Leigh V. Evans

Teaching and Assessing Procedural Skills Using Simulation: Metrics and Methodology

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.

Information Loss in Emergency Medical Services Handover of Trauma Patients

Abstrast Introduction. Little is known about how effectively information is transferred from emergency medical services (EMS) personnel to clinicians in the emergency department receiving the patient. Information about prehospital events and findings can help ensure expedient and appropriate care. The trauma literature describes 16 prehospital data points that affect outcome and therefore should be included in the EMS report when applicable. Objective. To determine the degree to which information presented in the EMS trauma patient handover is degraded. Methods. At a level I trauma center, patients meeting criteria for the highest level of trauma team activation (“full trauma”) were enrolled. As part of routine performance improvement, the physician leadership of the trauma program watched all available video-recorded full trauma responses, checking off whether the data points appropriate to the case were verbally “transmitted” by the EMS provider. Two EMS physicians then each independently reviewed the trauma teams chart notes for 50% of the sample (and a randomly selected 15% of the charts to assess agreement) and checked off whether the same elements were documented (“received”) by the trauma team. The focus was on data elements that were “transmitted” but not “received.” Results. In 96 patient handovers, a total of 473 elements were transmitted, of which 329 were received (69.6%). On the average chart, 72.9% of the transmitted items were received (95% confidence interval 69.0%–76.8%). The most commonly transmitted data elements were mechanism of injury (94 times), anatomic location of injury (81), and age (67). Prehospital hypotension was received in only 10 of the 28 times it was transmitted; prehospital Glasgow Coma Scale [GCS] score 10 of 22 times; and pulse rate 13 of 49 times. Conclusions. Even in the controlled setting of a single-patient handover with direct verbal contact between EMS providers and in-hospital clinicians, only 72.9% of the key prehospital data points that were transmitted by the EMS personnel were documented by the receiving hospital staff. Elements such as prehospital hypotension, GCS score, and other prehospital vital signs were often not recorded. Methods of “transmitting” and “receiving” data in trauma as well as all other patients need further scrutiny.

Use of Ultrasound Guidance Improves Central Venous Catheter Insertion Success Rates Among Junior Residents

The purpose of this study was to determine whether junior residents had higher rates of first cannulation and overall success at central venous catheter insertions with the use of ultrasound (US) guidance compared to the landmark technique.

Simulation and patient safety: evaluative checklists for central venous catheter insertion

In the advent of concerns for patient safety, simulation training is emerging as a method to train healthcare providers to perform invasive procedures such as central venous catheter (CVC) insertion while minimising harmful complications to the patient. New technologies in medical simulation have begun to shift research attention to the performance component of clinical competency. Accurate assessment of healthcare provider competence is a major priority in medical education necessitating the development of valid and reliable assessment tools. In the past year alone, nine evaluative tools, both global rating scales and procedural checklists, have been published in the research literature to evaluate the insertion of CVCs. A review of the advantages of published evaluation tools helps inform users with regard to the critical components necessary for a checklist. Ease of use, ability to be completed by a non-expert, categorical breakdown of critical actions involved in CVC insertion and the need for a comprehensive stepwise procedural checklist are discussed. The development of an ideal checklist may improve future competency-based training and performance evaluation in the clinical setting. A more thorough understanding of the status of checklists as evaluation tools in assessing performance of invasive procedures will lead to better training protocols and ultimately to improved patient safety.

The development of an independent rater system to assess residents' competence in invasive procedures.

Purpose To design an independent rater (IR) direct observation system to monitor invasive procedures performed by residents in the hospital setting. Method The authors recruited, trained, and tested nonphysicians to become IRs for an Agency for Healthcare Research and Quality–funded study evaluating the impact of partial task simulation training of ultrasound-guided central venous catheter (CVC) insertion on skills transfer at a major academic medical center. IR applicants completed four hours of training: a two-hour didactic session and a two-hour testing session, including observation of 5 of 10 choreographed CVC insertion videotapes and completion of a 50-data-point procedural checklist. Eligibility to be hired as an IR included timing the procedure accurately, detecting technical errors and complications, and completing the procedural checklist accurately. Results Thirty-eight IR trainees completed the training module and videotape examinations. Twenty-seven (71%) trainees met criteria to be hired IRs by accurately assessing the duration of the procedure to within one minute, validating the checklist to within 95% accuracy, and detecting technical errors/complications to within a 3% margin of error. The authors found no association between educational level and hired status, and all 13 IRs assessed after the study had maintained their skills. Conclusions Recent innovations in procedural training with partial task simulation trainers necessitate developing methods to measure skills transfer from the simulator to the clinical setting. This description of a nonphysician IR direct observation system for CVC insertion offers a feasible tool that may be generalized to monitoring other invasive procedures.

Defecation syncope secondary to functional inferior vena caval obstruction during a valsalva maneuver

This report describes a case of defecation syncope secondary to functional inferior vena cava (IVC) obstruction. Preoperative hemodynamic assessment revealed a marked decrease in blood pressure and IVC obstruction when the patient performed a Valsalva maneuver. The intraoperative approach included continuous hemodynamic monitoring as well as transesophageal ultrasonography to assess IVC patency during surgical mobilization of the IVC. Functional obstruction of the IVC at the diaphragmatic hiatus was identified, and this obstruction was relieved with extensive mobilization of the IVC and right crural myotomy. This report describes an effective surgical approach to a rare functional disorder involving the IVC.