Charles N. Pozner

Simulation-based trial of surgical-crisis checklists.

BACKGROUND Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events. METHODS Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists. RESULTS A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used. CONCLUSIONS In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: the Boston EMS experience.

With the many advances in rapid reperfusion therapy for management of acute ST segment elevation myocardial infarction (STEMI), there is a need to revisit the current plan for prehospital triage (point of entry). Until recently in Boston, and nationwide, there has been a policy that patients with suspected acute MI were brought to the nearest hospital. Then, if ST segment elevation was present, patients were treated with either thrombolytic therapy or primary percutaneous coronary intervention (PCI). Recent data, however, have shown that with advances in interventional devices, techniques and institutional experience, primary PCI is associated with improved outcomes compared with thrombolytic therapy for all patients with STEMI when provided at expert centers with high institutional volumes, with experienced interventional cardiologists as the operators, and with relatively short time to treatment. We describe the rationale for and the implementation of the Boston EMS STEMI Triage Plan and Treatment Registry. Many of the issues that prompted the implementation of the Boston STEMI plan are relevant to all EMS systems. Among these issues are the accuracy of prehospital identification of STEMI patients, the availability of mechanical reperfusion therapy, the appropriate triage of patients with complicated myocardial infarction or shock, as well as the local consensus regarding strength of the evidence favoring mechanical reperfusion. This article describes the history of the Boston EMS STEMI Triage Plan and Treatment Registry and suggests the need for other EMS systems to develop a systematic approach to patients with STEMI.

Cardiopulmonary resuscitation feedback improves the quality of chest compression provided by hospital health care professionals

STUDY OBJECTIVE High-quality chest compressions (CCs) are an important component of successful resuscitation. Suboptimal in-hospital CC are commonly reported. Skill degradation and fatigue have been implicated. We assessed the effect of a handheld feedback device on the measured and perceived quality of CC and rescuer physiologic response. METHODS This is a nonblinded randomized controlled study of nurses at an academic medical center. Participants performed CC on a mannequin either with or without a feedback device. Compression rate (CR) and compression depth (CD), heart rate, and oxygen saturation were documented. Perceived quality of CC, fatigue, and ease of use of the device were obtained. RESULTS Twelve nurses were in the feedback group (FG) and 13 were controls. Mean CD was significantly higher in the FG (1.99 ± 0.37 in vs 1.52 ± 0.36 in; P = .005) and mean CR significantly lower in the FG (127 ± 13.8 per min vs 101 ± 9.7 per min; P ≤ .0001). Using a CD of more than 1.5 in and a CR of 90 to 100 as a composite measure of high-quality CC, the FG performed significantly better (81.4% ± 22.0% vs 10.4% ± 21.9%; P < .0001). Perceived CD, CR, and fatigue did not differ between groups; however, participants overestimated depth and underestimated rate. The FG rated the design as user-friendly (85% + 26%) helpful in maintaining correct CR (83% + 26%). CONCLUSION A handheld accelerometer-based audiovisual cardiopulmonary resuscitation (CPR) feedback device significantly improved the quality of CCs provided by experienced hospital nurses in a simulated setting, with no perceived or measured difference in fatigue between the 2 groups. The CPR feedback provides an effective means to monitor and improve CPR performance.

Risk of Leakage and Tissue Dissemination With Various Contained Tissue Extraction (CTE) Techniques: An in Vitro Pilot Study

STUDY OBJECTIVE To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN In vitro study (Canadian Task Force classification: II-1). SETTING Academic hospital simulation laboratory. INTERVENTION Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

E MERGENCY M EDICAL S ERVICES C APACITIES IN THE D EVELOPING W ORLD : P RELIMINARY E VALUATION AND T RAINING IN A DDIS A BABA , E THIOPIA

In December 1999, a group of emergency physicians from the United States, Israel, and Ethiopia met for the Second Annual Symposium on Emergency Medicine and to perform an initial evaluation of the prehospital care system in Addis Ababa. The symposium was structured into a workshop on prehospital care and a clinical seminar for emergency medicine providers. This article describes the current prehospital infrastructure in Addis Ababa, Ethiopia. This serves as the basis for more specific needs assessments and training interventions, which are ongoing. The authors present a list of priorities for the development of an emergency medical services (EMS) system for Addis Ababa that was generated in partnership with local government and the World Health Organization. The article contrasts these initial recommendations with those found in the literature on the development of EMS systems in developing nations.

C ONCORDANCE OF F IELD AND E MERGENCY D EPARTMENT A SSESSMENT IN THE P REHOSPITAL M ANAGEMENT OF P ATIENTS WITH D YSPNEA

Objective. Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level. Methods. This was a retrospective, cohort study of consecutive patients aged ≥35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes. Results. Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa = 0.60; 95% confidence interval [CI] = 0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa = 0.69; 95% CI = 0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant. Conclusion. The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.

Concordance of field and emergency department assessment in the prehospital management of patients with dyspnea

OBJECTIVE Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level. METHODS This was a retrospective, cohort study of consecutive patients aged > or =35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes. RESULTS Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa=0.60; 95% confidence interval [CI]=0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa=0.69; 95% CI=0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant. CONCLUSION The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.

Comparison of Video, Optical, and Direct Laryngoscopy by Experienced Tactical Paramedics

Abstract Objectives. While optical and video laryngoscopy have been studied in the emergency department, the operating room, and the routine prehospital setting, their efficacy in the tactical environment—in which operator safety is as important as intubation success—has not been evaluated. This study compared direct laryngoscopes to optical (AirTraq) and video (King Vision) laryngoscopes in a simulated tactical setting. Methods. This prospective institutional review board-approved simulation study evaluated each of the laryngoscopes in the hands of seven experienced tactical paramedics. After a one-hour training session, each tactical paramedic used each of the laryngoscopes, in a random order, on each of four different airway manikins. A tactical environment was simulated using auditory and visual immersion, and the intubations occurred on the ground with the paramedics in full tactical gear. Outcomes included time to successful ventilation, first-pass success rate, Cormack-Lehane grade, and intubator head height during the intubation. Statistical analysis included chi-squared and Wilcoxon rank sum tests, and multivariate logistic regression was performed to determine contributing factors to outcomes with significant variation. Results. A total of 84 intubations were performed by seven tactical paramedics. While there were no significant differences in time to successful ventilation or first-pass success rate, the optical and video laryngoscopes had significantly better Cormack-Lehane grades, defined as grade I or II (100% for both compared to 85.7%), while direct laryngoscopy resulted in significantly less maximum vertical exposure of the intubator (51.82 cm compared to AirTraqs 56.64 cm and King Visions 56.13 cm). Conclusion. Video and optical laryngoscopes can be used successfully by experienced tactical paramedics in a simulated tactical setting. The King Vision and AirTraq resulted in improved Cormack-Lehane glottic views but similar times to ventilation and first-pass success compared to direct laryngoscopy. Intubator head height was lower with direct laryngoscopy. Clarifying the role of optical and video laryngoscopes in a tactical environment, especially in the hands of less experienced intubators, requires further research.

Using a medical simulation center as an electronic health record usability laboratory

Usability testing is increasingly being recognized as a way to increase the usability and safety of health information technology (HIT). Medical simulation centers can serve as testing environments for HIT usability studies. We integrated the quality assurance version of our emergency department (ED) electronic health record (EHR) into our medical simulation center and piloted a clinical care scenario in which emergency medicine resident physicians evaluated a simulated ED patient and documented electronically using the ED EHR. Meticulous planning and close collaboration with expert simulation staff was important for designing test scenarios, pilot testing, and running the sessions. Similarly, working with information systems teams was important for integration of the EHR. Electronic tools are needed to facilitate entry of fictitious clinical results while the simulation scenario is unfolding. EHRs can be successfully integrated into existing simulation centers, which may provide realistic environments for usability testing, training, and evaluation of human-computer interactions.

Expanding simulation-based education through institution-wide initiatives: A blueprint for success

BACKGROUND The Consortium of American College of Surgeons Accredited Education Institutes (ACS-AEIs) was created to promote patient safety through the use of simulation, develop innovative education and training, advance technologies, identify best practices, and encourage research and collaboration. METHODS During the seventh annual meeting of the consortium, leaders from across the consortium who have developed institution-wide simulation centers were invited to participate in a panel to discuss their experiences and the lessons learned. CONCLUSION These discussions resulted in definition of 5 key areas that need to be addressed effectively to support efforts of the ACS-AEIs.