Luca Carenzo

Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills.

Objectives This study tested the hypothesis that virtual reality simulation is equivalent to live simulation for testing naive medical students’ abilities to perform mass casualty triage using the Simple Triage and Rapid Treatment (START) algorithm in a simulated disaster scenario and to detect the improvement in these skills after a teaching session. Methods Fifty-six students in their last year of medical school were randomized into two groups (A and B). The same scenario, a car accident, was developed identically on the two simulation methodologies: virtual reality and live simulation. On day 1, group A was exposed to the live scenario and group B was exposed to the virtual reality scenario, aiming to triage 10 victims. On day 2, all students attended a 2-h lecture on mass casualty triage, specifically the START triage method. On day 3, groups A and B were crossed over. The groups’ abilities to perform mass casualty triage in terms of triage accuracy, intervention correctness, and speed in the scenarios were assessed. Results Triage and lifesaving treatment scores were assessed equally by virtual reality and live simulation on day 1 and on day 3. Both simulation methodologies detected an improvement in triage accuracy and treatment correctness from day 1 to day 3 (P<0.001). The time to complete each scenario and its decrease from day 1 to day 3 were detected equally in the two groups (P<0.05). Conclusion Virtual reality simulation proved to be a valuable tool, equivalent to live simulation, to test medical students’ abilities to perform mass casualty triage and to detect improvement in such skills.

Does noninvasive ventilation delivery in the ward provide early effective ventilation

BACKGROUND: Although noninvasive ventilation (NIV) is increasingly used in general wards, limited information exists about its ability to provide effective ventilation in this setting. We aim to evaluate NIV delivered in the ward by assessing (1) overall time of application and occurrence of adverse events and (2) differences between daytime and nighttime NIV application. METHODS: We studied subjects with hypercapnic acute hypercapnic respiratory failure not fulfilling strict criteria for ICU admission, and excluded those who interrupted NIV prior to 48 h. Time spent on NIV, presence and extent of air leaks, and occurrence of desaturations were assessed for the overall study period, and compared between daytime and nighttime. RESULTS: We enrolled 42 subjects, 25 of whom received NIV for at least 48 h and were included in the data analysis. NIV was successful for 20 subjects, who did not reach criteria for ICU admission. Both PaCO2 and pH significantly improved on average after 2 h and at the end of the study period. NIV was applied for 64.5% of the overall study period and had absent or compensated air leaks for 62.3% of the overall 48-h period. NIV was applied for 55.8% of daytime and for 79.3% of nighttime (P < .01). Effective NIV application was significantly longer overnight (76.9%) than during daytime (53.2%) (P < .01). CONCLUSIONS: In selected subjects with hypercapnic acute respiratory failure not fulfilling criteria for ICU admission, the application of NIV in the ward is feasible; in addition, NIV can be safely administered overnight.

Data collection in a live mass casualty incident simulation: automated RFID technology versus manually recorded system.

Objectives To demonstrate the applicability and the reliability of a radio frequency identification (RFID) system to collect data during a live exercise. Methods A rooftop collapse of a crowded building was simulated. Fifty-three volunteers were trained to perform as smart victims, simulating clinical conditions, using dynamic data cards, and capturing delay times and triage codes. Every victim was also equipped with a RFID tag. RFID antenna was placed at the entrance of the advanced medical post (AMP) and emergency department (ED) and recorded casualties entering the hospital. Results A total of 12 victims entered AMP and 31 victims were directly transferred to the ED. 100% (12 of 12 and 31 of 31) of the time cards reported a manually written hospital admission time. No failures occurred in tag reading or data transfers. A correlation analysis was performed between the two methods plotting the paired RFID and manual times and resulted in a r=0.977 for the AMP and r=0.986 for the ED with a P value of less than 0.001. Conclusion We confirmed the applicability of RFID system to the collection of time delays. Its use should be investigated in every aspect of data collection (triage, treatments) during a disaster exercise.

Efficacy of ventilator waveform observation for detection of patient-ventilator asynchrony during NIV: a multicentre study

The objective of this study was to assess ability to identify asynchronies during noninvasive ventilation (NIV) through ventilator waveforms according to experience and interface, and to ascertain the influence of breathing pattern and respiratory drive on sensitivity and prevalence of asynchronies. 35 expert and 35 nonexpert physicians evaluated 40 5-min NIV reports displaying flow–time and airway pressure–time tracings; identified asynchronies were compared with those ascertained by three examiners who evaluated the same reports displaying, additionally, tracings of diaphragm electrical activity. We determined: 1) sensitivity, specificity, and positive and negative predictive values; 2) the correlation between the double true index (DTI) of each report (i.e., the ratio between the sum of true positives and true negatives, and the overall breath count) and the corresponding asynchrony index (AI); and 3) the influence of breathing pattern and respiratory drive on both AI and sensitivity. Sensitivities to detect asynchronies were low either according to experience (0.20 (95% CI 0.14–0.29) for expert versus 0.21 (95% CI 0.12–0.30) for nonexpert, p=0.837) or interface (0.28 (95% CI 0.17–0.37) for mask versus 0.10 (95% CI 0.05–0.16) for helmet, p<0.0001). DTI inversely correlated with the AI (r2=0.67, p<0.0001). Breathing pattern and respiratory drive did not affect prevalence of asynchronies and sensitivity. Patient–ventilator asynchrony during NIV is difficult to recognise solely by visual inspection of ventilator waveforms. Detection of patient–ventilator asynchrony during NIV by visual inspection of ventilator waveforms is difficult http://ow.ly/3ce930eGdn6

Hospital preparedness and response in CBRN emergencies: TIER assessment tool.

Introduction Chemical, biological, radiological, and nuclear (CBRN) emergencies need particular hospital preparedness and resources availability. Also, specific skills and capabilities are required for efficient response to these types of events. The aim of this study was to develop an assessment tool to evaluate hospital preparedness and response performance with respect to CBRN emergencies. Methods An evaluation tool was developed using the Delphi technique. A panel of experts from 10 countries, both European and non-European, with more than 5 years of experience in research or practice in CBRN emergency management was involved in this study. The study was run online, and the experts were asked to evaluate a list of items on hospital preparedness and response in CBRN emergencies. A threshold of 85% agreement level was defined as the consensus of experts in this study. Results The first-round questionnaire was answered by 13 experts. Consensus on the preparedness section was reached for all 29 items during the first round and one item was also added by the experts. Consensus on the response performance indicators were reached in 51 out of the 59 items, during the first round, and eight items were modified and then approved in the second round by the experts. Conclusion Hospitals need a specific level of preparedness to enable an effective response to CBRN emergencies. The assessment tool, developed through experts’ consensus in this study, provides a standardized method for the evaluation of hospital preparedness and response performance with respect to CBRN emergencies. The feasibility and reliability of this assessment tool could be evaluated before and during simulated exercises in a standardized manner.

Virtual Laboratory and Imaging: an online simulation tool to enhance hospital disaster preparedness training experience.

Objective Hospitals play a pivotal role as basic healthcare providers during mass casualty incidents (MCIs). Radiological studies and emergency laboratory test are of high importance for the management of hospital patients. However, it is known that during these events, they can generate significant bottlenecks. Appropriate request of such tests is of utmost importance to not generate delays in the patient flow. The aim of this paper is to describe a software designed to increase the realism of hospital-based MCI training through a realistic reproduction of radiology and laboratory departments. Methods In this paper, we present a Virtual Laboratory and Imaging system that we designed with the goal of increasing the realism of full-scale mass casualty simulations. The system is able to dynamically manage the speed and load of virtual departments while collecting data on usage and load, and provide data useful for the after-event debriefing. We tested this system in two pilot simulations involving, respectively, 105 and 89 simulated casualties. Results The system, by measuring the number of requests and exams’ turnaround time, enabled an objective measurement of the laboratory and radiology workload during simulated MCIs. It was possible to identify bottlenecks and consequently use these data for after-action debriefing. Conclusion The tool not only increased the simulation realism by adding the radiology and laboratory departments but also provided valuable data that could be used for educational and organizational purposes.

Professionalization of Anesthesiologists and Critical Care Specialists in Humanitarian Action: A Nationwide Poll Among Italian Residents

BACKGROUND Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies. METHODS The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll. RESULTS A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%). CONCLUSIONS In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

A novel simulation competition format as an effective instructional tool in post-graduate medical education

ObjectiveMedical simulation competitions are a growing reality. This study aims at exploring if a novel format of simulation competition (SIMCUP) can be an effective educational format in post-graduate education.DesignWe designed a 2-day event that included scientific educational lectures, an orientation to the competition, familiarization with the simulation lab, and competition time. Day 1 was devoted to preliminary rounds and was structured using an Objective Structured Clinical Examination (OSCE)-like system. On day 2, the first four teams advanced to semi-finals and then to finals, which were held using a classical SimWars style.Setting and subjectsA total of 14 four-participant teams participated in the event over two editions (Ed.1 in 2015 and Ed.2 in 2016).InterventionsExternal referees evaluated both technical and non-technical skills for each simulated scenario. Each participant was also administered pre- and post-test questionnaires covering self-perception about the confidence in managing simulated clinical cases, educational effectiveness, satisfaction with the simulation experience, and previous simulation training.Main resultsOverall participants found SIMCUP a useful learning experience, rating it 10 [9, 10] and 10 [7.75–10] out of 10 for Ed.1 and Ed.2, respectively. Participants reported, using a 10-point semantic differential scale ranging from “1 - strongly disagree.” to “10 - strongly agree,” finding both days to be educationally effective: day 1 was rated 9 [7–10] and 9 [8–10] as day 2 was rated 8 [7–10] and 8 [7–10] for Ed. 1 and Ed. 2, respectively.Participants’ self-perception regarding the confidence of managing the specific scenarios significantly improved immediately after the event as measured by pre- and post-questionnaires for all stations and during both editions.ConclusionThis study suggests that simulation competition can serve as an effective instructional format in residency training.