Jeffrey M. Taekman

Objective measures of situation awareness in a simulated medical environment

One major limitation in the use of human patient simulators is a lack of objective, validated measures of human performance. Objective measures are necessary if simulators are to be used to evaluate the skills and training of medical practitioners and teams or to evaluate the impact of new processes or equipment design on overall system performance. Situation awareness (SA) refers to a person’s perception and understanding of their dynamic environment. This awareness and comprehension is critical in making correct decisions that ultimately lead to correct actions in medical care settings. An objective measure of SA may be more sensitive and diagnostic than traditional performance measures. This paper reviews a theory of SA and discusses the methods required for developing an objective measure of SA within the context of a simulated medical environment. Analysis and interpretation of SA data for both individual and team performance in health care are also presented.

Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration

Objectives The authors conducted a randomised controlled trial of four pedagogical methods commonly used to deliver teamwork training and measured the effects of each method on the acquisition of student teamwork knowledge, skills, and attitudes. Methods The authors recruited 203 senior nursing students and 235 fourth-year medical students (total N=438) from two major universities for a 1-day interdisciplinary teamwork training course. All participants received a didactic lecture and then were randomly assigned to one of four educational methods: didactic (control), audience response didactic, role play and human patient simulation. Student performance was assessed for teamwork attitudes, knowledge and skills using: (a) a 36-item teamwork attitudes instrument (CHIRP), (b) a 12-item teamwork knowledge test, (c) a 10-item standardised patient (SP) evaluation of student teamwork skills performance and (d) a 20-item modification of items from the Mayo High Performance Teamwork Scale (MHPTS). Results All four cohorts demonstrated an improvement in attitudes (F1,370=48.7, p=0.001) and knowledge (F1,353=87.3, p=0.001) pre- to post-test. No educational modality appeared superior for attitude (F3,370=0.325, p=0.808) or knowledge (F3,353=0.382, p=0.766) acquisition. No modality demonstrated a significant change in teamwork skills (F3,18=2.12, p=0.134). Conclusions Each of the four modalities demonstrated significantly improved teamwork knowledge and attitudes, but no modality was demonstrated to be superior. Institutions should feel free to utilise educational modalities, which are best supported by their resources to deliver interdisciplinary teamwork training.

Assessing teamwork in medical education and practice: relating behavioural teamwork ratings and clinical performance.

Background: Problems with communication and team coordination are frequently linked to adverse events in medicine. However, there is little experimental evidence to support a relationship between observer ratings of teamwork skills and objective measures of clinical performance. Aim: Our main objective was to test the hypothesis that observer ratings of team skill will correlate with objective measures of clinical performance. Methods: Nine teams of medical students were videotaped performing two types of teamwork tasks: (1) low fidelity classroom-based patient assessment and (2) high fidelity simulated emergent care. Observers used a behaviourally anchored rating scale to rate each individual on skills representative of assertiveness, decision-making, situation assessment, leadership, and communication. A checklist-based measure was used to assess clinical team performance. Results: Moderate to high inter-observer correlations and moderate correlations between cases established the validity of a behaviourally anchored team skill rating tool for simulated emergent care. There was moderate to high correlation between observer ratings of team skill and checklist-based measures of team performance for the simulated emergent care cases (r = 0.65, p = 0.06 and r = 0.97, p < 0.0001). Conclusions: These results provide prospective evidence of a positive relationship between observer ratings of team skills and clinical team performance in a simulated dynamic health care task.

Time of day effects on the incidence of anesthetic adverse events

Background: We hypothesized that time of day of surgery would influence the incidence of anesthetic adverse events (AEs). Methods: Clinical observations reported in a quality improvement database were categorized into different AEs that reflected (1) error, (2) harm, and (3) other AEs (error or harm could not be determined) and were analyzed for effects related to start hour of care. Results: As expected, there were differences in the rate of AEs depending on start hour of care. Compared with a reference start hour of 7 am, other AEs were more frequent for cases starting during the 3 pm and 4 pm hours (p<0.0001). Post hoc inspection of data revealed that the predicted probability increased from a low of 1.0% at 9 am to a high of 4.2% at 4 pm. The two most common event types (pain management and postoperative nausea and vomiting) may be primary determinants of these effects. Conclusions: Our results indicate that clinical outcomes may be different for patients anesthetized at the end of the work day compared with the beginning of the day. Although this may result from patient related factors, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of anesthetic AEs for cases that start in the late afternoon.

Virtual environments in healthcare: immersion, disruption, and flow.

Old forms of education are slowly crumbling under the weight of rapidly advancing computer and communication technologies along with the demands of learners who have grown up digital. These advances necessitate new thinking about the ways we educate and assess our healthcare workforce. Choosing anesthesiology (or any other healthcare profession) constitutes a commitment to life-long learning. Our careers span decades, and therefore, we need to constantly update our knowledge and skills. Yet, the traditional model of medical education has not changed in more than 100 years. The majority of our preclinical, and continuing education comes in the form of passive teacher-centric lectures. To paraphrase an example used by Sir Ken Robinson in his book, The Element, if we had a time machine and were able to bring a student forward in time from the 18th century, our educational system would be one of the few parts of society they would recognize.

To die or not to die? A review of simulated death.

Summary Statement Simulation as an educational technique is increasingly used in health care to teach about managing critical events and life-threatening situations and, infrequently, to teach about death. There is considerable controversy over whether to allow the simulator to die during a session when death is not a predefined learning objective. Some educators never allow the simulator to die unless death is the objective of the scenario, and others allow the simulator to die unexpectedly during any scenario. We do not know whether such a fatal event may affect a student’s learning process and emotions, and no randomized trials have been conducted to determine the impact of simulated death. In this narrative review, we survey the literature on simulated death during health care training, present arguments for and against the broad incorporation of such training in curricula for health care providers, and outline recommendations for using death scenarios in health care simulation.

Handovers from the OR to the ICU.

The case was long and difficult—a redo sternotomy and coronary artery bypass grafting procedure on a fragile 82-year-old patient. While you are pushing the bed down the hallway, you move cautiously toward the intensive care unit (ICU) because the patient is hemodynamically unstable and receiving high doses of inotropes and intra-aortic balloon pump support. Upon rounding a corner, equipment temporarily being stored in the hallway forces you to swerve forcefully disconnecting the helium tubing from the balloon pump. Alarms chiming, you quickly make it to your assigned ICU bed space to find the receiving ICU nurse absent. She left the bedside to look for a missing pressure cable. You handover the bag-mask system to the respiratory therapist, and she asks whether you had any problems with intubation or ventilation. You want to tell her that intubation was difficult, but you notice that the arterial pressure is very low. “Please don’t disconnect the a-line yet,” you ask the

Preliminary Report on the Use of High-Fidelity Simulation in the Training of Study Coordinators Conducting a Clinical Research Protocol

Training of health care research personnel is acritical component of quality assurance in clinical trials. Interactivity (such as simulation) is desirable compared with traditional methods of teaching. We hypothesized that the addition of an interactive simulation exercise to standard training methods would increase the confidence of study coordinators. A simulation exercise was developed to replicate a complex clinical trial. Eighteen study coordinators completed pre- and postexercise confidence questionnaires. Questions were targeted at key trial components using a 0–10 scale (not confident to confident) and were categorized using Bloom’s Taxonomy. The primary analysis compared overall mean pre-and postexercise responses. Secondary analyses assessed affective, psychomotor, and cognitive confidence. Significance was at P < 0.05. A significant increase in overall confidence (8.64 versus 5.77; P < 0.0001) was reproduced in the subcategory analyses (affective, 8.24 versus 4.89; P < 0.0001; cognitive, 8.75 versus 6.42; P = 0.0003; psychomotor, 8.63 versus 5.26; P < 0.0001). A high level of internal consistency and reliability in question responses within domains was observed, validating the questionnaire tool. In this preliminary report, we confirmed that addition of a simulation exercise to the training of study coordinators resulted in increased confidence. Simulation exercises should be considered when training study coordinators for clinical research trials.

New educational technology.

In many ways education has not changed much from the days when books were scarce and knowledge was spread slowly by word of mouth or advertisements, at meetings or demonstrations. In fact, much of our training in medicine still relies on direct observation, reading, lectures, and practice, practice, and practice. Technologic advances in medicine have not always been paralleled by advances in educational techniques, but new devices and technologies are now radically changing how people learn. Formal healthcare education no longer relies on the haphazard presentation of topics and complexity inherent in medical practice. Learning experiences can be augmented by strategically combining old methods such as lectures and textbooks with new teaching tools such as simulators and standardized patients. Practice can be organized to provide increasing complexity and responsibility as the student develops the knowledge, skills, and judgment needed to treat patients. Web-based information for learning and patient care is now available at the point-of-care to extend and enhance recall of needed information. Access to the ever-growing body of medical knowledge is immediate at the press of a button. The promise and challenge of health

Say what you mean to say: improving patient handoffs in the operating room and beyond.

CASE INFORMATION Demographics Patient Name: Patient J Simulation Developers: Lauren McQueen-Shadfar, MD, and Jeffrey Taekman, MD Date of Development: May 20, 2009 Appropriate for the following learning groups: Faculty: CME Residents (PGY): 1, 2, 3, 4, 5, 6, 7 Specialties: Anesthesiology, Nurse Anesthesia, Surgery, Critical Care, Emergency Medicine, Obstetrics Medical Students (yr): 1, 2, 3, 4 Nurse Anesthesia Faculty: CEU Nursing Students (yr): 1, 2