Frank Overly

Bispectral analysis during pediatric procedural sedation.

Objective: Bispectral analysis (BIS) is a technology using EEG information from a forehead electrode to calculate an index (0-100; 0 = coma, 90-100 = awake). Our objective was to determine the degree of agreement between sedation scales and BIS values in pediatric patients undergoing sedation. Methods: Patients ages 2 to 17 years, undergoing procedural sedation, were enrolled. Sedation was performed in the customary manner with the addition of BIS monitoring and assessment of a clinical sedation scale: the Observers Assessment of Alertness/Sedation (OAA/S), every 5 minutes during the sedation procedure. Clinical scales were performed by an investigator blinded to the BIS index. The association between a clinical scale and BIS scores was analyzed using longitudinal regression analysis. Results: We enrolled 47 subjects; 55% were sedated with ketamine and midazolam and the remaining 45% received methohexital, propofol or midazolam and a narcotic. The results of the regression analysis demonstrated a highly significant association between the OAA/S score and BIS value (β = 5.0, 95% CI 4.3 to 5.7, P < 0.0001). Patients were divided into 2 groups, those sedated with ketamine and those sedated with nonketamine medications. The association between OAA/S score and BIS value was not statistically significant for the ketamine population (β = 0.809, 95% CI −0.1 to 1.7, P = 0.09), but remained significant for the nonketamine subjects (β = 8.6, 95% CI 7.7 to 9.4, P < 0.0001). Conclusions: The OAA/S sedation scale predicts the BIS value for pediatric patients undergoing procedural sedation when sedated with certain medications, excluding ketamine.

Educational and Research Implications of Portable Human Patient Simulation in Acute Care Medicine

Advanced medical simulation has become widespread. One development, the adaptation of simulation techniques and manikin technologies for portable operation, is starting to impact the training of personnel in acute care fields such as emergency medicine (EM) and trauma surgery. Unencumbered by cables and wires, portable simulation programs mitigate several limitations of traditional (nonportable) simulation and introduce new approaches to acute care education and research. Portable simulation is already conducted across multiple specialties and disciplines. In situ medical simulations are those carried out within actual clinical environments, while off-site portable simulations take place outside of clinical practice settings. Mobile simulation systems feature functionality while moving between locations; progressive simulations are longer-duration events using mobile simulations that follow a simulated patient through sequential care environments. All of these variants have direct applications for acute care medicine. Unique training and investigative opportunities are created by portable simulation through four characteristics: 1) enhancement of experiential learning by reframing training inside clinical care environments, 2) improving simulation accessibility through delivery of training to learner locations, 3) capitalizing on existing care environments to maximize simulation realism, and 4) provision of improved training capabilities for providers in specialized fields. Research agendas in acute care medicine are expanded via portable simulations introduction of novel topics, new perspectives, and innovative methodologies. Presenting opportunities and challenges, portable simulation represents an evolutionary progression in medical simulation. The use of portable manikins and associated techniques may increasingly complement established instructional measures and research programs at acute care institutions and simulation centers.

Design, implementation, and psychometric analysis of a scoring instrument for simulated pediatric resuscitation: a report from the EXPRESS pediatric investigators.

Introduction: Robustly tested instruments for quantifying clinical performance during pediatric resuscitation are lacking. Examining Pediatric Resuscitation Education through Simulation and Scripting Collaborative was established to conduct multicenter trials of simulation education in pediatric resuscitation, evaluating performance with multiple instruments, one of which is the Clinical Performance Tool (CPT). We hypothesize that the CPT will measure clinical performance during simulated pediatric resuscitation in a reliable and valid manner. Methods: Using a pediatric resuscitation scenario as a basis, a scoring system was designed based on Pediatric Advanced Life Support algorithms comprising 21 tasks. Each task was scored as follows: task not performed (0 points); task performed partially, incorrectly, or late (1 point); and task performed completely, correctly, and within the recommended time frame (2 points). Study teams at 14 childrens hospitals went through the scenario twice (PRE and POST) with an interposed 20-minute debriefing. Both scenarios for each of eight study teams were scored by multiple raters. A generalizability study, based on the PRE scores, was conducted to investigate the sources of measurement error in the CPT total scores. Inter-rater reliability was estimated based on the variance components. Validity was assessed by repeated measures analysis of variance comparing PRE and POST scores. Results: Sixteen resuscitation scenarios were reviewed and scored by seven raters. Inter-rater reliability for the overall CPT score was 0.63. POST scores were found to be significantly improved compared with PRE scores when controlled for within-subject covariance (F1,15 = 4.64, P < 0.05). The variance component ascribable to rater was 2.4%. Conclusions: Reliable and valid measures of performance in simulated pediatric resuscitation can be obtained from the CPT. Future studies should examine the applicability of trichotomous scoring instruments to other clinical scenarios, as well as performance during actual resuscitations.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation

INTRODUCTION High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulations ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulations role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

Three scenarios to teach difficult discussions in pediatric emergency medicine: sudden infant death, child abuse with domestic violence, and medication error.

Within an emergency medicine (EM) environment, the pace of clinical care delivery rarely allows time to stop and observe extended interactions between trainees and patients, or to provide feedback on communication skills. Once residency and fellowship conclude, however, these same trainees will be required to manage complicated medical and social interactions independently. In particular, unique challenges in the realm of patient-doctor interaction arise in the field of pediatric emergency medicine (PEM), with most clinical encounters involving both a child and their caregiver. Whether delivering bad news to a family or screening and managing cases of suspected child abuse, child neglect or domestic violence, many physicians report having no formal training in communicating effectively and compassionately under difficult conditions.1–4 It is imperative to consider and prepare future physicians for the emotional relationship between the (pediatric) patient and the family when caring for the family unit, especially in emergent situations and times of crisis. The occurrence of medical error presents another tremendously challenging situation for physicians and requires sophisticated communications skills. Despite clinicians’ best preventive and conscientious efforts, various elements can lead to a medical error, and the physicians involved will need to disclose and discuss the event with the family. Once again, few physicians have had formal training in managing these situations.5 To improve training in PEM physician communications during difficult discussions, we created a hybrid medical simulation program, a combination of standardized patients and high-fidelity medical simulation. The primary objective was to educate EM residents and PEM fellows on the communication skills necessary to engage in difficult discussions when caring for children in an emergency department setting. Authors will present three scenarios developed for an educational activity designed to focus on difficult discussion communication skills in PEM.

Pilot-phase findings from high-fidelity In Situ medical simulation investigation of emergency department procedural sedation.

Introduction Emergency department procedural sedation (EDPS) is becoming widespread. Simulation may enhance patient safety through evidence-based training, effective assessment, and research of EDPS operators in pertinent knowledge, skills, processes, and teamwork. Methods Investigators developed a 2-scenario in situ simulation-based methodology and research tool kit for objective examination of EDPS practice. The emphasis was on protocol-driven presedation preparation, intrasedation vigilance and readiness for adverse events, and postsedation reassessment. Pilot sessions were conducted to test the methodology at an academic 719-bed hospital, with Institutional Review Board approval. Results Five interns and 5 attending emergency physicians completed pilot sessions resulting in protocol revisions to optimize simulation consistency, research tool sets, data acquisition, and operational conditions. Pilot data sets demonstrated interscenario consistency and intersubject reproducibility for timing, progression, and duration of critical EDPS events; high levels of perceived realism and relevance; and utility and suggested validity of the study methodology as an EDPS research mechanism. Small sample sizes limited the study methodology’s ability to distinguish between the subject groups’ clinical performances (critical action completion, probe detection, and situational awareness) except with composite scoring of presedation and postsedation assessments. Key EDPS preparation, adverse event management, and reassessment actions were selected to derive a Simulation EDPS Safety Composite Score that differentiated inexperienced [4.60 ± 0.8 on a 10-point score (n = 3)] and experienced EDPS operators [8.95 ± 1.03 (n = 5); P = 0.0007]. Conclusions In situ simulation is a useful and relevant means to investigate EDPS patient safety. Pilot sessions have cleared the way for further experimental safety intervention research and development with the simulation-based methodology.

Does simulation booster impact retention of resuscitation procedural skills and teamwork

Objective:The Neonatal Resuscitation Program (NRP) has transitioned to a simulation-based format. We hypothesized that immersive simulation differentially impacts similar trainee populations’ resuscitation knowledge, procedural skill and teamwork behavior.Study Design:Residents from NICU and non-NICU programs were randomized to either control or a booster simulation 7 to 10 months after NRP. Procedural skill and teamwork behavior instruments were validated. Individual resident’s resuscitation performance was assessed at 15 to 18 months. Three reviewers rated videos.Result:Fifty residents were assessed. Inter-rater reliability was good for procedural skills (0.78) and team behavior (0.74) instruments. The intervention group demonstrated better procedural skills (71.6 versus 64.4) and teamwork behaviors (18.8 versus 16.2). The NICU program demonstrated better teamwork behaviors (18.6 versus 15.5) compared with non-NICU program.Conclusion:A simulation-enhanced booster session 9 months after NRP differentiates procedural skill and teamwork behavior at 15 months. Deliberate practice with simulation enhances teamwork behaviors additively with residents’ clinical resuscitation exposure.

Creation and Delphi-method Refinement of Pediatric Disaster Triage Simulations

Abstract Objective. There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. Methods. We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. Results. After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. Conclusions. The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills

ABSTRACT Objective: Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT). Methods: Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK. Results: The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073). Conclusion: This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

In situ medical simulation investigation of emergency department procedural sedation with randomized trial of experimental bedside clinical process guidance intervention.

Introduction Patient safety during emergency department procedural sedation (EDPS) can be difficult to study. Investigators sought to delineate and experimentally assess EDPS performance and safety practices of senior-level emergency medicine residents through in situ simulation. Methods Study sessions used 2 pilot-tested EDPS scenarios with critical action checklists, institutional forms, embedded probes, and situational awareness questionnaires. An experimental informatics system was separately developed for bedside EDPS process guidance. Postgraduate year 3 and 4 subjects completed both scenarios in randomized order; only experimental subjects were provided with the experimental system during second scenarios. Results Twenty-four residents were recruited into a control group (n = 12; 6.2 ± 7.4 live EDPS experience) and experimental group (n = 12; 11.3 ± 8.2 live EDPS experience [P = 0.10]). Critical actions for EDPS medication selection, induction, and adverse event recognition with resuscitation were correctly performed by most subjects. Presedation evaluations, sedation rescue preparation, equipment checks, time-outs, and documentation were frequently missed. Time-outs and postsedation assessments increased during second scenarios in the experimental group. Emergency department procedural sedation safety probe detection did not change across scenarios in either group. Situational awareness scores were 51% ± 7% for control group and 58% ± 12% for experimental group. Subjects using the experimental system completed more time-outs and scored higher Simulation EDPS Safety Composite Scores, although without comprehensive improvements in EDPS practice or safety. Conclusions Study simulations delineated EDPS and assessed safety behaviors in senior emergency medicine residents, who exhibited the requisite medical knowledge base and procedural skill set but lacked some nontechnical skills that pertain to emergency department microsystem functions and patient safety. The experimental system exhibited limited impact only on in-simulation time-out compliance.