Marc Shapiro

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

Objective: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Setting: Level 1 trauma center and academic emergency medicine training program. Participants: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. Intervention: : ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC®) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Design: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. Results: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. Conclusion: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

Use of the ED as a Regular Source of Care: Associated Factors Beyond Lack of Health Insurance

STUDY OBJECTIVE To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care. METHODS We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED. RESULTS Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than

Shift Changes among Emergency Physicians: Best of Times, Worst of Times

30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a

Defining Team Performance for Simulation‐based Training: Methodology, Metrics, and Opportunities for Emergency Medicine

25 copayment were in effect. CONCLUSION Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

Educational and Research Implications of Portable Human Patient Simulation in Acute Care Medicine

The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. Shift changes have long been viewed as risky times, for failures in the transfer of information, authority, or responsibility care can result in adverse events. We observed shift transitions in the ED as part of a study on safety in emergency care. We found that, in addition to being an expected point of failure, transitions were also, unexpectedly, associated with recovery from failure. We report two illustrative case studies, and examine implications for strategies aimed at reducing the number of and volume of transitions.

A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

A Comparison of Manual and Electronic Status Boards in the Emergency Department: What's Gained and What's Lost?

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.

Transitions in Care: Signovers in the Emergency Department:

Aims: Disaster and bioterrorism preparedness is poorly integrated into the curricula of internal medicine residency programs. Given that victims may present to a variety of healthcare venues, including primary care practices, inpatient hospital wards, and intensive care units, we developed a curriculum to address this need. Methods: The curriculum consisted of four didactic sessions with supplemental readings covering biologic, chemical, and radiologic agents, as well as public health infrastructure. All 30 internal medicine resident participants also underwent a four hour training seminar at a high fidelity human simulation center. Instruction included the use of personal protective equipment (PPE) and participation in simulated scenarios utilizing technologically sophisticated mannequins with monitoring and interactive capability. Sessions were videotaped, reviewed with participants, and followed by self-evaluation and constructive feedback. Results: Compared to a control group of residents who did not undergo training, the participants’ level of knowledge was significantly better, with mean objective test scores of 66.8% ;± ;11.8% SD vs. 50% ;± ;13.1% SD, p ;< ;0.0001. Although there was a trend toward increasing knowledge with increasing level of training in the control group, this difference was not significant. Subjective preparedness was also significantly better in the intervention group (p ;< ;0.0001). Objective improvements were not maintained after one year. Conclusions: In this pilot study, a disaster-preparedness curriculum including simulation-based training had a positive effect on residents’ knowledge base and ability to respond to disaster. However, this effect had diminished after one year, indicating the need for reinforcement at regular intervals.

Conceptual Framework for Studying Shift Changes and other Transitions in Care

Emergency departments (EDs) are complex, high tempo, high risk work environments that require dynamic sharing of information across a group of caregivers. EDs commonly use status boards as tools to facilitate this sharing. Manual status boards have been replaced in some institutions by electronic ones, for a variety of reasons. We contrast the use of manual and electronic status boards in 4 different EDs to assess the gains and losses for workers.

Profiles in Patient Safety: Emergency Care Transitions

The need for 24-hour emergency care requires emergency department (ED) staff to work in shifts. We observed shift transitions in 5 EDs as part of a study on safety in emergency care. We found the observable characteristics of shift transitions to be highly variable across institutions and dynamically variable within shift change episodes. However, across all sites, turnovers were interactional rather than transactional, and were highly tailored to the immediate context. The high degree of situatedness in the turnovers suggest they are not likely to be adapted to a standardized tool or protocol.