an asymptomatic patient with what was eventually determined to be an incomplete biochemical workup. The intraoperative course was complicated by labile and rapid increases in blood pressure and heart rate, suggesting the missed diagnosis of pheochromocytoma. It is important for anesthesiologists to ensure adequate preoperative biochemical workup before excluding the possibility of coexisting pheochromocytoma.

Healthcare-Associated Mycobacterium chimaera Infection Subsequent to Heater-Cooler Device Exposure During Cardiac Surgery

A SERIES of reports in the United States and Europe have linked Mycobacterium chimaera infections to contaminated heater-cooler devices used during cardiac surgery. Heater-cooler devices commonly are used for cardiopulmonary bypass during cardiac surgery. M. chimaera is a slow-growing nontuberculous mycobacterium that has been shown to cause cardiac complications that can lead to fatal disease following cardiac surgery. Given that more than 250,000 cardiothoracic surgical procedures requiring cardiopulmonary bypass take place each year in the United States, the estimated number of patient exposures to M. chimaera has prompted a public health crisis. The goal of this review is to summarize the present status of the M. chimaera outbreak and provide cardiothoracic surgeons, cardiac anesthesiologists, and other clinicians with current approaches to patient management and to discuss risk mitigation.