Elizabeth K. Weidman

Assessing the impact of immersive simulation on clinical performance during actual in-hospital cardiac arrest with CPR-sensing technology: A randomized feasibility study

AIM Advanced simulation tools are increasingly being incorporated into cardiopulmonary resuscitation (CPR) training. These educational methods have been shown to improve trainee performance in simulated settings, but translation into clinical practice remains unknown for many aspects of CPR quality. This study attempts to measure the impact of simulation-based training for resuscitation team leaders on some measures of CPR quality during actual in-hospital resuscitation attempts. METHODS In this prospective, randomized interventional cluster trial, internal medicine resident physicians (post-graduate year 2) were randomized using a random number generator to participate in a 4-h, immersive simulation course in cardiopulmonary resuscitation leadership using a high-fidelity simulator with video debriefing prior to serving as resuscitation team leaders at an academic medical center. Objective metrics of actual resuscitation performance were obtained from a CPR-sensing monitor/defibrillator. RESULTS Thirty-two residents were randomized to receive simulation training or no additional training between April and July 2007 and data were collected following 98 actual resuscitations between July 2007 and June 2008. CPR quality from resuscitations led by 14 simulation-trained and 16 control group residents was similar in terms of mean compression depth (48 vs 49 mm; p = 0.53); compression rate (107 vs 104 min⁻¹; p = 0.30); ventilation rate (12 vs 12 min⁻¹; p = 0.45) and no-flow fraction (0.08 vs 0.07; p = 0.34). CONCLUSIONS Although we failed to detect any significant differences in objective measures of CPR quality, we have demonstrated that CPR-sensing technology has the potential for use in assessing the impact of a simulation curriculum on some aspects of actual resuscitation performance. A larger study, performed in a setting with lower baseline performance, would be required to assess the specific simulation curriculum.

Patient acuity rating: Quantifying clinical judgment regarding inpatient stability

BACKGROUND New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed. OBJECTIVE To develop and test a judgment-based scale for conveying the risk of clinical deterioration. DESIGN Prospective observational study. SETTING University teaching hospital. SUBJECTS Internal medicine clinicians and patients. MEASUREMENTS The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or intensive care unit (ICU) transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes. RESULTS Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy-four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3 ± 1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (P = 0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours. CONCLUSIONS Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.