Benjamin W. Berg

In Situ, Multidisciplinary, Simulation-Based Teamwork Training Improves Early Trauma Care

OBJECTIVE Evaluate the impact of a team training curriculum for residents and multidisciplinary trauma team members on team communication, coordination and clinical efficacy of trauma resuscitation. DESIGN Prospective, cohort intervention comparing pre- vs. post-training performance. The intervention was a human patient simulator (HPS)-based, in situ team training curriculum, comprising a one-hour web based didactic followed by HPS training in the emergency department (ED). Teams were trained in multidisciplinary groups of 5-8 persons. Each HPS session included three fifteen minute scenarios with immediate video-enabled debriefing. Structured debriefing and teamwork assessment was performed with a modified NOTECHS scale for trauma (T-NOTECHS). Teams were assessed for performance changes during HPS-based training, as well as in actual trauma resuscitations. SETTING The Queens Trauma Center (Level II); the primary teaching hospital for the University of Hawaii Surgical Residency. PARTICIPANTS 137 multidisciplinary trauma team members, including residents (n = 24), ED and trauma attending physicians, nurses, respiratory therapists, and ED technicians. RESULTS During HPS-based training sessions, significant improvements in teamwork ratings, and in clinical task speed and completion rates were noted between the first and the last scenario.244 real-life blunt trauma resuscitations were observed for six months before and after training. There was a significant improvement in mean teamwork scores from the pre-to post-training resuscitations. Moreover, there were significant improvements in the objective parameters of speed and completeness of resuscitation. This was manifest by a 76% increase in the frequency of near-perfect task completion (≤ 1 unreported task), and a reduction in the mean overall ED resuscitation time by 16%. CONCLUSIONS A relatively brief (four-hour) HPS-based curriculum can improve the teamwork and clinical performance of multidisciplinary trauma teams that include surgical residents. This improvement was evidenced both in simulated and actual trauma settings, and across teams of varying composition. HPS-based trauma teamwork training appears to be an educational method that can impact patient care.

Assessing teamwork in the trauma bay: introduction of a modified “NOTECHS” scale for trauma

BACKGROUND A modified nontechnical skills (NOTECHS) scale for trauma (T-NOTECHS) was developed to teach and assess teamwork skills of multidisciplinary trauma resuscitation teams. In this study, T-NOTECHS was evaluated for reliability and correlation with clinical performance. METHODS Interrater reliability (intraclass correlation coefficient) and correlation with the speed and completeness of resuscitation tasks were assessed during simulation-based teamwork training and during actual trauma resuscitations. RESULTS For T-NOTECHS ratings done in real time, intraclass correlation coefficients were .44 for simulated and .48 for actual resuscitations. Reliability was higher (intraclass correlation coefficient = .71) for video review of resuscitations. Better T-NOTECHS scores were correlated with better performance during simulations, evidenced by a greater number of completed resuscitation tasks (r = .50, P < .01) and faster time to completion (r = -.38, P < .05) In actual resuscitations, T-NOTECHS ratings improved after teamwork training (P < .001). Higher T-NOTECHS scores were correlated with better clinical performance, evidenced by faster resuscitation (r = -.13, P < .05) and fewer unreported resuscitation tasks (r = -.16, P < .05). CONCLUSIONS Improvement in T-NOTECHS scores after teamwork training, and correlation with clinical parameters in simulated and actual trauma resuscitations, suggest its clinical relevance. Further evaluation, aiming to improve reliability, may be warranted.

The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance: a randomized trial.

Introduction Debriefing is a critical component of effective simulation-based medical education. The optimal format in which to conduct debriefing is unknown. The use of video review has been promoted as a means of enhancing debriefing, and video-assisted debriefing is widely used in simulation training. Few empirical studies have evaluated the impact of video-assisted debriefing, and the results of those studies have been mixed. The objective of this study was to compare the effectiveness of video-assisted debriefing to oral debriefing alone at improving performance in neonatal resuscitation. Methods Thirty residents, divided into 15 teams of 2 members each, participated in the study. Each team completed a series of 3 neonatal resuscitation simulations. Each simulation was followed by a facilitated debriefing. Teams were randomly assigned to receive either oral debriefing alone or video-assisted debriefing after each simulation. Objective measures of performance and times to complete critical tasks in resuscitation were evaluated by blinded video review on the first (pretest) and the third (posttest) simulations using a previously validated tool. Results Overall neonatal resuscitation performance scores improved in both groups [mean (SD), 83% (14%) for oral pretest vs. 91% (7%) for oral posttest (P = 0.005); 81% (16%) for video pretest vs. 93% (10%) for video posttest (P < 0.001)]. There was no difference in performance scores between the 2 groups on either the pretest or posttest [overall posttest scores, 91.3% for oral vs. 93.4% for video (P = 0.59)]. Times to complete the critical tasks of resuscitation also did not differ significantly between the 2 study groups. The educational effect of the video-assisted debriefing versus oral debriefing alone was small (d = 0.08). Conclusions Using this study design, we failed to show a significant educational benefit of video-assisted debriefing. Although our results suggest that the use of video-assisted debriefing may not offer significant advantage over oral debriefing alone, exactly why this is the case remains obscure. Further research is needed to define the optimal role of video review during simulation debriefing in neonatal resuscitation.

Deliberate practice using simulation improves neonatal resuscitation performance.

Introduction: Simulation will soon become the standard method of training in the Neonatal Resuscitation Program (NRP). Deliberate practice (DP) using simulation has been shown to improve performance in other areas of medicine. The objective of this study was to evaluate the effectiveness of DP using simulation on improving NRP performance. Methods: Using a pretest-posttest design, 15 teams of 2 residents participated in a series of 3 NRP simulations followed by a facilitated debriefing. Objective measures of NRP performance and time to complete critical tasks were evaluated on the first (pretest) and the third (posttest) simulations by blinded video review using a validated scoring instrument. Results: Improvements were seen in scores for overall NRP performance (pretest 82.5% vs. posttest 92.5%, mean difference 10% [95% CI, 1.5–18.5]; P = 0.024) and positive-pressure ventilation (pretest 73.3% vs. posttest 95.0%, mean difference 21.7% [95% CI, 0.8–42.5]; P = 0.043). Time to the vascular access decreased by over 1 minute from baseline (pretest 404 second vs. posttest 343 second, mean difference −60.3 second [95% CI, −119.6 to −0.9]; P = 0.047) as did the time to first IV medication (pretest 452 second vs. posttest 387 second, mean difference −64.9 second [95% CI, −112.4 to −17.5]; P = 0.011). Conclusions: Our results suggest that DP using simulation is associated with improvements in NRP performance and support the use of DP using simulation in NRP training.

Microwave stethoscope: development and benchmarking of a vital signs sensor using computer-controlled phantoms and human studies.

This paper describes a new microwave-based method and associated measurement system for monitoring multiple vital signs (VS) as well as the changes in lung water content. The measurement procedure utilizes a single microwave sensor for reflection coefficient measurements, hence the name “microwave stethoscope (MiSt),” as opposed to the two-sensor transmission method previously proposed by the authors. To compensate for the reduced sensitivity due to reflection coefficient measurements, an improved microwave sensor design with enhanced matching to the skin and broadband operation, as well as an advanced digital signal processing algorithm are used in developing the MiSt. Results from phantom experiments and human clinical trials are described. The results clearly demonstrate that MiSt provides reliable monitoring of multiple VS such as the respiration rate, heart rate, and the changes in lung water content through a single microwave measurement. In addition, information such as heart waveforms that correlates well with electrocardiogram is observed from these microwave measurements. Details of the broadband sensor design, experimental procedure, DSP algorithms used for VS extraction, and obtained results are presented and discussed.

Alarm limit settings for early warning systems to identify at-risk patients

AIM This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems. BACKGROUND Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings. METHODS A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003-January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits. RESULTS A total of 317 patients satisfied the inclusion criteria, with 780.71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130-135, low 40-45; respiratory rate high 30-35, low 7-8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow. CONCLUSION Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.

Technology-enabled interprofessional education for nursing and medical students: A pilot study.

The US Joint Commission, a non-profit healthcare accreditation organization, identified miscommunication as the main cause of serious, unexpected patient injuries (The Joint Commission, 2007), and improving the effectiveness of communication among healthcare providers as a 2009 US National Patient Safety Goal (The Joint Commission, 2009). One strategy for improving interprofessional communication is the Situation-BackgroundAssessment-Recommendation (SBAR) communication tool (Haig, Sutton, & Whittington, 2006). This tool has four components: situation (a description of the clinical event), background (circumstances surrounding the event), assessment (possible causes), and recommendation (possible corrective actions). Medical and nursing students have demonstrated improved information transfer when using the SBAR method during manikin-based simulations within their own professional schools (Krautscheid, 2008; Marshall et al., 2007). Medical simulation may be resource intensive in terms of equipment and trained faculty, and distance education technologies have the potential to leverage limited resources (Berg, Wong, & Vincent, 2007). This paper reports on a study that assessed the feasibility of conducting interprofessional SBAR training with nursing and medical students using remote technologies coupled with manikin simulation. The feasibility of using a university-based faculty nurse experienced in simulation-based education as a manikin operator, student evaluator, and mentor at a site distant from the students and simulation was also assessed.

Mass-casualty triage training for international healthcare workers in the Asia-Pacific Region using manikin-based simulations.

INTRODUCTION More than half of the worlds disasters occur in the Asia-Pacific region. A simulation-based exercise to teach healthcare workers prehospital triage, tagging, and treatment methods was used to link disaster management theory to practice with a student-centered, hands-on educational activity. Various strategies for teaching disaster health education have been advocated, and best-practice disaster education models continue to be sought. METHODS A manikin-based, primary triage and treatment course was adapted for international healthcare providers in the Asia-Pacific region using symbolic representations of triage categories and physical findings. The pedagogical construct that was used was an interactive, formative assessment in which faculty members mediated learner information gathering and interpretation during four simulation scenarios. After establishing a multi-casualty disaster context, a wireless, audience response system anonymously collected learner responses to four clinical situations: (1) leg wound (hemorrhagic shock/immediate); (2) chest wound (tension pneumothorax/immediate); (3) head wound (traumatic brain injury/expectant); and (4) limb trauma (leg fracture/delayed). RESULTS There were 182 healthcare providers from eight Asia-Pacific countries (including the US) that participated in four simulation seminars. The simulation sessions were successfully tailored to groups of learners that varied in size and professional composition. Expectant and delayed triage categories posed the greatest challenge to learners. In one of two groups that were queried, learner self-confidence in applying principles of triage and treatment improved significantly. At the conclusion of the simulation sessions, learners strongly agreed that manikin-based simulation improved their understanding of triage, and should be used to teach principles of primary triage and treatment. CONCLUSIONS Simulation training represents an opportunity to engage learners regardless of language and cultural barriers. Simulation-based training can be effective in introducing healthcare professionals to principles of primary triage and treatment in an effective and culturally sensitive manner. The characteristics of the course with respect to planned formative assessment and culturally competent scholarship were reviewed.

Teaching mass casualty triage skills using iterative multimanikin simulations.

Objective. Effective mass casualty triage requires rapid andaccurate decision making. First responders need to be trained, but opportunities to practice triage andreceive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, andself-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. Methods. Learners initially developed baseline knowledge of MC triage by listening to four short podcasts andpassing a written examination. They then experienced three sequential MC scenarios (A, B, andC) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) andintervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, andtriage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy andreaction to the training. Results. Twenty-one medical students were enrolled and20 students passed the examination. The TS andIS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment andresources, identifying high-risk casualties, andlearning to be an effective first responder. Conclusion. Novice learners demonstrated improved triage andintervention scores, speed, andself-efficacy during an iterative, multimanikin MC training experience

Modification of the Laerdal SimBaby to include an integrated umbilical cannulation task trainer.

Background: Given the emphasis on early vascular access via the umbilical vein in neonatal resuscitation it is essential that participants in neonatal resuscitation simulation training be given the opportunity to practice both the placement and use of an emergency umbilical venous catheter. By integrating available parts from the Laerdal catalog, combined with a few other inexpensive components, into a Laerdal SimBaby we were able to create a single, integrated neonatal simulator that could be used to practice both the placement and use of an emergent umbilical vein catheter. Methods: To integrate an umbilical cannulation task trainer into the Laerdal SimBaby we used a specially modified replaceable umbilical cord and reservoir from the Laerdal Neonatal Resuscitation Baby. To this reservoir we attached a flanged outlet drain and drainage tube which allows for the infusion of medications and fluids. The modified SimBaby with integrated umbilical cannulation task trainer was validated for both face and content by simulation participants and a panel of neonatal resuscitation experts. Results: The umbilical cannulation task trainer integrated well into the SimBaby and in no way altered the function of the mannequin. The modified Laerdal SimBaby was thought to work well by both participants and experts. Simulation participants liked having the chance to practice emergency umbilical vein cannulation and thought that the simulated umbilical cord was an important component in their learning experience. The expert panel thought that the modified SimBaby could be used for emergency umbilical vein cannulation skills training and that the addition gave the modified SimBaby major advantage over other simulators they had used to teach newborn resuscitation. Discussion: We have developed a modification to the Laerdal SimBaby involving the integration of a usable umbilical cannulation task trainer. The modification was easily accomplished using available parts from the Laerdal catalog and a few other inexpensive components. Given the emphasis on early vascular access via the umbilical vein and the complexities involved with the administration of medications and fluids via this route we believe that a usable umbilical cannulation task trainer is essential to neonatal resuscitation simulation training. When modified as described the Laerdal SimBaby can act as a high-fidelity newborn simulator that allows participants to practice both the placement and use of an emergency umbilical vessel catheter. Given our positive experience we think others could apply the above modification to their own SimBaby.