Paul Phrampus

Debriefing Using a Structured and Supported Approach

Debriefing is recognized as a best practice in simulation education but is only one of several methods of providing participant feedback. The purpose of a debriefing is to provide students with the opportunity for review of their simulation experience through facilitated dialogue which leads to reflection, enhanced learning, and change in practice. In this chapter, the authors describe the development and use of a structured method for debriefing individuals and teams of providers. Developed in collaboration with the American Heart Association, the “structured and supported method” includes three phases with associated goals, objectives, and time frames. Many simulation educators are busy, practicing professionals. Because of this, the primary development goal was to build a streamlined debriefing method which was both easy to learn and scalable. It was also important that the method drew on available literature and was validated by use at the Winter Institute for Simulation Education and Research (WISER). Another aspect when considering the method includes use of the gather, analyze, and summarize (GAS) debriefing tool. This tool allows even novice debriefers to rapidly gain skill in debriefing while remaining comfortable with the process. Ability to maintain a student-centric, safe environment where gaps in knowledge, skill, or performance are identified and addressed is central to the method.

Comparison of Video Laryngoscopy and Direct Laryngoscopy in a Critical Care Transport Service

Abstract Objective. We evaluated video laryngoscopy (VL) (C-MAC, Karl Storz, Tuttlingen, Germany) for use in a critical care transport system. We hypothesized that the total number of airway attempts would decrease when using a video laryngoscope versus use of direct laryngoscopy (DL). Methods. We performed a nonrandomized group-controlled trial where six aircraft were outfitted with VL and the remainder utilized DL responding to a mix of scene runs and interfacility transports. Our primary outcome measure was the number of intubation attempts. We also compared the first-pass success (FPS) rates, laryngoscopic grades, and frequencies of rescue device use (including utilization of surgical airways) between VL and DL. Results. Crews intubated 348 patients with VL and 510 with DL. Successful endotracheal intubation within three attempts occurred 97.6% (confidence interval [CI] 96.5–98.6) of the time. The FPS rate was 85.8% (CI 83.4–88.1). In this cohort of patients, VL did not differ from DL with respect to total number of airway attempts (1.17 [CI 1.11–1.22] vs. 1.16 [CI 1.12–1.20]), FPS rate (85.6% [CI 82–89%] vs. 86.1% [CI 83-89]), or use of rescue airways (2.6% vs. 2.2%). The laryngoscopic view was superior in the VL group relative to the DL group (median Cormack-Lehane grade 1 [interquartile range (IQR) 1, 2] vs. 2 [IQR 1, 2]). Conclusion. VL using the C-MAC video laryngoscope did not reduce the total number of airway attempts or improve intubation compared with DL in a system of highly trained providers.

Willingness to perform mouth-to-mouth ventilation by health care providers: A survey ,

BACKGROUND During cardiopulmonary resuscitation (CPR), mouth-to-mouth ventilation (MTM) is only effective if rescuers are willing to perform it. METHODS To assess the degree of willingness or reluctance in performing MTM, a survey including 17 hypothetical scenarios was created. In each scenario health hazards for the rescuer needed to be balanced against the patients need for MTM. Respondents were recruited from health care workers attending courses at a medical simulation center. Respondents reported their willingness or reluctance to perform MTM for each scenario using a 4 point scale. RESULTS The questionnaire had responses by 560 health care workers. Reluctance to perform MTM varied with the scenario. Some health care workers refused to ventilate patients who could benefit from MTM. In all scenarios even when resuscitation was both futile and potentially hazardous, some health care workers were willing to perform MTM. Age and level of experience tend to reduce the propensity to engage in MTM. Parental propensity to ventilate ones own child was stronger than any other motivator. CONCLUSIONS HIV infection is not the only condition for which rescuers hesitate to perform MTM. Bag-valve-mask devices for mechanical ventilation should be available in all locations where health care workers may be called upon to resuscitate apneic patients making the decision to perform MTM moot.

Simulated rescue airway use by laypersons with scripted telephonic instruction

BACKGROUND The King LT-D is a supraglottic airway with the potential for use by trained first responders in settings where access to advanced life support interventions by a physician or Emergency Medical Services may be delayed. OBJECTIVES To determine the success rate of novice users in the telephone-directed placement of the King LT-D airway during a simulated respiratory arrest in order to establish the feasibility of conducting further study into use of the device by first responders after minimal training. METHODS We conducted a prospective study using 30 undergraduate students without medical training and a high-fidelity simulator. Subjects were instructed using a telephone-directed protocol to assess the airway, place the King LT-D and ventilate the simulator. Subjects were assessed on the successful placement of the King LT-D, time to placement, and perceived ease of use of the device. A Likert scale was used to identify the participants perceptions. Subjects with CPR/AED certification were compared to those without such training. Data were analyzed using descriptive statistics and a t-test. RESULTS The King airway was successfully placed in 80% (95% CI: 65; 95) of attempts. Success rate did not differ with prior CPR training. The median time to successful placement was 1min 50s (95% CI: 1min 6s; 2min 39s). The participants perceived the King LT-D to be easy to place in 90% (27/30) of cases. CONCLUSION The King LT-D is simple enough to use, that it can be successfully placed by novice users with minimal telephonic instruction. This suggests that further studies could be conducted to determine the effect of King LT-D use on quality of airway management in scenarios depicting management of cardiac arrest by first responders in areas with delayed access to ALS interventions.

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

PURPOSE Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center. METHODS A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe. RESULTS One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity. CONCLUSIONS One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.

Motion capture measures variability in laryngoscopic movement during endotracheal intubation: a preliminary report.

Introduction Success rates with emergent endotracheal intubation (ETI) improve with increasing provider experience. Few objective metrics exist to quantify differences in ETI technique between providers of various skill levels. We tested the feasibility of using motion capture videography to quantify variability in the motions of the left hand and the laryngoscope in providers with various experience. Methods Three providers with varying levels of experience [attending physician (experienced), emergency medicine resident (intermediate), and postdoctoral student with no previous ETI experience (novice)] each performed ETI 4 times on a mannequin. Vicon, a 16-camera system, tracked the 3-dimensional orientation and movement of markers on the providers, handle of the laryngoscope, and mannequin. Attempt duration, path length of the left hand, and the inclination of the plane of the laryngoscope handle (mean square angular deviation from vertical) were calculated for each laryngoscopy attempt. We compared interattempt and interprovider variability of each measure. Results All ETI attempts were successful. Mean (SD) duration of laryngoscopy attempts differed between experienced [5.50 (0.68) seconds], intermediate [6.32 (1.13) seconds], and novice [12.38 (1.06) seconds] providers (P = 0.021). Mean path length of the left hand did not differ between providers (P = 0.37). Variability of the plane of the laryngoscope differed between providers: 8.3 (experienced), 28.7 (intermediate), and 54.5 (novice) degrees squared. Conclusions Motion analysis can detect interprovider differences in hand and laryngoscope movements during ETI, which may be related to provider experience. This technology has potential to objectively measure training and skill in ETI.

Impact of stylet use in a simulated difficult airway model

BACKGROUND Stylet use during endotracheal intubation (ETI) is variable across medical specialty and geographic location; however, few objective data exist regarding the impact of stylet use on ETI performance. OBJECTIVE We evaluated the impact of stylet use on the time required to perform ETI in cases of simulated difficult airways in novice and experienced providers. METHODS We performed a prospective, randomized observational study of experienced (attending anesthesiologists and emergency physicians) vs inexperienced airway providers (emergency medical technician, paramedic and medical students) comparing the use of stylet vs no stylet in random order using a simulated difficult airway. The primary outcome was attempt time for each of 6 attempts defined as entry of the laryngoscope in the mouth until successfully passing the endotracheal tube past the vocal cords. We analyzed the data using descriptive statistics including means with SDs and t tests. We used generalized estimating equations to evaluate potential changes in the attempt time over multiple attempts. RESULTS There were 23 providers per group. The mean (SD) inexperienced attempt time in seconds was 25.88 (28.46) and 10.50 (5.47) for experienced providers (P < .0001). Stylet use did not alter attempt time for either group. When adjusting for stylet use, the attempt time did not change over repeated intubations (P = .541). When adjusting for experience status, inexperienced intubators had shorter attempt times with each successive trial, whereas experienced intubators attempt times remained constant (P < .001). CONCLUSION Stylet use does not improve attempt time in a simulated difficult airway model for either inexperienced or experienced intubators.

Perceptions of Experiencing Simulated Death

CONCLUSIONS During a medical simulation scenario the appropriate physiological response may be for the simulator to “die”. There has been recent debate about simulated death causing an untoward experience for the learner, or creating an impediment to accomplishing the learning objectives. Largely they have been anecdotal discussions amongst simulation based educators. We queried groups of students participating in simulation based training programs about their perceptions of experiencing a simulated death.

Multimodal feature analysis for quantitative performance evaluation of endotracheal intubation (ETI)

Endotracheal intubation (ETI) is a crucial medical procedure performed on critically ill patients. It involves insertion of a breathing tube into the trachea i.e. the windpipe connecting the larynx and the lungs. Often, this procedure is performed by the paramedics (aka providers) under challenging prehospital settings e.g. roadside, ambulances or helicopters. Successful intubations could be lifesaving, whereas, failed intubation could potentially be fatal. Under prehospital environments, ETI success rates among the paramedics are surprisingly low and this necessitates better training and performance evaluation of ETI skills. Currently, few objective metrics exist to quantify the differences in ETI techniques between providers. In this pilot study, we develop a quantitative framework for discriminating the kinematic characteristics of providers with different experience levels. The system utilizes statistical analysis on spatio-temporal multimodal features extracted from optical motion capture, accelerometers and electromyography (EMG) sensors. Our experiments involved three individuals performing intubations on a dummy, each with different levels of training. Quantitative performance analysis on multimodal features revealed distinctive differences among different skill levels. In future work, the feedback from these analysis could potentially be harnessed for enhanced ETI training.

The impact of an international faculty development program on simulation-based healthcare education.

The dissemination of innovation in medical education including simulation-based healthcare education (SBHE) has been influenced by a Western bias. Countries less experienced with SBHE often import Western programs to initiate efforts for delivering simulation training. Acknowledging cultural differences, we sought to determine whether an SBHE faculty development program in the United States could be successfully transported for use in training teachers in Korea. We adapted a multi-professional program from a preexisting Western model. The process focused on prioritization of curricular elements based on local needs, translation of course materials, and delivery of the program in small group exercises. Evaluation data collected included: participant’s simulation experience; participant’s ratings of the course; and participant’s self-assessment of the course’s impact on their knowledge, skills, and attitudes (KSA) toward simulation teaching. Twenty-eight out of 30 participants strongly agreed or agreed that the course was excellent and relevant to their needs. Participants’ assessment of the impact of the course on their KSA toward simulation teaching improved significantly. Although the project is an adaptation from a well-operated model, it was challenging to overcome differences in culture, language, and educational systems. When transferring curricula to another country or culture, there is a risk of not appreciating these differences. A comprehensive development plan, including targeting barriers to change, with strategies at different levels, is needed to achieve successful transport of Western teaching program to a non-English speaking Asian culture.