Demian Szyld

What You See (Sonographically) Is What You Get: Vein and Patient Characteristics Associated With Successful Ultrasound-guided Peripheral Intravenous Placement in Patients With Difficult Access

OBJECTIVES Ultrasound (US) has been shown to facilitate peripheral intravenous (IV) placement in emergency department (ED) patients with difficult IV access (DIVA). This study sought to define patient and vein characteristics that affect successful US-guided peripheral IV placement. METHODS This was a prospective observational study of US-guided IV placement in a convenience sample of DIVA patients in an urban, tertiary care ED. DIVA patients were defined as having any of the following: at least two failed IV attempts or a history of difficult access plus the inability to visualize or palpate any veins on physical exam. Patient characteristics (demographic information, vital signs, and medical history) were collected on enrolled patients. The relationships between patient characteristics, vein depth and diameter, US probe orientation, and successful IV placement were analyzed. RESULTS A total of 169 patients were enrolled, with 236 attempts at access. Increasing vessel diameter was associated with a higher likelihood of success (odds ratio [OR] = 1.79 per 0.1-cm increase in vessel diameter, 95% confidence interval [CI] = 1.37 to 2.34). Increasing vessel depth did not affect success rates (OR = 0.96 per 0.1-cm increase of depth, 95% CI = 0.89 to 1.04) until a threshold depth of 1.6 cm, beyond which no vessels were successfully cannulated. Probe orientation and patient characteristics were unrelated to success. CONCLUSIONS Success was solely related to vessel characteristics detected with US and not influenced by patient characteristics or probe orientation. Successful DIVA was primarily associated with larger vessel, while vessel depth up to >1.6 cm and patient characteristics were unrelated to success. Clinically, if two vessels are identified at a depth of <1.6 cm, the larger diameter vessel, even if comparatively deeper, should yield the greatest likelihood of success.

Beyond the simulation laboratory: a realist synthesis review of clinical outcomes of simulation-based mastery learning.

Purpose Translational educational outcomes have been defined as starting in simulation laboratories (T1) and moving downstream to improved patient care practices (T2), patient outcomes (T3), and cost/other value outcomes (T4). The authors conducted a realist synthesis review of the literature to evaluate the translational effect of simulation-based mastery learning (SBML) principles beyond the laboratory. They also sought to address future directions in SBML to improve patient care processes and outcomes and, thus, the quality of health care delivery. Method The authors searched multiple databases for simulation-based medical education (SBME) studies published through April 2013. They screened articles using the PICO method—population (P), intervention (I), control (C), outcome (O)—to answer the research question: For (P) any health care providers, does the (I) implementation of SBML training, compared with (C) other training methodologies or no extra training, result in (O) a change in patient care practices or T2–T4 outcomes? Studies implementing SBME interventions with training methodologies that met all SBML principles and reporting T2–T4 outcomes were identified. Results The 14 included studies used pre/post or cohort study designs; the majority were limited to individual performance and procedural competency. They reported improvement after SBML training in procedure performance, task success, patient discomfort, procedure time, complication rates, or T4 impacts (e.g., cost reduction). Conclusions Findings suggest health professions education conducted using SBML methodology can improve patient care processes and outcomes. Further research is needed to understand the translational impact of SBML for nontechnical skills, including teamwork, and skill retention.

The Emerging Role of Simulation Education to Achieve Patient Safety: Translating Deliberate Practice and Debriefing to Save Lives

Simulation-based educational processes are emerging as key tools for assessing and improving patient safety. Multidisciplinary or interprofessional simulation training can be used to optimize crew resource management and safe communication principles. There is good evidence that simulation training improves self-confidence, knowledge, and individual and team performance on manikins. Emerging evidence supports that procedural simulation, deliberate practice, and debriefing can also improve operational performance in clinical settings and can result in safer patient and population/system outcomes in selected settings. This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.

Bedside ultrasound curriculum for medical students: report of a blended learning curriculum implementation and validation.

Medical students on clinical rotations rarely receive formal bedside ultrasound (BUS) training. We designed, implemented, and evaluated a standardized BUS curriculum for medical students on their Emergency Medicine (EM) rotation. Teaching was aimed toward influencing four cognitive and psychomotor learning domains: BUS instrumentation knowledge, image interpretation, image acquisition, and procedural guidance.

Experience curves as an organizing framework for deliberate practice in emergency medicine learning.

Deliberate practice is an important skill-training strategy in emergency medicine (EM) education. Learning curves display the relationship between practice and proficiency. Forgetting curves show the opposite, and demonstrate how skill decays over time when it is not reinforced. Using examples of published studies of deliberate practice in EM we list the properties of learning and forgetting curves and suggest how they can be combined to create experience curves: a longitudinal representation of the relationship between practice, skill acquisition, and decay over time. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and assessment in favor of more emphasis on what can be done to improve durability of competence over time. The authors highlight the implications for both educators and education researchers.

Do orthopaedic fracture skills courses improve resident performance

INTRODUCTION We hypothesized that resident participation in a hands-on fracture fixation course leads to significant improvement in their performance as assessed in a simulated fracture fixation model. METHODS Twenty-three junior orthopaedic surgery residents were tasked to treat radial shaft fractures with standard fixation techniques in a sawbones fracture fixation simulation twice during the year. Before the first simulation, 6 of the residents participated in a fraction fixation skills course. The simulation repeated 6 months later after all residents attended the course. Residents also completed a 15-question written examination. Assessment included evaluation of each step of the procedure, a score based on the objective structured assessment of technical skill (OSATS) system, and grade on the examination. Comparisons were made between the two cohorts and the two testing time points. RESULTS Significant improvements were present in the percentage of tasks completed correctly (64.1% vs 84.3%) the overall OSATS score (13.8 vs 17.1) and examination correct answers (8.6 vs 12.5) for the overall cohort between the two testing time points (p<0.001, p<0.03, p<0.04 respectively). Residents who had not participated in the surgical skills course at the time of their initial simulation demonstrated significant improvements in percentage of tasks completed correctly (61.3% vs 81.2%) and OSATS score (12.4 vs 17.0) (p<0.002, p<0.01 respectively). No significant difference was noted in performance for the cohort who had already participated in the course (p=0.87 and p=0.68). The cohort that had taken the course prior to the initial simulation showed significantly higher scores at initial evaluation (88.5% vs 58.5% percentage of tasks completed correctly, 17.3 vs 12.0 OSATS score, 12.5 vs 8.6 correct answers on the examination). At the second simulation, no significant difference was seen with task completion or examination grade, but a significant difference still existed with respect to the OSATS score (20.0 vs 17.0; p<0.03). CONCLUSION Participation in a formal surgical skills course significantly improved practical operative skills as assessed by the simulation. The benefits of the course were maintained to 6 months with residents who completed the training earlier continuing to demonstrate an advantage in skills. Such courses are a valuable training resource which directly impact resident performance.

Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs

Summary Statement Formal faculty development programs for simulation educators are costly and time-consuming. Peer coaching integrated into the teaching flow can enhance an educators debriefing skills. We provide a practical guide for the who, what, when, where, why, and how of peer coaching for debriefing in simulation-based education. Peer coaching offers advantages such as psychological safety and team building, and it can benefit both the educator who is receiving feedback and the coach who is providing it. A feedback form for effective peer coaching includes the following: (1) psychological safety, (2) framework, (3) method/strategy, (4) content, (5) learner centeredness, (6) co-facilitation, (7) time management, (8) difficult situations, (9) debriefing adjuncts, and (10) individual style and experience. Institutional backing of peer coaching programs can facilitate implementation and sustainability. Program leaders should communicate the need and benefits, establish program goals, and provide assessment tools, training, structure, and evaluation to optimize chances of success.

Debriefing with Good Judgment

Debriefing is the learning conversation that follows a simulation session. The instructor’s role in providing feedback and guiding reflection is critical to ensure that reflecting on the simulation experience yields learning and growth in accordance with the stated educational goals of the session. This chapter describes the philosophy of “Debriefing with Good Judgment” which was developed at the Center for Medical Simulation in Cambridge, Massachusetts. In particular the focus is on four key principles that debriefers should follow: have learning objectives that are clearly defined prior to the simulation session, set expectations clearly for the debriefing session, be curious, give feedback, try not to “fix” your learners, and organize the debriefing session into three phases.

What's your best time? Chronometry in the learning of medical procedures

Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments.

Towards entrusting medical students: recognising safety behaviours.

National Health Service (NHS). In Liverpool, rather than attempting to convey the importance of leadership and teamwork within the confines of the classroom, an innovative experiential approach to encourage self-awareness and team-working was developed using elements of the well established leadership programmes developed by the armed forces. What was tried? Following months of organisation and planning with 208 Field Hospital (Liverpool), 280 Year 1 medical students were taken for an overnight stay at Altcar Training Camp. Prior to the trip, some students expressed concerns on health and religious grounds and felt that they would not be able to participate. However, with appropriate organisation to allow the provision of prayer spaces and alternatives for the more physical tasks, the vast majority of students attended the course. Students were randomly allocated into groups in order to demonstrate the reality of working in teams. The roles of leader and team member were clearly defined, and students were required to listen to and communicate with each other in order to work effectively. Each student had the opportunity of leading a team. They faced command tasks building simple structures, planning exercises solving multidimensional logistical problems, and physical elements (undertaken by most participants) that emphasised the importance of working as a team and helping weaker members to complete the tasks. All of these tasks were overseen by experienced army staff, who offered constructive feedback and suggestions, and students were encouraged to critique one another’s leadership styles and to identify their own strengths and weaknesses. After the event, all students completed a structured reflective assignment What lessons were learned? Overall, the students’ reports demonstrated that they had learned more than simply how to complete a task. They reported that they could work effectively within a randomly selected team; they realised that individually they possessed a range of skills that could help and motivate other team members; they had learned how to listen and how to observe other people’s talents and limitations, and about how this meant they could complete tasks together as a team, thereby creating a sense of pride and shared achievement; they observed that the fact that someone is quiet in a team does not mean he or she has nothing to contribute, and, finally, they had found that it was acceptable to ask for help or to admit they were struggling. Fundamentally, they had learned that as doctors they will be required to serve as both leaders and team members, and that if they want to provide the best patient care possible, the ability to work effectively with colleagues will be essential. The success of this joint initiative with the army has parallels with the recent experiential leadership development delivered by the NHS Staff College. It has reinforced our belief that leadership potential and team-working should be taught in a practical way and should be developed from the time students enter medical school. Simply teaching leadership principles in the classroom will not necessarily alter attitudes and behaviours.