Kristian Krogh

Time matters – Realism in resuscitation training

BACKGROUND The advanced life support guidelines recommend 2min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting. METHODS This study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120s) or shortened CPR cycles (30-45s instead of 120s) in the scenarios. Adherence to time was measured using the European Resuscitation Councils Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course. RESULTS The real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p<0.001.) CONCLUSION This study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome.

A novel protocol for dispatcher assisted CPR improves CPR quality and motivation among rescuers—A randomized controlled simulation study

BACKGROUND Emergency dispatchers use protocols to instruct bystanders in cardiopulmonary resuscitation (CPR). Studies changing one element in the dispatchers protocol report improved CPR quality. Whether several changes interact is unknown and the effect of combining multiple changes previously reported to improve CPR quality into one protocol remains to be investigated. We hypothesize that a novel dispatch protocol, combining multiple beneficial elements improves CPR quality compared with a standard protocol. METHODS A novel dispatch protocol was designed including wording on chest compressions, using a metronome, regular encouragements and a 10-s rest each minute. In a simulated cardiac arrest scenario, laypersons were randomized to perform single-rescuer CPR guided with the novel or the standard protocol. PRIMARY OUTCOME a composite endpoint of time to first compression, hand position, compression depth and rate and hands-off time (maximum score: 22 points). Afterwards participants answered a questionnaire evaluating the dispatcher assistance. RESULTS The novel protocol (n=61) improved CPR quality score compared with the standard protocol (n=64) (mean (SD): 18.6 (1.4)) points vs. 17.5 (1.7) points, p<0.001. The novel protocol resulted in deeper chest compressions (mean (SD): 58 (12)mm vs. 52 (13)mm, p=0.02) and improved rate of correct hand position (61% vs. 36%, p=0.01) compared with the standard protocol. In both protocols hands-off time was short. The novel protocol improved motivation among rescuers compared with the standard protocol (p=0.002). CONCLUSIONS Participants guided with a standard dispatch protocol performed high quality CPR. A novel bundle of care protocol improved CPR quality score and motivation among rescuers.

TelePresence in Rural Medical Education: A Mixed Methods Evaluation

In response to rural health workforce shortages, universities and training providers offer rural and remote clinical placements. This has led to development of educational methods to counter the barriers of distance. In this emerging field, recent improvements in technology have provided solutions including the use of sophisticated videoconferencing systems such as the Cisco TelePresence model CTS-500. This paper evaluates the use of TelePresence in diverse medical education activities using a mixed methods design—questionnaires , individual interviews , and observed practice of activities . TelePresence was found to be beneficial to learning and teaching and superior to other systems participants had used. In particular, the audiovisual quality, resulting intimacy, convenience, and ease of use facilitated teaching and learning, while the fixed camera and poorly arranged physical environment were found to be limitations. The system is best suited for small group activities. Clinical skills-based activities are viable. It is recommended that technical support be available during setup and use and a picture-in-picture mode be included and improved integration of office suite software to provide a joint workspace for display of presentations, images, editing or annotation of documents, and file sharing.

Designing in situ simulation in the emergency department: evaluating safety attitudes amongst physicians and nurses

BackgroundThis intervention study aimed to enhance patient safety attitudes through the design of an in situ simulation program based on a needs analysis involving thematic analysis of patient safety data and short-term ethnography. The study took place at an Emergency Department (ED) in the Central Region of Denmark. Research suggests that poor handover communication can increase the likelihood of critical incidents and adverse events in the ED. Furthermore, simulation is an effective strategy for training handover communication skills. Research is lacking, however, on how to use patient safety data and a needs analysis to the design of in situ simulation communication training.MethodsThis is a prospective pre-post study investigating the interventional effects of in situ simulation. It used a three-pronged strategy: (1) thematic analysis of patient safety data consisting of reported critical incidents and adverse events, (2) a needs analysis based on short-term ethnography in the ED, and (3) pre-post evaluation using the validated Safety Attitudes Questionnaire (SAQ) and the Trainee Reactions Score.ResultsSixteen different healthcare teams participated composed by 9 physicians and 30 nurses. In the SAQ, participating staff scored their safety attitudes in six categories (n = 39). Two measures where significantly higher for the post-SAQ than those for the pre-SAQ: teamwork climate (p < 0.001) and safety climate (p < 0.05). The Trainee Reactions Score showed that the training was positively evaluated.ConclusionsThis study designed a feasible strategy for implementing in situ simulation based on a needs analysis of critical incidents and adverse events and short-term ethnography.

Skills among young and elderly laypersons during simulated dispatcher assisted CPR and after CPR training

Dispatcher assisted cardiopulmonary resuscitation (DA‐CPR) increase the rate of bystander CPR. The aim of the study was to compare the performance of DA‐CPR and attainable skills following CPR training between young and elderly laypersons.

Time for Reflection: The Balance between Repetition and Feedback in Resuscitation Training—A Randomised Controlled Trial

Background. The simulation literature widely agrees that the reflective learning phase after the simulation is equal to or perhaps of even greater importance than the actual simulated scenario in ensuring learning. Nevertheless, advanced life support (ALS) tends to have many simulated scenarios followed by short feedback sessions. The aim of this study was to compare the ability of two groups of novice learners to stay adherent to the ALS guidelines in their provision of ALS after they had received either 8 or 12 simulated resuscitation scenarios, both in 4 hours. Methods. This study was a randomised controlled trial. Participants were either randomised to the control group with 12 scenarios (15 minutes per scenario) with 5 minutes of feedback or the intervention group with 8 simulations (15 minutes per scenario) with 15 minutes of feedback. Results. There was no statistically significant difference in test scores between the intervention group and control group in the 1-week retention test and the 12-week retention test .   Conclusion. This study suggests that the lower number of repetitive ALS simulation scenarios does not diminish learning when the feedback is equally prolonged to ensure sufficient time for reflection.

Board 361 - Research Abstract Time Matters: Realism in Resuscitation Training (Submission #102)

Introduction/Background The advanced life support (ALS) guidelines recommend two minutes cardiopulmonary resuscitation (CPR) and a minimum of hands-off time to ensure the cardiac and cerebral perfusion.1,2 We have observed several doctors who rush CPR during actual and simulated resuscitation attempts without adherence to the recommended time intervals.3 Rushed CPR caused by frequent interruptions due to abbreviated intervals between rhythm control, endangers the perfusion as quality of CPR is impaired when frequent interruptions increases hand-off .4,5 During resuscitation training, to ensure as many simulations scenarios as possible, providing the learner with increased learning opportunity, the time is often compressed and the two minutes of CPR between rhythm control/defibrillation are shortened to 30-60 seconds where the instructor discontinues this part of the training to save time. This practice is presumably used relatively often and it has been observed on several occasions in several different settings by the authors and ALS instructors confirm it as a common practice. The aim of this study is to test the hypothesis that compressed time during simulation based resuscitation training is associated with a lack of adherence to time during resuscitation. Methods The study was designed as a randomized control trial study. Fifty-four 4th year medical students with no prior advanced resuscitation training participated in an extracurricular one day advanced life support course based on the European Resuscitation Council’s (ERC) ALS Guidelines 2010. Participants were randomized to receive either real-time simulation scenarios or compressed time simulation scenarios during the course. The control group was trained during simulation scenarios using compressed time, 30-45 seconds CPR between rhythm controls/defibrillation. The intervention group was trained during simulation scenarios using real-time, 120 seconds of CPR between rhythm controls/defibrillation. Participants were assessed in a post and retention test using the validated ERC Cardiac Arrest Simulation Test (CAS-Test), developed to the ERC ALS provider .6 For the individual assessment, three assistants aided the participant according to his or her instructions. Test scenario including a briefing and short post scenario debriefing with a total duration of 30 minutes per participant. Results Data was analyzed using commercial available statistical software Stata/IC 11.2 (StataCorp LP, Texas, USA). The ability to stay adherent to the recommended time and perform two minutes of CPR between rhythm controls was found to be significantly better (p<0.05) for the intervention group, compared to the control group in both post test and retention test. (Intervention group; Mean 115 sec ±SD 28 seconds, Control group; Mean 81 seconds ±SD 42 seconds). There were no statistically significant differences from post test to retention test within the individual groups. Conclusion Novices practice the way they are taught in training. Even with cognitive aids and timekeeping tools the control group presented with a skewed adherence to time. The intervention group had a strong and significantly better adherence to recommended time intervals. Despite the best intention and the attempt to give participants the best opportunity to learn by exposing them to as many simulated scenarios as possible by compressing time. It is likely that real-time should be used in order to enable the trainee to keep track of time during time-critical events in SBE or at least during advanced life support simulation training. Our Results suggest that time critical scenario training should be run real-time to ensure correct time management and adherence to time when practiced outside the training environment. In the immediate future, we believe that a shift to real-time scenarios will provide instructors with the tool or rather the time to improve the quality of training without impairment of adherence to time. References 1. Deakin, C. D. et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 81 Suppl 1, e93–e174 (2010). 2. Neumar, R. W. et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122, S729–67 (2010). 3. Høyer, C. B., Christensen, E. F. & Eika, B. Junior physician skill and behaviour in resuscitation: a simulation study. Resuscitation 80, 244–8 (2009). 4. Cunningham, L. M., Mattu, A., O’Connor, R. E. & Brady, W. J. Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation. The American journal of emergency medicine 30, 1630–8 (2012). 5. Steen, S., Liao, Q., Pierre, L., Paskevicius, A. & Sjöberg, T. The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation 58, 249–258 (2003). 6. Ringsted, C. et al. Assessment of Advanced Life Support competence when combining different test Methods–reliability and validity. Resuscitation75, 153–60 (2007). Disclosures Grant from ’The Laerdal Foundation for Acute Medicine’ and ’SkejSim’.

Board 360 - Research Abstract Effective Debriefing Approaches in Simulation-Based Education: A Qualitative Study of Simulation Experts (Submission #101)

Introduction/Background Debriefing facilitates participants learning from the simulated experiences through reflection and feedback. The value of debriefing post scenario in simulation-based education (SBE) has been well documented. For example, a review by McGaghie et al1 identifies feedback (including debriefing) as the most important feature of SBE.1 There are many different models and approaches to facilitate debriefing in SBE within healthcare, building on research, experiences and practical application. However, there is little evidence supporting one approach over another. It is likely that several variables are important such as what is taught, the level of learners, their experience and not least the educator. 2,3 Though the literature describes what constitutes effective debriefing, there are discrepancies as to what is actually being practiced.4 There is limited information as to how experts or experienced debriefers practice.4 This national study explores the practice of expert debriefers, who work within full-scale, high-stakes immersive SBE environments. Methods Individual semi-structured interviews were conducted with experts in debriefing after immersive simulation based education. Respondents were nominated by peers through purposive sampling across Australian states. Interviews were audio recorded and transcribed for thematic analysis with NVivo9. Three researchers working independently each inductively coded between three and five transcripts and jointly developed a high level coding framework, used to guide a deductive interpretive thematic analysis of all interviews. Triangulation through independent analysis continued throughout the thematic analysis process. Ethical approval was obtained for the study and all participants signed a consent form. Results A total of 24 interviews of 45-95 minutes were transcribed. Participants were from all states of Australia. The majority of participants were located in larger cities such as Melbourne, Sydney, Brisbane, Perth and Adelaide from 20 different workplaces and centres, 6 different disciplines and 14 sub-disciplines. The participants had between 4 and 23 years of experience with debriefing in SBE, with an average of 9.7 years of experience. The three high order categories are: features of expert practice, the development of expertise and the influence of context upon debriefing practice. Analysis is indicating that dominant practice features include: debriefing models used, video assisted debriefing, briefing and continues professional development. Most participants used a blended approach to debriefing combining different models to fit the need of the learners and the contexts of the simulated scenario and the debriefing. Key success factors identified by several participants were: the importance of showing genuine interest, being honest and continuing to strive for being better by continues professional development. Influences on debriefing practice included a range of peer interactions such as: peer feedback, observation of other debriefers, formalized courses in debriefing and conference workshop participation. Conclusion This study looks at the self-reported practices of expert debriefers. The purposive sampling covered a large range of disciplines and no new themes (saturation) were introduced within the final interview set. While there were many convergent features of expert practice and development, there were also context-dependent divergences. The need for peer interaction to develop and sustain expertise was marked. This study contributes to the research on debriefing in SBE by bringing evidence to the use of a highly contextualized approach to debriefing to fit the need of the learners. The interviewed expert debriefers do not use a single model for practice but have a blended approach to debriefing with genuine interest and honesty as the main drivers. References 1. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Medical education. 2010;44(1):50–63. doi:10.1111/j.1365-2923.2009.03547.x. 2. Issenberg BS, Scalese RJ. Best evidence on high-fidelity simulation: what clinical teachers need to know. The Clinical Teacher. 2007;4(2):73–77. doi:10.1111/j.1743-498X.2007.00161.x. 3. Steinwachs B. How to Facilitate a Debriefing. Simulation & Gaming. 1992;23(2):186–195. doi:10.1177/1046878192232006. 4. Dieckmann P, Friis SM, Lippert A, Østergaard D. The art and science of debriefing in simulation : Ideal and practice. 2009;31(7):287–294. doi:10.1080/01421590902866218. Disclosures Grant from ’The Laerdal Foundation for Acute Medicine’ and ’SkejSim’ Health Workforce Australia for the NHET-Sim program Convincis Ltd.