Debriefing Assessment For Simulation In Healthcare Research Articles

Septic Abortion Complicated by Disseminated Intravascular Coagulation.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC). Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality. At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU). This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows. Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Thirteen learners completed a feedback form out of seventeen participants. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores. This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in. Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.

Inhalational Injury Secondary to House Fire.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of patients with an inhalational airway injury secondary to a house fire. Burn injuries are a common occurrence encountered by the emergency physician. According to the National Hospital Ambulatory Medical Care Survey, around 371,000 patients were treated in emergency departments for fire or burn injuries across the United States in 2020. This represents around 1% of emergency department visits related to injury, poisoning, or adverse effects.1 One of the most dangerous and time critical aspects of managing severely burned patients is inhalation injury. Inhalation injury is a relatively vague term which may refer to pulmonary exposure to a wide range of chemicals in various forms. In the context of burn patients, this is most often smoke exposure. It is critical that the emergency medicine provider rapidly identifies the potential for an inhalational injury in order to determine the need for definitive airway management. It is also important that the provider has the necessary skills and systematic approach to manage what is likely to be a difficult airway. Furthermore, providers must then have the knowledge of how to best manage and resuscitate these severely burned patients post-intubation. At the conclusion of the simulation session, learners will be able to: 1) recognize the indications for intubation in a thermal burn/inhalation injury patient; 2) develop a systematic approach to an inhalational injury airway; and 3) recognize indications for transfer to burn center. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of inhalational airway injury secondary to a house fire. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form2 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Nine learners completed a feedback form. This session received all 6 & 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. This is a cost-effective method for reviewing inhalational airway injury diagnosis and management. The case may be modified for targeted audiences, expected resources, and learning objectives, such as removal of a bronchoscope availability in settings which are expected to be resource-limited. Some readers may choose to focus on other aspects of burn management instead of airway securement such as cyanide and/or carbon monoxide toxicity. We encourage readers to limit the number of learning objectives because airway algorithms and troubleshooting for this scenario was a rich, stand-alone debriefing. There was not enough time to review in detail all nuanced aspects of the burned patient, including: Lund-Browder versus rule of 9's, modified Brooke versus Parkland formulas, indications for and completion of escharotomies, and/or identification and treatment of cyanide and carbon monoxide toxicity. Medical simulation, burns, airway emergencies, emergency medicine.

Ventricular Tachycardia.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of ventricular tachycardia (VT) that is refractory to single dose anti-arrhythmic management. Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours,1 has a mortality rate up to 14% in the first 48 hours.2 Ventricular tachycardia may present in a heterogenous fashion, not only with stable versus unstable clinical presentations, but also with different electrocardiographic morphologies and etiologies.1 Understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital in the setting of refractory ventricular tachycardia rather than relying on the success of first-line agents. Appreciation for what medications are readily available in your crash cart and medication dispensing cabinet is critical for timely management for refractory ventricular tachycardia. At the conclusion of the simulation session, learners will be able to: 1) identify the different etiologies of VT, including structural heart disease, acute ischemia, and acquired or congenital QT syndrome; 2) describe confounding factors of VT, such as electrolyte abnormalities and sympathetic surge; 3) describe how to troubleshoot an unsuccessful synchronized cardioversion, including checking equipment connections, increasing delivered energy, and changing pad placement; 4) compare and contrast treatments of VT based on suspected underlying etiology; 5) describe reasons to activate the cardiac catheterization lab other than occlusive myocardial infarction; and 6) identify appropriate disposition of the patient to the cardiac catheterization lab. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of VT. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case. Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form3 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Twelve learners completed a feedback form. This session received 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated 5 scores. The lowest average score was 6.67 for "Before the simulation, the instructor set the stage for an engaging learning experience." The highest average score was 7 for "The instructor helped me see how to improve or how to sustain good performance." The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Excellent care and debrief." Specific scores are available upon request. This is a cost-effective method for reviewing VT diagnosis and management. The case may be modified for appropriate audiences, such as describing what medications may be readily available in a free-standing emergency department or pre-hospital setting. Medical simulation, ventricular tachycardia, cardiac emergencies, dysrhythmias, cardiology, emergency medicine.

한국판 시뮬레이션 디브리핑 평가 도구(K-DASH) 신뢰도와 타당도 검증

Objectives Debriefing is the core of simulation education that helps learners to meaningfully structure their experience. A valid and reliable scale capable of evaluating debriefing in Korean culture is required. This study translated the Debriefing Assessment for Simulation in Healthcare (DASH), into Korean, and analyzed its validity and reliability. Methods A total of 66 participants from nursing colleges in 3 different regions evaluated the tools and 4 participated via in-depth interviews. Results A one-factor model showed acceptable fit indices (χ2=20.21, χ2/df=2.25, comparative fit index=.95, standardized root mean square residual=.05, normed fit index=.91, tucker-lewis index=.92, root mean square error of approximation=.15). Via in-depth interviews, using K-DASH was identified to helped in successful debriefing. Cronbach’s α was .94. Conclusions This study demonstrated acceptable validity and reliability of K-DASH and its introduction into the Korean simulation curriculum can improve the efficacy of simulation education.

Impact of the PEARLS Healthcare Debriefing cognitive aid on facilitator cognitive load, workload, and debriefing quality: a pilot study

BackgroundThe Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool is a cognitive aid designed to deploy debriefing in a structured way. The tool has the potential to increase the facilitator’s ability to acquire debriefing skills, by breaking down the complexity of debriefing and thereby improving the quality of a novice facilitator’s debrief. In this pilot study, we aimed to evaluate the impact of the tool on facilitators’ cognitive load, workload, and debriefing quality.MethodsFourteen fellows from the New York City Health + Hospitals Simulation Fellowship, novice to the PEARLS Healthcare Debriefing Tool, were randomized to two groups of 7. The intervention group was equipped with the cognitive aid while the control group did not use the tool. Both groups had undergone an 8-h debriefing course. The two groups performed debriefings of 3 videoed simulated events and rated the cognitive load and workload of their experience using the Paas-Merriënboer scale and the raw National Aeronautics and Space Administration task load index (NASA-TLX), respectively. The debriefing performances were then rated using the Debriefing Assessment for Simulation in Healthcare (DASH) for debriefing quality. Measures of cognitive load were measured as Paas-Merriënboer scale and compared using Wilcoxon rank-sum tests. Measures of workload and debriefing quality were analyzed using mixed-effect linear regression models.ResultsThose who used the tool had significantly lower median scores in cognitive load in 2 out of the 3 debriefings (median score with tool vs no tool: scenario A 6 vs 6, p=0.1331; scenario B: 5 vs 6, p=0.043; and scenario C: 5 vs 7, p=0.031). No difference was detected in the tool effectiveness in decreasing composite score of workload demands (mean difference in average NASA-TLX −4.5, 95%CI −16.5 to 7.0, p=0.456) or improving composite scores of debriefing qualities (mean difference in DASH 2.4, 95%CI −3.4 to 8.1, p=0.436).ConclusionsThe PEARLS Healthcare Debriefing Tool may serve as an educational adjunct for debriefing skill acquisition. The use of a debriefing cognitive aid may decrease the cognitive load of debriefing but did not suggest an impact on the workload or quality of debriefing in novice debriefers. Further research is recommended to study the efficacy of the cognitive aid beyond this pilot; however, the design of this research may serve as a model for future exploration of the quality of debriefing.

Lightning Strike.

This scenario was developed to educate emergency medicine residents on the various presentations and management of a patient struck by lightning. Annually, there are approximately 1.4 billon lightning strikes around the world; of these, an estimated 24,000 strikes cause significant injury or death.1 In the United States, there are approximately 400 lightning-related injuries every year resulting in 40 average annual deaths.1 Although only one in approximately 14,000 people will ever be struck by lightning, this still represents a significant injury mechanism for which emergency department providers must be prepared.2 Lightning is formed by static electricity built up due to ice crystals in clouds which creates a differential charge between the cloud and another object, such as the ground. Approximately one in every five lightning strikes is a cloud-to-ground strike which can result in injury or death. Lightning current flows may be as high as 100,000 amperes; this is survived 90% of the time only because the strong current of the bolt is applied in a very small timeframe, limiting the amount of energy transferred.3 Even so, with such large amperages, substantial injuries or death are possible. Not limited to a single mechanism, lightning can harm people in a variety of ways, including a direct strike, side-splash, ground current or upward streamers from the ground, or cause blast-type injury.2 The large electric currents involved can generate non-perfusing cardiac rhythms resulting in death if the patient is not immediately resuscitated through cardiopulmonary resuscitation (CPR) techniques with respiratory support.2. At the conclusion of the simulation session, learners will be able to: 1) Describe how to evaluate for scene safety in an outdoor space during a thunderstorm, 2) Obtain a relevant focused physical examination of the lightning strike patient, 3) Describe the various manifestations of thermo-electric injury, 4) Discuss the management of the lightning strike patient, including treatment and disposition, 5) Outline the principles of reverse triage for lightning strike patients, and 6) Describe long-term complications of lightning strike injuries. This session was conducted using a simulation scenario with a mix of high-fidelity manikins and standardized patients followed by a debriefing session on the presentation, differential diagnosis, and management of lightning strike patients. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case. The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as to provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Feedback from the residents was overwhelmingly positive, although several learners struggled with identifying Lichtenberg figures and keraunoparalysis either due to the low-light setting, unfamiliarity of the pathology, or that the depictions were not as expected. The subsequent debriefings allowed for multiple areas of discussion. Debriefing topics included the comparing and contrasting low voltage/high voltage/lightning strike injuries, possible clinical presentations of the lightning strike patient, reverse triage principles, categorizing blast injuries, discussion of disposition, and the determination of prehospital scene safety.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form4 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Thirty-one learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The statement, "Before the simulation, the instructor set the stage for an engaging learning experience," received the lowest average score with 6.81, while "The instructor structured the debriefing in an organized way" received an average score of 6.94.The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Absolutely loved this sim. Tested multiple aspects of massCal care. Communication, critical care, scene safety, etc., nailed it," and "Very engaging and fun with a lot (of) good debriefing." This is an easily reproducible method for reviewing management of the lightning strike patient. Faculty may choose to use a combination of high- or low-fidelity manikins, task trainers, standardized patients, or confederate actors/volunteers as patients. There are multiple potential presentations and complications of the lightning strike patient to further customize the experience for learners' needs. For those who are looking to scale down the scenario, victims may be limited to one or two individuals, using whatever preferred mixture of manikins or standardized patients is needed or desired. Medical simulation, lightning strike patient, thermo-electrical burn, wilderness first-aid, blast injuries, wilderness medicine, emergency medicine, austere medicine.

Immediate faculty feedback using debriefing timing data and conversational diagrams

BackgroundDebriefing is an essential skill for simulation educators and feedback for debriefers is recognised as important in progression to mastery. Existing assessment tools, such as the Debriefing Assessment for Simulation in Healthcare (DASH), may assist in rating performance but their utility is limited by subjectivity and complexity. Use of quantitative data measurements for feedback has been shown to improve performance of clinicians but has not been studied as a focus for debriefer feedback.MethodsA multi-centre sample of interdisciplinary debriefings was observed. Total debriefing time, length of individual contributions and demographics were recorded. DASH scores from simulation participants, debriefers and supervising faculty were collected after each event. Conversational diagrams were drawn in real-time by supervising faculty using an approach described by Dieckmann. For each debriefing, the data points listed above were compiled on a single page and then used as a focus for feedback to the debriefer.ResultsTwelve debriefings were included (µ = 6.5 simulation participants per event). Debriefers receiving feedback from supervising faculty were physicians or nurses with a range of experience (n = 7). In 9/12 cases the ratio of debriefer to simulation participant contribution length was ≧ 1:1. The diagrams for these debriefings typically resembled a fan-shape. Debriefings (n = 3) with a ratio < 1:1 received higher DASH ratings compared with the ≧ 1:1 group (p = 0.038). These debriefings generated star-shaped diagrams. Debriefer self-rated DASH scores (µ = 5.08/7.0) were lower than simulation participant scores (µ = 6.50/7.0). The differences reached statistical significance for all 6 DASH elements. Debriefers evaluated the ‘usefulness’ of feedback and rated it ‘highly’ (µ= 4.6/5).ConclusionBasic quantitative data measures collected during debriefings may represent a useful focus for immediate debriefer feedback in a healthcare simulation setting.

Who Can Debriefing Assessment for Simulation in Healthcare? Different Perspectives on Teledebriefing Assessments.

Virtual debriefing is a cardinal element to achieve the effectiveness of telesimulation. There are different instruments to assess face-to-face debriefing to determine the degree of effectiveness of debriefing; Debriefing Assessment for Simulation in Healthcare (DASH) instrument is one of them. This study aims to describe and compare the evaluation of raters, instructors, and students during a virtual debriefing using the DASH. A cross-sectional study was performed evaluating the virtual debriefing of 30 instructors after a heart failure telesimulation scenario. The evaluation was conducted by 30 instructors, 338 undergraduate students in the seventh semester, and 7 simulation raters. The 3 versions of the DASH instrument in Spanish were applied, respectively. Two comparisons were made, student versus instructor and rater versus instructor. Cronbach α was 0.97 for each version. The averages of the results on the DASH instrument were: 6.61 (3.34-7.0), 5.95 (4.65-7.0), and 4.84 (2.68-6.02) for student, rater, and instructor versions, respectively. The size effect between student and debriefer perspectives was 0.42. In contrast, the size effect between instructor and rater was 0.72. All differences were significant. There are different rates between the persons who use the DASH. In this study, from the perspective of the instructor and rater, the difference was 1 point with a wide range, in contrast with the difference between instructor and student, which is relatively minor. It is necessary to consider the perspectives of experts in the subject to achieve a virtual debriefing of high quality and improve a debriefing by using the DASH.

Peer Debriefing Versus Instructor-Led Debriefing for Nursing Simulation.

Debriefing is the reflective process following the simulation experience. We aimed to compare the debriefing assessment and debriefing satisfaction perceived by nursing students who underwent different debriefing methods. An experimental study conducted on three groups (instructor-led debriefing, peer debriefing, and combined debriefing) was performed for 177 nursing students. Differences in the debriefing satisfaction were assessed using the Clinical Experience Simulation scale, the Visual Analogue scale, and the Debriefing Assessment for Simulation in Healthcare (DASH). VAS scores for satisfaction differed significantly between the instructor-led debriefing, peer debriefing, and combined debriefing groups. In the Clinical Experience Simulation scale, the combined debriefing group was significantly higher compared with instructor-led debriefing. The total score for DASH was significantly higher in the combined debriefing group compared with instructor-led debriefing, and in instructor-led debriefing compared with peer debriefing. Combining debriefing after a simulation session improves the debriefing satisfaction and the perceived debriefing assessment among nursing students. [J Nurs Educ. 2021;60(2):90-95.].

Extracorporeal Membrane Oxygenation (ECMO) for Refractory Cardiac Arrest.

Extracorporeal Membrane Oxygenation (ECMO) for Refractory Cardiac Arrest.

Cardiac Tamponade.

This simulation is designed to educate emergency medicine residents and medical students on the recognition and management of cardiac tamponade, as well as encourage providers to become familiar with their states' disclosure laws for sentinel events. Cardiac tamponade is an emergent condition in which the accumulation of pericardial fluid and the consequent increase in hydrostatic pressure becomes severe enough to compromise the normal diastolic and systolic function of the heart, resulting in hemodynamic instability.1 The causes of cardiac tamponade are numerous because it is a potential complication of any of a number of pericardial disease processes, including infectious, inflammatory, traumatic, and malignant etiologies.1,2 Clinical presentations may vary and symptoms can be non-specific, which can lead to delayed or missed diagnoses and poor patient outcomes.3 In addition to this, the incidence of this condition is rising due to the increasing frequency of cardiac procedures performed (ie, pacemaker placement).4 Therefore, it is important for medical providers to have a high index of suspicion for the diagnosis based on patient presentation and to quickly provide necessary treatment to stabilize the patient. By the end of this simulation session, the learner will be able to: (1) describe a diagnostic differential for dizziness (2) describe the pathophysiology of cardiac tamponade (3) describe the acute management of cardiac tamponade, including fluid bolus and pericardiocentesis (4) describe the electrocardiogram (ECG) findings of pericardial effusion (5) describe the ultrasound findings of cardiac tamponade (6) describe the indications for emergent bedside pericardiocentesis versus medical stabilization and delayed pericardiocentesis for cardiac tamponade (7) describe the procedural steps for pericardiocentesis, and (8) describe your state's laws regarding disclosure for sentinel events. This session is conducted using high-fidelity simulation, followed by a debriefing session on evaluation and treatment of cardiac tamponade. However, it may also be run as an oral board case. Our residents were provided an electronic survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Feedback was largely positive because many learners mentioned during debriefing that they are not comfortable with pericardiocentesis and have limited opportunities to practice the procedure. None of our residents were familiar with our state's or institution's disclosure laws for sentinel events.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.5 This session received a majority of 6 (consistently effective/very good) and 7 scores (extremely effective/outstanding). This is a potential method for educating future medical providers on the diagnosis and management of cardiac tamponade in an emergency department setting. Learners initially had a wide range of differentials for the chief complaint of dizziness. We used an ECG with low voltage but without electrical alternans. When asked to provide an ECG interpretation, low voltage was intermittently explicitly interpreted by learners. We were concerned that if we showed an ECG with electrical alternans, learners may quickly arrive at the diagnosis without focusing on the subtleties of a physical exam, including looking for jugular venous distention (JVD) or pulsus paradoxus.We did not have the patient decompensate if their international normalized ratio (INR) was not immediately reversed, given likely delay for in vivo coagulation to occur in the face of life-threatening tamponade, but this provided a robust discussion during debriefing if reversal should be emergently initiated.Many residents voiced that they were uncomfortable performing a pericardiocentesis because they only had a few opportunities to do so on human cadavers, and they appreciated the opportunity to review this.Unexpectedly, when the patient asked the learners if he should sue the cardiologist, the majority of groups told the patient that the cardiologist was not liable because tamponade is a known complication of cardiac ablation and likely reviewed this while obtaining informed consent. None of the learners were familiar with Ohio's disclosure laws for sentinel events. This identified a gap in knowledge that may be addressed in future learning sessions.Our main take-away is to continue providing low-frequency, high-acuity cases that provide the opportunity to review infrequent pathologies and procedures, as well as including patient safety and administrative learning points. Medical simulation, cardiac tamponade, pericardial effusion, cardiac emergencies, obstructive shock, sentinel events, iatrogenic injury, medical disclosure.

Agitated Psychiatric Patient.

This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient. The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation is the leading cause of hospital staff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history and physical examination on the agitated psychiatric patient. 2) Develop a differential for the agitated psychiatric patient, including primary psychiatric conditions and other organic pathologies. 3) Discuss the management of the agitated psychiatric patient, including the different options available for chemical sedation. 4) Prioritize safety of self and staff when caring for an agitated psychiatric patient. This session was conducted using simulation with a standardized patient, followed by a debriefing session and lecture on the presentation, differential diagnosis, and management of the agitated psychiatric patient. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case. The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Feedback from the residents was overwhelmingly positive, although many stated that they felt some degree of intimidation or stress from the standardized patient who did not break from their role throughout the scenario.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form9 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received mostly 7 scores (extremely effective/outstanding). This is a physically safe method for reviewing management of the agitated psychiatric patient. There are multiple potential presentations of the agitated psychiatric patient, as well as varying underlying etiologies. These scenarios may be tailored to the needs of the learner, including identifying agitation, pharmacologic review, and de-escalation techniques. Medical simulation, agitated psychiatric patient, chemical sedation, verbal de-escalation, emergency medicine, psychiatry.

An Interprofessional Simulation-Based Orientation Program for Transitioning Novice Nurses to Critical Care Roles in the Emergency Department: Pilot Implementation and Evaluation

The emergency department (ED) relies on high-functioning teams to deliver consistent and safe patient care. Experts recommend that both emergency physicians and ED nurses participate in team training. However, there are currently no nationally accepted curricula for either profession to embed this training in their professional development, particularly for health workers who are novice or transitioning into critical care roles. An interprofessional educator team designed and embedded a series of simulation scenarios within a novel orientation program for novice nurses transitioning to critical care roles in the ED to teach clinical and teamwork skills for conjoint groups of resident physician and novice nurse learners. The team created four interprofessional simulations to represent the acuity and breadth of patient populations in the ED critical care bays. To date, the team has conducted 24 two-week orientation sessions for 48 nurses and 51 resident physicians. Overall mean scores for the Debriefing Assessment for Simulation in Healthcare (DASH) instrument from nursing participants in the first 18 sessions were high. Qualitative evaluation data from both nurses and physicians demonstrated a positive impact of the simulations and provided insight into respective roles, identities, and priorities across professions. Participant feedback led to iterative steps in refinement of the simulations, including adjustments in debriefings and logistics of the orientation program. A team-based interprofessional simulation program was found to be feasible and acceptable for practicing novice physicians and nurses as part of a nursing critical care orientation program in the ED. Future work will assess the program's long-term impact on teamwork and safety in the actual clinical environment.

Psychometric Testing of the Debriefing Assessment for Simulation in Healthcare (DASH) for Trainee-led, In Situ Simulations in the Pediatric Emergency Department Context.

Effective trainee-led debriefing after critical events in the pediatric emergency department has potential to improve patient care, but debriefing assessments for this context have not been developed. This study gathers preliminary validity and reliability evidence for the Debriefing Assessment for Simulation in Healthcare (DASH) as an assessment of trainee-led post-critical event debriefing. Eight fellows led teams in three simulated critical events, each followed by a video-recorded discussion of performance mimicking impromptu debriefings occurring after real clinical events. Three raters assessed the recorded debriefings using the DASH, and their feedback was collated. Data were analyzed using generalizability theory, Gwet's AC2, intraclass correlation coefficient (ICC), and coefficient alpha. Validity was examined using Messick's framework. The DASH instrument had relatively low traditional inter-rater reliability (Gwet's AC2= 0.24, single-rater ICC range= 0.16-0.35), with 30% fellow, 19% rater, and 23% rater by fellow variance. DASH generalizability (G) coefficient was 0.72, confirming inadequate reliability for research purposes. Decision (D) study results suggest the DASH can attain a G coefficient of 0.8 with five or more raters. Coefficient alpha was 0.95 for the DASH. A total of 90 and 40% of items from Elements 1 and 4, respectively, were deemed "not applicable" or left blank. Our results suggest that the DASH does not have sufficient validity and reliability to rigorously assess debriefing in the post-critical event environment but may be amenable to modification. Further development of the tool will be needed for optimal use in this context.

Linguistic Validation of the Debriefing Assessment for Simulation in Healthcare in Spanish and Cultural Validation for 8 Spanish Speaking Countries.

Debriefing Assessment for Simulation in Healthcare (DASH) is an instrument to assist in developing and evaluating faculty debriefing and instructional skills that, in the context of trained raters, yields reliable data and internal consistency. Support for its validity is grounded in both its content and the scores arising from its use. The utilization of this and other assessment tools, guidelines, and protocols is expanding internationally, but most of them are available only in English and there is not a single established methodology for translation. The objectives of this study were to demonstrate a translation technique and conduct a linguistic validation of the translation of the DASH from English to Spanish and to demonstrate and conduct a cultural validation across 8 Spanish-speaking countries. A forward translation and review of the DASH score sheets and Rater's Handbook defined the consensus harmonized version. A backward translation was reviewed by the original authors and discussed with the translators to produce the approved harmonized version. This was then tested through a questionnaire to assess clarity, comprehensiveness, appropriateness, and cultural relevance among 5 monolingual subjects from 8 Spanish-speaking countries. During the forward translation, 16 discrepancies were detected in the Spanish DASH. Sixty-two participants were sent the Spanish cultural questionnaire and 48% responded. A total of 82 different interpretations and 57 extra recommendations (42% terms, 16% concepts, and 42% syntax) were made. Twenty-seven percent of them were applied. The translated DASH has undergone a linguistic validation into Spanish, and a cultural validation across 8 Spanish-speaking countries. It may be used to assess debriefings in healthcare settings in these countries. The methodology used is applicable for translating and assessing a cross-cultural validation of assessment instruments.

Telementoring for remote simulation instructor training and faculty development using telesimulation

IntroductionSimulation-based training is essential for high-quality medical care, but it requires access to equipment and expertise. Technology can facilitate connecting educators to training in simulation. We aimed to explore the...

High Altitude Pulmonary Edema.

This simulation was developed to educate emergency medicine residents on the diagnosis and management of high-altitude pulmonary edema (HAPE). This case is also appropriate for senior medical students and advanced practice providers. The principles of crisis resource management, teamwork, and communication are incorporated into the case. High altitude pulmonary edema may present similarly to pneumonia with nonspecific symptoms, including decreased exercise tolerance, cough, dyspnea with exertion, and fever. Symptoms more specific to HAPE include dyspnea at rest, tachypnea, history of rapid ascent to high altitude, a lowlander patient exposed to high-altitude, or a highlander patient on re-entrance to high altitude after lowland stay. Laboratory and imaging workup may include infiltrates on chest x-ray and leukocytosis.1,2 Of the various forms of altitude sickness, HAPE has the highest fatality rate, estimated at 50% in travellers to the Himalayas who are unable to descend.1 Providers should inquire as to the current elevation of their facility, the patient's recent altitude gain, and the rate of ascent. Treatment priorities include oxygen and immediate descent, as well as supplemental treatment with nifedipine and phosphodiesterase (PDE) inhibitors such as sildenafil or tadalafil. At the conclusion of the simulation session, learners will be able to:obtain a thorough history relevant to altitude illnessesdevelop a differential for dyspnea in a patient with environmental exposuresdiscuss prophylaxis and management of HAPEdiscuss appropriate disposition of the patient including descent and subsequent appropriate level of care. This session was conducted using high-fidelity simulation followed by a debriefing session and lecture on the diagnosis and management of HAPE. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This technique includes an observation statement, a statement describing the framework of the observer, and an invitation to review further to explore the participants' frames. An example of this advocacy-inquiry is as follows: "I heard Sam suggest to the team that acetazolamide be given, but then I didn't hear any follow-up discussion. Acetazolamide is often utilized for acute mountain illness prophylaxis or treatment. I wasn't sure if the team did not hear his suggestion or disagreed with the treatment plan. Tell me more." This scenario was designed as a simulation, but it could be adapted as an oral boards case. Our residents were provided with a survey at the completion of the simulation and debriefing to rate different aspects of the simulation, as well as to provide qualitative feedback. Participants expressed positive feedback, with comments focused on appreciating the review of the presentation, diagnosis, and treatment of altitude illness. The emergency medicine residents surveyed currently practice in a low altitude setting and were appreciative to simulate a scenario to which they might otherwise not get exposure during their residency. Our simulation center's feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form. This session received all 6 or 7 scores (consistently effective/very good or extremely effective/outstanding) other than a 5 for setting the stage, a 4 for maintaining an engaging context for learning, and two 5s for structured debriefing. This was an effective method to review high altitude illness with learners that may otherwise get limited exposure to such clinical cases during residency. Learners had a broad range of differential diagnoses and demonstrated variable levels of knowledge related to the diagnosis and treatment of high-altitude illness. We used visual stimuli and a reminder from our nurse to reinforce for the learners that the case was taking place at a critical access emergency room at 11,000 feet of elevation. Medical simulation, high altitude pulmonary edema, high altitude cerebral edema, altitude sickness, emergency medicine, wilderness medicine.

Blast Crisis.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of blast crisis. Chronic myeloid leukemia (CML) makes up 15% of diagnosed adult leukemias with the median age of diagnosis being 67 years old. Chronic myeloid leukemia consists of three phases: chronic, accelerated, and blast phases. Most patients are initially diagnosed while in the chronic phase.1 Of those diagnosed in the chronic phase and being treated with a tyrosine kinase inhibitor (TKI), about 1% -1.5% of CML patients per year will subsequently transform into an advanced phase or blast crisis.2 While rare, blast crisis is considered an oncologic emergency, with increased mortality occurring primarily from subsequent infections or bleeding. Therefore, emergency physicians must be familiar with its clinical presentation and subsequent management. By the end of this simulation, the participant will be able to: 1) create a thorough differential for the undifferentiated febrile, altered patient, 2) identify the signs and symptoms of blast crisis, 3) describe proper resuscitation of a patient in blast crisis, and 4) describe the indications, steps, and contraindications of performing a lumbar puncture. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of blast crisis. Debriefing methods may be left to the discretion of participants, but the authors have used advocacy-inquiry techniques. This scenario may also be run as an oral boards case. Our simulation center's feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form, with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received all 6 or 7 scores (consistently effective/very good or extremely effective/outstanding). During the debriefing session, feedback from the residents was largely positive. They appreciated reviewing the broad differential of altered mental status and oncologic emergencies. While many groups anchored on the diagnosis of encephalitis, they also expressed that after this experience, blast crisis would be added to their differential for patients with CML. This is a cost-effective method for reviewing blast crisis. Learners were able to identify more common causes of altered mental status in their differentials, but without further prompting, they were unable to ultimately come up with the diagnosis of blast crisis. Our main take-away is to continue reviewing oncologic emergencies as a part of our residency curriculum. Medical simulation, chronic myeloid leukemia, blast crisis, leukostasis, emergency medicine, oncologic emergencies, hematologic emergencies.

Simulation-based medical education can be used to improve the mental health competency of emergency physicians.

We explored the feasibility of developing, running and evaluating a simulation-based medical education (SBME) workshop to improve the knowledge, skills and attitudes of emergency department (ED) doctors when called on to assess patients in psychiatric crisis. We designed a four-hour workshop incorporating SBME and a blend of pre-reading, short didactic elements and multiple-choice questions (MCQs). Emergency department nurses (operating as SBME faculty) used prepared scripts to portray patients presenting in psychiatric crisis. They were interviewed in front of, and by, ED doctors. We collected structured course evaluations, Debriefing Assessment for Simulation in Healthcare (DASH) scores, and pre- and post-course MCQs. The pilot workshop was delivered to 12 ED registrars using only existing resources of the Psychiatry and Emergency Departments. Participants highly valued both 'level of appropriateness' (Likert rating μ = 4.8/5.0) and 'overall usefulness' (μ = 4.7/5.0) of the programme. They reported an improved understanding of the mental state and of relevant legal issues and rated the debriefings highly (participant DASH rating: n = 193; score μ = 6.3/7.0). Median MCQ scores improved non-significantly pre- and post-course (7.5/12 vs 10/12, p = 0.261). An SBME workshop with these aims could be delivered and evaluated using the existing resources of the Psychiatry and Emergency Departments.

Training and evaluating simulation debriefers in low-resource settings: lessons learned from Bihar, India

BackgroundTo develop effective and sustainable simulation training programs in low-resource settings, it is critical that facilitators are thoroughly trained in debriefing, a critical component of simulation learning. However, large knowledge gaps exist regarding the best way to train and evaluate debrief facilitators in low-resource settings.MethodsUsing a mixed methods approach, this study explored the feasibility of evaluating the debriefing skills of nurse mentors in Bihar, India. Videos of obstetric and neonatal post-simulation debriefs were assessed using two known tools: the Center for Advanced Pediatric and Perinatal Education (CAPE) tool and Debriefing Assessment for Simulation in Healthcare (DASH). Video data was used to evaluate interrater reliability and changes in debriefing performance over time. Additionally, twenty semi-structured interviews with nurse mentors explored perceived barriers and enablers of debriefing in Bihar.ResultsA total of 73 debriefing videos, averaging 18 min each, were analyzed by two raters. The CAPE tool demonstrated higher interrater reliability than the DASH; 13 of 16 CAPE indicators and two of six DASH indicators were judged reliable (ICC > 0.6 or kappa > 0.40). All indicators remained stable or improved over time. The number of ‘instructors questions,’ the amount of ‘trainee responses,’ and the ability to ‘organize the debrief’ improved significantly over time (p < 0.01, p < 0.01, p = 0.04). Barriers included fear of making mistakes, time constraints, and technical challenges. Enablers included creating a safe learning environment, using contextually appropriate debriefing strategies, and team building. Overall, nurse mentors believed that debriefing was a vital aspect of simulation-based training.ConclusionSimulation debriefing and evaluation was feasible among nurse mentors in Bihar. Results demonstrated that the CAPE demonstrated higher interrater reliability than the DASH and that nurse mentors were able to maintain or improve their debriefing skills overtime. Further, debriefing was considered to be critical to the success of the simulation training. However, fear of making mistakes and logistical challenges must be addressed to maximize learning. Teamwork, adaptability, and building a safe learning environment enhanced the quality enhanced the quality of simulation-based training, which could ultimately help to improve maternal and neonatal health outcomes in Bihar.