Leo Kobayashi

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.

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.

Use of in situ simulation and human factors engineering to assess and improve emergency department clinical systems for timely telemetry-based detection of life-threatening arrhythmias

Background and objectives Medical simulation and human factors engineering (HFE) may help investigate and improve clinical telemetry systems. Investigators sought to (1) determine the baseline performance characteristics of an Emergency Department (ED) telemetry system implementation at detecting simulated arrhythmias and (2) improve system performance through HFE-based intervention. Methods The prospective study was conducted in a regional referral ED over three 2-week periods from 2010 to 2012. Subjects were clinical providers working at the time of unannounced simulation sessions. Three-minute episodes of sinus bradycardia (SB) and of ventricular tachycardia (VT) were simulated. An experimental HFE-based multi-element intervention was developed to (1) improve system accessibility, (2) increase system relevance and utility for ED clinical practice and (3) establish organisational processes for system maintenance and user base cultivation. The primary outcome variable was overall simulated arrhythmia detection. Pre-intervention system characterisation, post-intervention end-user feedback and real-world correlates of system performance were secondary outcome measures. Results Baseline HFE assessment revealed limited accessibility, suboptimal usability, poor utility and general neglect of the telemetry system; one simulated VT episode (5%) was detected during 20 pre-intervention sessions. Systems testing during intervention implementation recorded detection of 4 out of 10 arrhythmia simulations (p=0.03). Twenty post-intervention sessions revealed more VT detections (8 of 10) than SB detections (3 of 10) for a 55% overall simulated arrhythmia detection rate (p=0.001). Conclusions Experimental investigations helped reveal and mitigate weaknesses in an ED clinical telemetry system implementation. In situ simulation and HFE methodologies can facilitate the assessment and abatement of patient safety hazards in healthcare environments.

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.

Development and Validation of a High-Fidelity Porcine Laryngeal Surgical Simulator

Objective Design and validate a laryngeal surgical simulator to teach phonomicrosurgical techniques. Study Design Device development and prospective validation. Setting Tertiary medical center. Subjects and Methods A novel laryngeal fixation device and custom laryngoscope were produced for use with ex vivo porcine larynx specimens. Vocal fold lesions such as nodules and keratotic lesions were simulated with silicone injections and epithelial markings. A prospective validation using postsimulation surveys, global rating scales, and procedure-specific checklists was performed with a group of 15 medical students, otolaryngology residents, fellows, and attending laryngologists. Three procedures were performed: vocal fold augmentation, excision of a simulated vocal fold nodule, and excision of a simulated vocal fold keratosis. Results Participants overwhelmingly agreed that the simulator provided a realistic dissection experience that taught skills that would transfer to real operating scenarios. Expert performance was statistically superior to novice performance for excision of simulated vocal fold nodules and keratotic lesions, while no difference was observed for injection laryngoplasty. Conclusion The ability to learn and rehearse surgical procedures in a safe environment is invaluable, particularly for delicate and highly technical phonomicrosurgical operations. We have developed a high-fidelity laryngeal surgical simulator complete with pathological lesions such as nodules and keratoses to teach these procedures. A prospective study demonstrated validity of our global rating scale and checklist assessments for vocal fold nodule and keratosis excision procedures, allowing them to be confidently incorporated into phonomicrosurgical training programs for surgeons of all levels of expertise.

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.

Simulation intervention with manikin-based objective metrics improves CPR instructor chest compression performance skills without improvement in chest compression assessment skills.

Introduction Cardiopulmonary resuscitation (CPR) instructor/coordinator (CPR-I/C) adherence to published guidelines during resuscitation and learner assessment for basic life support (BLS)/CPR skills has not been experimentally studied. Investigators sought to (1) determine the quality of CPR-I/C chest compression and the accuracy of CPR-I/C chest compression assessment, and (2) improve CPR-I/C compression and assessment skills through cardiac arrest simulations with objective in-scenario performance feedback. Methods Thirty CPR-I/Cs (median, 20 years [range, 4–40 years] of BLS provider experience; 6 years [range 1–40 years] of BLS instructor experience) were randomized to control or experimental group. Each subject performed compressions during a 2-minute simulation, then reviewed 6 videos of simulated CPR performances (featuring prespecified chest compression parameters) for scoring as “pass” or “needs remediation.” Subjects participated in a second simulation with or without real-time manikin compression feedback, then reviewed 6 additional videos. Primary outcome variables were the proportion of subjects with more than 80% (American Heart Association regional criteria) or more than 23 of 30 (ie, 77%; American Heart Association instructor manual criteria) correct compressions and subjects’ accuracy of “pass”/“needs remediation” assessment for videos. The secondary outcome variable was correlation between subjects’ correctness of chest compressions and their assessment accuracy for simulated CPR compression performance. Results All CPR-I/C subjects compressed suboptimally at baseline; real-time manikin feedback improved the proportion of subjects with more than 77% correct compressions to 0.53 (P < 0.01). Video review data revealed persistently low CPR-I/C assessment accuracy. Correlation between subjects’ correctness of compressions and their assessment accuracy remained poor regardless of interventions. Conclusions Real-time compression feedback during simulation improved CPR-I/C’s chest compression performance skills without comparable improvement in chest compression assessment skills.

Color-Coding and Human Factors Engineering to Improve Patient Safety Characteristics of Paper-Based Emergency Department Clinical Documentation:

Objective: Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented. Background: Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments. Methods: During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0–23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. Results: Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40) Conclusions: Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Development and Application of a Clinical Microsystem Simulation Methodology for Human Factors-Based Research of Alarm Fatigue

Objectives: (1) To develop a clinical microsystem simulation methodology for alarm fatigue research with a human factors engineering (HFE) assessment framework and (2) to explore its application to the comparative examination of different approaches to patient monitoring and provider notification. Background: Problems with the design, implementation, and real-world use of patient monitoring systems result in alarm fatigue. A multidisciplinary team is developing an open-source tool kit to promote bedside informatics research and mitigate alarm fatigue. Method: Simulation, HFE, and computer science experts created a novel simulation methodology to study alarm fatigue. Featuring multiple interconnected simulated patient scenarios with scripted timeline, “distractor” patient care tasks, and triggered true and false alarms, the methodology incorporated objective metrics to assess provider and system performance. Developed materials were implemented during institutional review board–approved study sessions that assessed and compared an experimental multiparametric alerting system with a standard monitor telemetry system for subject response, use characteristics, and end-user feedback. Results: A four-patient simulation setup featuring objective metrics for participant task-related performance and response to alarms was developed along with accompanying structured HFE assessment (questionnaire and interview) for monitor systems use testing. Two pilot and four study sessions with individual nurse subjects elicited true alarm and false alarm responses (including diversion from assigned tasks) as well as nonresponses to true alarms. In-simulation observation and subject questionnaires were used to test the experimental system’s approach to suppressing false alarms and alerting providers. Conclusions: A novel investigative methodology applied simulation and HFE techniques to replicate and study alarm fatigue in controlled settings for systems assessment and experimental research purposes.