Maneesha Bangar

392: NUMBERED JERSEYS IMPROVE TEAMWORK DURING SIMULATED EMERGENCIES

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Teamwork and leadership skills in Cardiac Arrest/Rapid Response (CA/RR) scenarios have been shown to correlate with clinical outcomes such as mortality. During these high stress and high acuity events, leaders must be able to rapidly assign roles and tasks, as well as give effective commands to each team member to optimize teamwork. We hypothesize that the use of individual numbered jerseys for each code team member improves overall teamwork performance during simulated CA/ RR scenarios. Methods: Internal Medicine Residents PGY-1 (n = 48) were randomized into two groups. In the experimental group, the team leader received a yellow jersey with the number 1 printed on it and each team member received white numbered jerseys (2 through 8). The control team leader and members wore their regular work clothes. Each group participated in 8 simulated CA/RR cases using high-fidelity simulation, and participants alternated between team leader and team member roles for each case. The 16-item validated Mayo High Performance Teamwork Scale (MHPTS) was independently completed by an experienced faculty member observer. Results: A total of 64 simulated cases and 64 Mayo scales were completed. In the experimental jersey group, the overall teamwork score was significantly higher as compared to the control group (24.8 vs 18.2, p < 0.01). In addition, team leaders in the experimental group were better recognized by the other team members (2.0 vs 1.8, p < 0.01) and were better at finding balance between command authority and team member participation (1.7 vs 1.2, p < 0.01). Furthermore, team members in the experimental group had a clearer understanding of their assigned team role (1.6 vs 1.1, p < 0.01) and had improved team communication and recognition of errors (1.4 vs 0.8, p < 0.01). Conclusions: The use of numbered jerseys to identify each member of the CA/RR team is an effective method of improving overall teamwork as well as many specific critical team components during CA/RR scenarios. Further research is needed to evaluate the feasibility of using these jerseys during real in-hospital events 392

Comparison between Simulation-based Training and Lecture-based Education in Teaching Situation Awareness. A Randomized Controlled Study

Rationale: Situation awareness has been defined as the perception of the elements in the environment within volumes of time and space, the comprehension of their meaning, and the projection of their status in the near future. Intensivists often make time‐sensitive critical decisions, and loss of situation awareness can lead to errors. It has been shown that simulation‐based training is superior to lecture‐based training for some critical scenarios. Because the methods of training to improve situation awareness have not been well studied in the medical field, we compared the impact of simulation vs. lecture training using the Situation Awareness Global Assessment Technique (SAGAT) score. Objectives: To identify an effective method for teaching situation awareness. Methods: We randomly assigned 17 critical care fellows to simulation vs. lecture training. Training consisted of eight cases on airway management, including topics such as elevated intracranial pressure, difficult airway, arrhythmia, and shock. During the testing scenario, at random times between 4 and 6 minutes into the simulation, the scenario was frozen, and the screens were blanked. Respondents then completed the 28 questions on the SAGAT scale. Sample items were categorized as Perception, Projection, and Comprehension of the situation. Results were analyzed using SPSS Version 21. Results: Eight fellows from the simulation group and nine from the lecture group underwent simulation testing. Sixty‐four SAGAT scores were recorded for the simulation group and 48 scores were recorded for the lecture group. The mean simulation vs. lecture group SAGAT score was 64.3 ± 10.1 (SD) vs. 59.7 ± 10.8 (SD) (P = 0.02). There was also a difference in the median Perception ability between the simulation vs. lecture groups (61.1 vs. 55.5, P = 0.01). There was no difference in the median Projection and Comprehension scores between the two groups (50.0 vs. 50.0, P = 0.92, and 83.3 vs. 83.3, P = 0.27). Conclusions: We found a significant, albeit modest, difference between simulation training and lecture training on the total SAGAT score of situation awareness mainly because of the improvement in perception ability. Simulation may be a superior method of teaching situation awareness.

13: TEACHING SITUATION AWARENESS DURING CARDIAC ARRESTS AND RAPID RESPONSES - A SIMULATION STUDY

Learning Objectives: During rapid responses (RR) and cardiac arrests (CA), team leaders must be aware of multiple factors simultaneously in order to successfully manage them. Situation awareness (SA) is a necessary skill for leaders to optimize patient outcomes. SA can be divided into 3 components: facts, comprehension, and projection. SA involves understanding the current situation, having the ability to look at all the data, synthesizing the information and determining its relevance. We hypothesized that residents’ SA and ability to manage RR/CA scenarios can be improved with simulation training. Methods: Internal Medicine residents (n=48) participated in 8 RR/CA scenarios using High Fidelity Simulation (HFS). They were scored in 2 pre-training cases, then received feedback and education about SA and RR/CA management, participated in 4 more cases for education penetrance, and scored again in 2 cases as post-training evaluation. A modified SABAR (Situation Awareness Behaviorally Anchored Rating) scale was used, ranging from 1 (very poor) to 5 (very good). Scoring was performed by a trained observer. Results: After training the residents’ SA during RR/CA scenarios improved from 2.4+0.6 to 4.4+0.4 (p< 0.01). All 20 evaluated items showed statistically significant improvement (p<0.01) The greatest improvements were in: employ team members appropriately to perform needed tasks (2.1 to 5.0); use team members to effectively assess the situation (1.8 to 4.4) and ask for pertinent information (2.4 to 4.7). After training the lowest scores were in: gather follow up information when needed (3.4); perform a team leader’s overview (3.5); project future possibilities and create contingency plans (3.5). Conclusions: Novice code leaders often struggle with maintaining awareness of the dozens of inputs they may receive during a RR/CA situation. HFS training improves SA of medical residents markedly and rapidly. Although improved, residents still had some difficulty with items related to taking a general overview and projection of the future patient course.

Board 304 - Research Abstract Leadership Skills and Clinical Performance of Internal Medicine Residents in Cardiac Arrests and Rapid Responses - A Simulation Study (Submission #504)

Introduction/Background Internal Medicine residents are expected to lead and participate in rapid responses (RA) and cardiac arrests (CA) throughout their residency training. While the American Heart Association Advance Cardiac Life Support course provides education in resuscitative protocols, not all residents have the same confidence level and skills to run RR/CA scenarios. Scenario-based training (SBT) with a high-fidelity simulator (HFS) allows trainees to experience high-risk, low-frequency events that are typical of inpatient medicine without exposing patients to the risks inherent in trainee learning. We hypothesized that simulation training offered during residency training is an effective teaching modality that can improve residents’ self-confidence, teamwork, leadership and ability to manage RR/CA scenarios. Methods A prospective, before and after study design was used. All first and second year Internal Medicine residents at Montefiore Medical Center (n=126) were divided into small groups to replicate RR/CA teams. Each group participated in 8 RR/CA scenarios in random order using a HFS (SimMan - Laerdal). First, the residents participated in two pre-training cases with evaluation scores and without feedback. Then they received teaching feedback, as well as a brief talk focusing on team performance and crew resource management techniques. They then participated in two more cases to allow for education penetrance. Their performance in these cases were not evaluated. Finally, they participated in four more cases that were evaluated and scored as post-training cases. The pre and post-training case scores were compared. Cases were designed by a teaching committee to anonymously replicate actual RR/CA cases that had been observed in the hospital. The clinical component was evaluated through pertinent checklists divided by levels of difficulty (level A being the easiest and level D the most difficult). The teamwork performance was evaluated with the validated Mayo Clinic Teamwork Scale. Analysis was performed using STATA/IC 11.2. Results After each scenario all groups showed improvement in their RR/CA clinical performance. The pre vs. post-training combined score improved from 41.8 % + 15% to 68% + 18% (delta +26.2%, p<0.00). Level A (basic) performance on checklists improved from 54.4% + 10% to 95% + 16% (+40.6%p<0.00); Level B (intermediate) from 65.4% + 9% to 87.6% + 18% (+22.2% p<0.00); Level C (advanced) from 38.5% + 6 to 63.6% + 6 (+25.1% p<0.00); and Level D (expert) from 8.84% + 17 to 25.9% + 9 (+17.1%p<0.00). Leadership and teamwork skills improved from 26.5% +30% to 84.5% + 30% (+58% p<0.00). The greatest improvements were in the team’s ability to:understand their role (+68.3% p<0.00), appropriately manage disagreements (+69.3% p<0.00) and ask for clarifications when instructions were unclear(+76.5% p<0.00). Conclusion Training residents with a HFS provides instantaneous access to learning modules without compromising patient safety. Both clinical performance and teamwork skills improved significantly among all groups of residents and at all levels of complexity. Simulation training offered during residency training is an effective teaching modality that can improve resident’s self-confidence, teamwork, leadership and ability to manage rapid response/cardiac arrest scenarios. References 1. Stefan MS, et al: A simulation-based program to train medical residents to lead and perform advanced cardiovascular life support. Hosp Pract (Minneap) 2011 Oct; 39(4):63-9. 2. Langhan TS, et al: Simulation-based training in critical resuscitation procedures improves residents’ competence. CJEM 2009 Nov; 11(6):535-9. 3. Schroedl CJ, et al: Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care 2012 April; 27(2):219.e7-13. 4. Malec JF, Torsher LC, Dunn WF, et at: The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills. Simul Healthc 2007 Spring; 2(1):4-10. Disclosures 12.5% salary support for grant from Center for Medicare Services for study of new electronic dashboard to view ICU data.