Christopher Hicks

Building a Simulation‐based Crisis Resource Management Course for Emergency Medicine, Phase 1: Results from an Interdisciplinary Needs Assessment Survey

INTRODUCTION Emergency department (ED) resuscitation requires the coordinated efforts of an interdisciplinary team. Human errors are common and have a negative impact on patient safety. Although crisis resource management (CRM) skills are utilized in other clinical domains, most emergency medicine (EM) caregivers currently receive no formal CRM training. OBJECTIVES The objectives were to compile and compare attitudes toward CRM training among EM staff physicians, nurses, and residents at two Canadian academic teaching hospitals. METHODS Emergency physicians (EPs), residents, and nurses were asked to complete a Web survey that included Likert scales and short answer questions. Focus groups and pilot testing were used to inform survey development. Thematic content analysis was performed on the qualitative data set and compared to quantitative results. RESULTS The response rate was 75.7% (N = 84). There was strong consensus regarding the importance of core CRM principles (i.e., effective communication, team leadership, resource utilization, problem-solving, situational awareness) in ED resuscitation. Problems with coordinating team actions (58.8%), communication (69.6%), and establishing priorities (41.3%) were among factors implicated in adverse events. Interdisciplinary collaboration (95.1%), efficiency of patient care (83.9%), and decreased medical error (82.6%) were proposed benefits of CRM training. Communication between disciplines is a barrier to effective ED resuscitation for 94.4% of nurses and 59.7% of EPs (p = 0.008). Residents reported a lack of exposure to (64.3%), yet had interest in (96.4%) formal CRM education using human patient simulation. CONCLUSIONS Nurses rate communication as a barrier to teamwork more frequently than physicians. EM residents are keen to learn CRM skills. An opportunity exists to create a novel interdisciplinary CRM curriculum to improve EM team performance and mitigate human error.

A Crisis of Faith? A Review of Simulation in Teaching Team-Based, Crisis Management Skills to Surgical Trainees

BACKGROUND Team-based training using crisis resource management (CRM) has gained popularity as a strategy to minimize the impact of medical error during critical events. The purpose of this review was to appraise and summarize the design, implementation, and efficacy of peer-reviewed, simulation-based CRM training programs for postgraduate trainees (residents). METHODS Two independent reviewers conducted a structured literature review, querying multiple medical and allied health databases from 1950 to May 2010 (MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO). We included articles that (1) were written in English, (2) were published in peer-reviewed journals, (3) included residents, (4) contained a simulation component, and (5) included a team-based component. Peer-reviewed articles describing the implementation of CRM instruction were critically appraised using the Kirkpatrick framework for evaluating training programs. RESULTS Fifteen studies involving a total of 404 residents met inclusion criteria; most studies reported high resident satisfaction for CRM training. In several CRM domains, residents demonstrated significant improvements after training, which did not decay over time. With regard to design, oral feedback may be equivalent to video feedback and single-day interventions may be as efficacious as multiple-day interventions for residents. No studies demonstrated a link between simulation-based CRM training and performance during real-life critical events. CONCLUSIONS The findings support the utility of CRM programs for residents. A high degree of satisfaction and perceived value reflect robust resident engagement. The iteration of themes from our review provides the basis for the development of best practices in curricula design. A dearth of well-designed, randomized studies preclude the quantification of impact of simulation-based training in the clinical environment.

Beyond crisis resource management: new frontiers in human factors training for acute care medicine.

Purpose of review Error is ubiquitous in medicine, particularly during critical events and resuscitation. A significant proportion of adverse events can be attributed to inadequate team-based skills such as communication, leadership, situation awareness and resource utilization. Aviation-based crisis resource management (CRM) training using high-fidelity simulation has been proposed as a strategy to improve team behaviours. This review will address key considerations in CRM training and outline recommendations for the future of human factors education in healthcare. Recent findings A critical examination of the current literature yields several important considerations to guide the development and implementation of effective simulation-based CRM training. These include defining a priori domain-specific objectives, creating an immersive environment that encourages deliberate practice and transfer-appropriate processing, and the importance of effective team debriefing. Building on research from high-risk industry, we suggest that traditional CRM training may be augmented with new training techniques that promote the development of shared mental models for team and task processes, address the effect of acute stress on team performance, and integrate strategies to improve clinical reasoning and the detection of cognitive errors. Summary The evolution of CRM training involves a ‘Triple Threat’ approach that integrates mental model theory for team and task processes, training for stressful situations and metacognition and error theory towards a more comprehensive training paradigm, with roots in high-risk industry and cognitive psychology. Further research is required to evaluate the impact of this approach on patient-oriented outcomes.

In situ simulation in emergency medicine: Moving beyond the simulation lab

In situ simulation (ISS), a point of care training strategy that occurs within the patient care environment involving actual healthcare team members, provides additional benefits to centre‐based simulation. ISS can serve several roles within emergency medicine (EM): improves provider/team performance, identifies and mitigates threats to patient safety and improves systems and infrastructure. The effective use of ISS fosters inter‐professional team training and a culture of safety essential for high performance EM teams and resilient systems. Using a case example, this article addresses the uses of ISS in EM, strategies for implementation and mitigation strategies for ED‐specific challenges.

Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST)

Introduction Errors in trauma resuscitation are common and have been attributed to breakdowns in the coordination of system elements (eg, tools/technology, physical environment and layout, individual skills/knowledge, team interaction). These breakdowns are triggered by unique circumstances and may go unrecognised by trauma team members or hospital administrators; they can be described as latent safety threats (LSTs). Retrospective approaches to identifying LSTs (ie, after they occur) are likely to be incomplete and prone to bias. To date, prospective studies have not used video review as the primary mechanism to identify any and all LSTs in trauma resuscitation. Methods and analysis A series of 12 unannounced in situ simulations (ISS) will be conducted to prospectively identify LSTs at a level 1 Canadian trauma centre (over 800 dedicated trauma team activations annually). 4 scenarios have already been designed as part of this protocol based on 5 recurring themes found in the hospitals mortality and morbidity process. The actual trauma team will be activated to participate in the study. Each simulation will be audio/video recorded from 4 different camera angles and transcribed to conduct a framework analysis. Video reviewers will code the videos deductively based on a priori themes of LSTs identified from the literature, and/or inductively based on the events occurring in the simulation. LSTs will be prioritised to target interventions in future work. Ethics and dissemination Institutional research ethics approval has been acquired (SMH REB #15-046). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will also be presented to key institutional stakeholders to inform mitigation strategies for improved patient safety.

The Human Factor

Resilience is built, not born, and there is no single strategy that reliably manufactures resilient performance in all circumstances. Optimizing team performance in dynamic environments involves the complex interplay of strategies that target individual preparation, team interaction, environmental optimization, and systems-level resilience engineering. To accomplish this, health care can draw influence from human factors research to inform tangible, practical, and measurable improvements in performance and outcomes, modified to suit local and domain-specific needs.

Tracking workflow during high-stakes resuscitation: the application of a novel clinician movement tracing tool during in situ trauma simulation

Introduction Clinician movement and workflow analysis provides an opportunity to identify inefficiencies during trauma resuscitation care. Inefficient workflows may represent latent safety threats (LSTs), defined as unrecognised system-based elements that can negatively impact patients. In situ simulation (ISS) can be used to model resuscitation workflows without direct impact on patients. We report the pilot application of a novel, tracing tool to track clinician movement during high-fidelity ISS trauma sessions. Methods Twelve unannounced ISSs were conducted. An open source, Windows-based video overlay tracing tool was developed to generate a visual representation of participant movement during ISS. This tracing tool used a manual mouse tracking algorithm to produce point-by-point location information of a selected participant in a video. The tracing tool was applied to video recordings of clinicians performing a cricothyroidotomy during ISS trauma scenarios. A comparative workflow and movement analysis was completed, which included distance travelled and space utilisation. This data was visually represented with time-lapsed movement videos and heat maps. Results A fourfold difference in the relative distance travelled was observed between participants who performed a cricothyroidotomy during an ISS trauma resuscitation. Variation in each participant’s movement was attributable to three factors: (1) team role assignment and task allocation; (2) knowledge of clinical space: equipment location and path to equipment retrieval; and (3) equipment bundling. This tool facilitated LST identification related to cricothyroidotomy performance. Conclusion This novel tracing tool effectively generated a visual representation of participants’ workflows and quantified movement during ISS video review. An improved understanding of human movement during ISS trauma resuscitations provides a unique opportunity to augment simulation debriefing, conduct human factor analysis of system elements (eg, tools/technology, physical environment/layout) and foster change management towards efficient workflows.

Bougie-assisted cricothyroidotomy: Delphi-derived essential steps for the novice learner

OBJECTIVE A cricothyroidotomy is a life-saving procedure, performed as a final option to emergency airway algorithms, and is essential for all clinicians who perform emergency airway management. The bougie-assisted cricothyroidotomy (BAC) is a novel technique that may be performed faster and with fewer complications than other traditional approaches. There is no established standard set of steps to guide the instruction of BAC performance. This study sought to systematically develop a BAC checklist for novice instruction using a modified Delphi methodology and international airway experts. METHODS A literature review informed the creation of a preliminary BAC checklist. A three round, modified Delphi method was used to establish a BAC checklist intended for novice-level instruction. The consensus level for each step and the final checklist were predefined at 80%. Participants were international airway experts identified by study personnel and snowball sampling. RESULTS Fourteen international airway experts across six acute care specialities participated in the study. The checklist was refined using a seven-point rating scale for each item and participant comments. A 17-item checklist was developed with expert consensus achieved after three rounds. Internal consistency, measured with Cronbachs α, was 0.855 (95% confidence interval 0.73-0.94). CONCLUSION This modified Delphi-derived checklist is the first systematically developed list of essential steps for guiding BAC instruction for novice learners. This tool serves to standardize BAC skill instruction and provide learners with a structured and consistent set of steps for deliberate practice.

Crisis Resource Management Training in Trauma

Trauma care is a high-risk, high-hazard operation. Ambient noise and distractions competing priorities coupled with acute, ambiguous, and rapidly evolving scenarios contribute to the “organized chaos” that defines modern trauma care. Effective team-based skills can mitigate the extent to which these human, situational, and environmental factors influence the clinical care of patients. Team-based or nontechnical skills are not innate, but can be learned and developed over time through the study and application of human factors theory and system design. The following chapter briefly outlines the history of human factors and crisis resource management in high-risk industry, with a focus on nontechnical skills training for high-performance medical teams.