John Lutz

Willingness to perform mouth-to-mouth ventilation by health care providers: A survey ,

BACKGROUND During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patients need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate ones own child was stronger than any other motivator. CONCLUSIONS HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.

Regurgitant reflux, vs non‐regurgitant reflux, is preceded by rectus abdominis contraction in infants

Abstract Infants commonly regurgitate during some, but not all, gastro‐oesophageal reflux episodes. As several different mechanisms for reflux episodes have been identified, it was hypothesized that the mechanisms for regurgitant and non‐regurgitant reflux differ. To test whether regurgitant episodes are associated with, and perhaps propelled by, rectus abdominis contraction, ten infants, aged 9–30 weeks (median 16.5 weeks), with regurgitant reflux and no other cause for their regurgitation, were studied with concurrent distal oesophageal pH probe monitoring and surface electromyography of the rectus abdominis muscles. Reflux episodes with material emanating from the mouth (regurgitant reflux) were distinguished from those without visible regurgitation, and were characterized as being, or not being, temporally associated with rectus abdominis activity.

Simulation: a teaching tool for liver transplantation anesthesiology

Aggarwal S, Bane BC, Boucek CD, Planinsic RM, Lutz JW, Metro DG. Simulation: a teaching tool for liver transplantation anesthesiology.

Auto-positive end-expiratory pressure during tracheal gas insufflation : Testing a hypothetical model

ObjectiveThe major benefit of tracheal gas insufflation (TGI) is an increase in CO2 elimination efficiency by removal of CO2 from the anatomical deadspace. In conjunction with mechanical ventilation, TGI may also alter variables that affect CO2 elimination, such as minute ventilation and peak airway pressure (peak Paw) and cause the development of auto–positive end-expiratory pressure (auto-PEEP). We tested the hypothesis that TGI-induced auto-PEEP alters ventilatory variables. We predicted that TGI-induced auto-PEEP offsets the beneficial effects of TGI on CO2 elimination and that keeping total PEEP (ventilator PEEP + auto-PEEP) constant enhances the CO2 elimination efficiency afforded by TGI. DesignProspective study of two series of patients with acute respiratory distress syndrome receiving mechanical ventilation. SettingIntensive care units at a university medical center. PatientsEach series consisted of eight sequential hypercapnic patients. InterventionsIn series 1, we examined the effect of continuous TGI at 0 and 10 L/min on Paco2, without compensating for the development of auto-PEEP. In series 2, we examined this same effect of continuous TGI while reducing ventilator PEEP to keep total PEEP constant. TGI-induced auto-PEEP was calculated based on dynamic compliance measurements during zero TGI flow conditions (&Dgr;V/&Dgr;P) after averaging the two baseline values for peak Paw and tidal volume and assuming compliance did not change between the zero TGI and TGI flow conditions (&Dgr;VTGI/&Dgr;PTGI). Measurements and Main ResultsIn series 1, total PEEP increased from 13.2 ± 3.2 cm H2O to 17.8 ± 3.5 cm H2O without compensation for auto-PEEP (p = .01). Paco2 decreased (p = .03) from 56.2 ± 10.6 mm Hg (zero TGI) to 52.9 ± 9.3 mm Hg (TGI at 10 L/min), a 6% decrement. In series 2, total PEEP was unchanged (p = NS). Paco2 decreased (p = .03) from 59.5 ± 10.4 mm Hg (zero TGI) to 52.2 ± 8.3 mm Hg (TGI at 10 L/min), a 12% decrement. There was no significant change in Pao2; there were no untoward hemodynamic effects in either series. ConclusionsThese data are consistent with the hypothesis that mechanical ventilation + TGI causes an increase in auto-PEEP that can blunt CO2 elimination. In addition to the ventilator modifications necessary to keep ventilatory variables constant when TGI is used, it is also necessary to reduce ventilator PEEP to keep total PEEP constant and further enhance CO2 elimination efficiency.

Experience With a New Process—Condition T—for Uncontrolled Donation After Circulatory Determination of Death in a University Emergency Department

Background: In the United States, organ donation after circulatory death (DCD) determination is increasing among those who are removed from life-sustaining therapy but is rare when death is unexpected. We created a program for uncontrolled DCD (uDCD). Methods: A comprehensive program was created to train personnel to identify and respond quickly to potential donors after unexpected death. The process termed Condition T was implemented in the emergency department (ED) of 2 academic medical centers. All ED deaths were screened for uDCD potential. Eligible donors included patients with preexisting donor designation who received cardiopulmonary resuscitation, failed to respond, and were pronounced dead. Results: Over 350 nurses, physicians, perfusionists, organ procurement personnel, and administrators were trained. From February 2009 to June 2010, a total of 18 patients were potential Condition T candidates. Six Condition T responses were triggered. Three donors underwent cannulation, and 4 organs were recovered (3 kidney and 1 liver) from 2 donors. Time from Condition T trigger to perfusion with organ preservation solution ranged from 14 to 22.3 minutes. Perfusion duration was 197 and 221 minutes. No recovered organs were transplanted because biopsies showed prolonged warm ischemia. Conclusions: It is feasible to create a process to rapidly intervene in the ED for uDCD. However, no organ transplants resulted. The utility and sustainability of an uDCD program in this particular setting are questionable.

A Simulation Information Management System for use in Large Scale Simulation Centers.: Research Abstract: 68

at the Peter M. Winter Institute for Simulation, Education and Research (WISER) has allowed the institute to continue to operate at a high level of efficiency and effectiveness in spite of a significant increase in the number of classes and participants over the past academic year. SIMS integrates aspects of day to day operations, interactions with students and instructors, dissemination of course curriculum, and collection of course related information with research coordination and data handling.

Alterations in regional myocardial velocity by tissue Doppler echocardiography reflect changes in left ventricular contractility

Purpose: Clinical testing of a f u l l y automated epicardial/endocardial border detection algorithm (ABD), Methods: The current database for testing the algorithm consists of 110 d ig i ta l , short axis, 16 frame sequences taken from videotaped studies on 55 patients with c l i n i ca l l y acceptable images. The present ABD algorithm is f u l l y automatic and, given the end d iasto l ic (ED) and end systol ic (ES) frame numbers from the digi t ized video sequence, finds the image sector, the l e f t ventr ic le (LV). the center point of the LV, and proceeds to estimate the epicardial (Epi) and endocardial (Endo) contours of the LV on each systol ic frame of the sequence using only 6 points on each border. The ABD algorithm excludes the papi l lary muscles and mitral apparatus as recommended by the ASE. For comparison, two independent. trained observers also digi t ized the endocardial and epicardial borders at ED and ES. Areas, and fract ional area change (FAC) for Observer 2 (02) and ABD were compared to Observer 1 (01) using l inear regression, Results: r SEE ABD-01 02 01 ABD-01 02-01 Endo ED .972 .963 1.8 cm Z 1.7cm z ES .977 .979 1.5 1.3 FAC .895 .897 5.9 % 6.4 % Epi ED .963 .977 3.1 cm z 2.5 cm z ES .973 .981 2.5 2.2 r = correlat ion coef f ic ient , SEE = standard error of estimate, n = 110 for al l comparisons Run time = 6-8 sec for detection of epi and endo on al l systol ic frames (Risc 6000. 38 MIPs) Conclusion: We conclude that this preliminary version of a fu l l A8D algorithm has the ab i l i t y to function at the level of an independent trained observer on a representative c l in ica l database. 4-VI ALTERATIONS IN REGIONAL MYOCARDIAL VELOCITY BY TISSUE DOPPLER ECHOCARDIOGRAPHY REFLECT CHANGES IN LEFT VENTRICULAR CONTRACTILITY John Gorcsan III MD, David Strum MD, John Lutz MS, Michael R, Plnsky, MD. University of Pittsburgh, Pittsburgh, PA

Board 348 - Research Abstract Validation of the Mayo High Performance Team Work Scale and Ottawa Crisis Resource Management Global Rating Scale for Evaluation of Crisis Team Training (Submission #472)

Introduction/Background Evaluation is a key component of simulation education. There are various team performance assessments and non-technical skills team assessment tools that have been used and validated in simulation education. These instruments have been used in settings, such as operating rooms, emergency departments, pediatric settings and obstetrical units. The Crisis Team Training (CTT) simulation course at the Peter M. Winter Institute of Simulation Education and Research (WISER) emphasizes communication and teamwork during crisis response training.1 The purpose of this study was to evaluate the reliability and validity of the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS)2 and the Mayo High Performance Team Work Scale (MHPTWS)3 for CTT at WISER. Methods Audiovisual data was previously collected from Session 1 and Session 4 during CTT classes conducted at WISER from February 2007 to April 2012. Seven raters (four novices and three experts) watched randomly assigned videos and scored each independently. Novice raters were graduate nurse anesthesia students with previous experience as participants in three to four high fidelity simulation courses. Experts were previous instructors for simulation courses. Each rater was assigned to use either the Ottawa GRS or MHPTWS to evaluate CTT videos. All raters received a 1.5 hour training session prior to evaluating the CTT sessions. The training sessions included a brief orientation to CTT and a review of the assigned instrument with practice evaluation of three CTT sessions. The validity of these tools was tested to measure non-technical skills in CTT. Statistical analysis included inter-rater reliability using level of agreement with the Kappa statistic for the MHPTWS and interclass correlation coefficients for the Ottawa GRS. Inter-rater reliability was evaluated between novice raters and a subset of videos was compared between novice and expert raters. Reliability was evaluated for the first eight questions of the MHPTWS and six items of the Ottawa GRS. A paired t-test was used to evaluate change in rater scores for Session one and Session four using the overall performance item on the Ottawa GRS and a sum of the first eight questions for the MHPTWS. Results The Kappa values used to determine inter-rater agreement for the MHPTWS when evaluated by novice reviewers on 35 Session one CTT videos ranged from 0.00 to 0.359 with statistical significant (p<0.05) for two of the eight questions. Summed scores for questions one through eight for the MHPTWS were evaluated for improvement from session one to session four for novice and expert raters. Improvement was statistically significant (p<0.05) for two of two expert reviewers and one of two novice reviewers. Interclass correlation coefficients for the Ottawa GRS for the novice raters for Session one were 0.666, 0.653, 0.646, 0.623 and 0.633 for Leadership, Problem Solving, Situational Awareness, Resource Utilization and Communication respectively. Overall performance scores from Session one to Session four for the Ottawa GRS were statistically greater (p<0.05) for the expert rater and one of the two novice raters. Conclusion The differences between Session one and Session four scores for the MHWPTS and Ottawa GRS were greater for expert reviewers, thus suggesting greater validity when experts used the instruments. Indicators of agreement were greater for the Ottawa GRS when compared to the MHWPTS although different Methods of statistical analysis were used making it difficult to compare Results. References 1. Devita, M.A., Schaefer, J., Lutz, J., Dongilli, T., Wang, H. (2004). Improving medical crisis team performance. Critical Care Medicine, 32(2) S61-65. 2. Kim, J., Neilipovitz, D., Cardinal, P., Chiu, M., Clinch, J. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical CareMedicine, High-Fidelity Simulation, and Crisis Resource Management I Study. Critical Care Medicine, 34(8), 2167–2174. 3. Malec, J.F., Torsher, L.C., Dunn, W.F., Wiegmann, D.A., Arnold, J.J., Brown, D.A., Phatak, V. The Mayo High Performance Teamwork Scale: Reliability and validity for evaluating key crew resource management skills. Simulation in Health Care, 2(1) 4–10. Disclosures Speaker at conference for Laerdal Medical Japan Karl Storz USA SimMedical Pittsburgh Simulation Strategies Speaker at Laerdal Conference in Japan.

A Novel Debriefing Tool: Online facilitator guidance package for debriefing team training using simulation

Methods INTRODUCTION CONCLUSION REFERENCES A Novel Debriefing Tool: Online facilitator guidance package for debriefing team training using simulation Crisis team training (a form of crisis resource management training) focuses on helping ad hoc teams function together to attain group goals. Our program focuses on predetermined roles and role-appropriate tasks, coupled with an objective set of performance measures within time limits. Consistency and quality of debriefing within a course is a difficult task when facilitators have to be experts in both debriefing techniques and the model of care. The need for highly trained, expert facilitators limits the ability to mass train. Creation of tools that enable a lower level trainer who can deliver the same quality of training would benefit quality, reliability, reproducibility and throughput of training centers. To overcome this hurdle, we have developed a web-based, interactive facilitator website that includes: 1) a checklist of open ended debriefing questions to prompt instructors while debriefing students; 2) navigation tools (to “toggle” between videos, scoring sheets, performance graphs, citations, and the teaching slide set); 3) a library of “teaching points” which focus on the goal of each debriefing; 4) a library of simulations with errors and appropriate behaviors highlighted to teach facilitators what to look for. Our tool utilizes a checklist approach that allows competent (not expert) instructors to provide expert (not competent) debriefing by ensuring that they cover all teaching points, tasks, and ask questions during the debriefings. Each session debriefing has an overall goal (for example: role acquisition) and is subsequently divided into sections with central foci for each section. Instructors must check off each task and question acknowledging that they have been covered. The instructor cannot move onto the next section without having completed everything on the checklist. The web pages are designed in a way that they can be modified to be used with other courses taught at WISER. Creating an easy to use, reliable, and effective tool to guide and ease debriefing could greatly improve the ability to deliver a standardized training. The tool could make possible greater inter-class training consistency, enable a less trained facilitator so mass training is possible, and enhance ability to perform controlled trials. The described tool captures many of the qualities necessary for a team training debriefing. 1. DeVita MA, Schaefer J, Lutz J, Dongilli T, Wang H: Improving medical crisis team performance. Crit Care Med 2004; 32: S61-5 2. Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R: Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 1998; 89: 8-18 3. Lee A, Bishop G, Hillman K, et al. The medical emergency team. Anaesth Intensive Care 1995; 23: 183–186. Crisis Team Training (CTT)1 is a form of crisis resource management (CRM)2. CTT is designed to train groups of individuals to be able to demonstrate coordinated function as they treat crises encountered in responding to Medical Emergency Team (MET)3, also known as Rapid Response Team (RRT), calls. CTT differs from CRM in several ways: first, the hierarchy is flat; second, there are assigned roles and each role has pre-assigned tasks; third, organizational and treatment tasks must be completed within a pre-determined time frame; fourth, there are objective measures of performance; and fifth, patient care skills are emphasized over professional background. Although we have endeavored to create a choreographed response that is objectively measured, debriefing has remained a difficult task, because the facilitator must be an expert in simulation, education, critical care and team performance. As a result, there are few qualified facilitators. To overcome this hurdle, we wanted to create a web based tool to enable competent facilitators to deliver training comparable to that of an expert facilitator. We describe our work to date. This project was funded in part by the Jewish Healthcare Foundation, Pittsburgh PA. The design team included experts in CTT (MD, NM), Medical Emergency Teams (MD, WG, NM) and an expert in simulation systems and computer engineering (JL). We created nine standardized simulation scenarios, and utilize a random number generator to select the scenarios to be used in a CTT course. Each episode of simulation is called a training session. We video recorded expert facilitators performing debriefing, had both expert and competent trainers observing delivered courses to determine debriefing content. Based on our review of the trainers, we created a different debriefing goal for each training session. Within each debriefing session, a number of foci are emphasized to support the debriefing goal. The group also identified tools that facilitators need for delivering the training. We created a web based tool that has a total of 18 separate sequential debriefing screens. There are hyperlinks on each page to teaching resources: Lecture slides, Roles & Goals graphic, video recording, scoring sheet, performance graphs and the next debriefing page. We tested the ease of use with untrained personnel at WISER. The web based tool: 1) Facilitates moving between the 5 educational tools; 2) Prompts the facilitator to complete all the educational objectives for each debriefing focus; 3) “Forces” completion of educational objectives prior to moving forward in the debriefing; 4) Fosters use of a pre-existing scoring tool to objectively analyze performance; 5) Offers the ability to refer to the educational slide set; 6) Enables the facilitator to show progression of performance through real time graphic representation of performance for organizational tasks, patient care tasks, communication tasks, and outcome. The Four Debriefing Foci: 1) Roles 3) Communication 2) Roles & Tasks 4) Review: Organization effects outcome METHODS University of Pittsburgh Medical Center (UPMC) and the Peter M. Winter Institute for Simulation, Education and Research (WISER) Pittsburgh, PA List of tasks that need to be completed All debriefing tasks are completed, the facilitator can continue