Simulated Medical Emergencies Research Articles

Team talk and team activity in simulated medical emergencies: a discourse analytical approach.

BackgroundCommunication errors can reduce patient safety, especially in emergency situations that require rapid responses by experts in a number of medical specialties. Talking to each other is crucial for utilizing the collective expertise of the team. Here we explored the functions of “team talk” (talking between team members) with an emphasis on the talk-work relationship in interdisciplinary emergency teams.MethodsFive interdisciplinary medical emergency teams were observed and videotaped during in situ simulations at an emergency department at a university hospital in Norway. Team talk and simultaneous actions were transcribed and analysed. We used qualitative discourse analysis to perform structural mapping of the team talk and to analyse the function of online commentaries (real-time observations and assessments of observations based on relevant cues in the clinical situation).ResultsStructural mapping revealed recurring and diverse patterns. Team expansion stood out as a critical phase in the teamwork. Online commentaries that occurred during the critical phase served several functions and demonstrated the inextricable interconnections between team talk and actions.DiscussionDiscourse analysis allowed us to capture the dynamics and complexity of team talk during a simulated emergency situation. Even though the team talk did not follow a predefined structure, the team members managed to manoeuvre safely within the complex situation. Our results support that online commentaries contributes to shared team situation awareness.ConclusionsDiscourse analysis reveals naturally occurring communication strategies that trigger actions relevant for safe practice and thus provides supplemental insights into what comprises “good” team communication in medical emergencies.

Development and validation of clinical performance assessment in simulated medical emergencies: an observational study.

BackgroundCritical illness is a time-sensitive process which requires practitioners to process vast quantities of data and make decisions rapidly. We have developed a tool, the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN), aimed at enhancing care delivery in such situations. To determine the efficacy of CERTAIN and similar cognitive aids, we developed rubric for evaluating provider performance in a simulated medical resuscitation environments.MethodsWe recruited 18 clinicians with current valid ACLS certification for evaluation in three simulated medical scenarios designed to mimic typical medical decompensation events routinely experienced in clinical care. Subjects were stratified as experienced or novice based on prior critical care training. A checklist of critical actions was designed using face validity for each scenario to evaluate task completion and performance. Simulation sessions were video recorded and scored by two independent raters. Construct validity was assessed under the assumption that experienced clinicians should perform better than novice clinicians on each task. Reliability was assessed as percentage agreement, kappa statistics and Bland-Altman plots as appropriate.ResultsEleven experts and seven novices completed evaluation. The overall agreement on common checklist item completion was 84.8 %. The overall model achieved face validity and was consistent with our construct, with experienced clinicians trending towards better performance compared to novices for accuracy and speed of task completion.ConclusionsA standardized video assessment tool has potential to provide a valid and reliable method to assess 12 performances of clinicians facing simulated medical emergencies.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-015-0066-x) contains supplementary material, which is available to authorized users.

Task management skills and their deficiencies during care delivery in simulated medical emergency situation: A classification

Our objective was to develop the analysis of task management skills by proposing a framework classifying task management stages and deficiencies. Few studies of non-technical skills have detailed the components of task management skills through behavioural markers, despite their central role in care delivery. A post hoc qualitative behavioural analysis was performed of recordings made of professional training sessions based upon simulated scenarios. Four recorded sessions in a high-fidelity simulation setting were observed and recorded. Two scenarios were used (cardiac arrest and respiratory failure), and there were two training sessions per scenario. Four types of task management deficiencies were identified with regards to task constraints: constraint relaxation, unsatisfied constraints, additional constraints and constraint transgression. Both equipment and space constraints were also identified. The lack of prerequisite actions when preparing the environment, corequisite actions for equipment and protocol monitoring, or postrequisite actions to restore the environment were associated with task management deficiencies. Deficiencies in task management behaviours can be identified in simulated as well as actual medical emergency settings. This framework opens perspectives for both training caregivers and designing ergonomic work situations.

Salivary Cortisol Increases after One Immersive Simulation but the Repetition of Sessions does not Blunt it

Objective: Simulated life-threatening medical emergencies generate stress that can be apprehended by measurement of salivary cortisol (SC). The aim of this study was to analyze SC level in multidisciplinary teams (MDTs) members during immersive simulation and to study its evolution over time with repetition of simulation sessions in all team members. Methods: 48 participants constituted 12 Emergency Medical Service MDTs made up of 4 members each. Six MDTs underwent 9 simulations (experimental group) and 6 underwent 3 simulations over one year (control group). SC was assessed the day prior to simulation (T0), before simulation (T1), after simulation (T2) and after debriefing (T3). 1152 samples were analyzed by ELISA. Variation over time was analyzed using ANOVA for repeated measures. Mann-Whitney test was used for comparison between groups at two times and Kruskal-Wallis test was used to study stress response in the different status of teams. A p value <0.05 was considered significant. Results: SC increased from 0.16 ± 0.12 (T0) to 0.26 ± 0.14 (T1). SC level continued to rise up to 0.39 ± 0.27 at T2 before decreasing to 0.21 ± 0.12 at T3, p<0.0001. SC increase was found in all team members with no status effect. SC level was not blunt after repetition of sessions regardless of the frequency of sessions. Conclusion: SC raised during immersive simulation and this variation was not blunt after repetition of simulation sessions. No status effect was found among the MDTs’ members. Future study should investigate on other markers of stress response and correlate them to team performance.

Team regulation in a simulated medical emergency: An in-depth analysis of cognitive, metacognitive, and affective processes

This study examined the nature of cognitive, metacognitive, and affective processes among a medical team experiencing difficulty managing a challenging simulated medical emergency case by conducting in-depth analysis of process data. Medical residents participated in a simulation exercise designed to help trainees to develop medical expertise, effective leadership, and team management skills. Purposive sampling was used to select one team for case study based on overall performance. Video and audio data were collected from the simulation and debriefing session and a follow-up interview was conducted with the team leader. Performance measures were also collected from expert raters (i.e., experienced staff physicians). Video data were reviewed and coded for cognitive, metacognitive, and emotional events exhibited by team members during the simulation. Interview and debriefing transcripts were coded for themes related to these regulatory processes. Results from quantitative and qualitative analyses revealed that the team exhibited lower-order cognitive and metacognitive process (e.g., summarizing, providing information) more often than higher-order processes (e.g., evaluation, reasoning). Furthermore, team members expressed negative emotions (e.g., anxiety) more often than positive emotions (e.g., enjoyment). Chi square analyses of the team leader revealed that negative emotions were significantly more frequently preceded by lower-order processes compared to higher-order processes. Qualitative thematic analyses provided further corroboration of these findings. The findings suggest that medical trainees (particularly teams experiencing difficulty managing a challenging case) may require further scaffolding in their use of regulatory processes within medical emergencies. The results from this study are discussed in terms of implications for theories of self-regulation, methodological advances, and instructional design for medical education.

Combining First-Person Video and Gaze-Tracking in Medical Simulation: A Technical Feasibility Study

Crisis decision-making is an important responsibility of the resuscitation team leader but a difficult process to study. The purpose of this pilot study was to explore the potential of gaze-tracking technology to study decision-making and leadership behaviours in simulated medical emergencies. We studied five physicians with a broad range of experience in a simulated medical emergency using gaze-tracking glasses. Subjects were interviewed immediately after the scenario while viewing a first-person recording of their performance with a superimposed gaze indicator. The recordings were then studied independently by two reviewers, and rated for quality and their observations collated. Portable gaze-tracking devices were found to be useful and effective tools for studying information gathering and decision-making behaviours in simulated medical emergencies. The data obtained in this study provided information about the discrepancy between what each participant looked at compared to what each participant consciously noted. Analysis of the data also identified a number of recurrent gaze patterns performed by team leaders that could be used as end-points in future research. Gaze-tracking in resuscitation medicine is a new and promising field of study. The potential to study crisis decision-making behaviours, and cognitive load, as well as differences between novice and expert team leaders is substantial.

Randomised trial comparing the recording ability of a novel, electronic emergency documentation system with the AHA paper cardiac arrest record

ObjectiveTo evaluate the ability of an electronic system created at the University of Washington to accurately document prerecorded VF and pulseless electrical activity (PEA) cardiac arrest scenarios compared with the...

Hyperventilation in Pediatric Resuscitation: Performance in Simulated Pediatric Medical Emergencies

To examine the hypothesis that pediatric resuscitation providers hyperventilate patients via bag-valve-mask (BVM) ventilation during performance of cardiopulmonary resuscitation (CPR), quantify the degree of excessive ventilation provided, and determine if this tendency varies according to provider type. A retrospective, observational study was conducted of 72 unannounced, monthly simulated pediatric medical emergencies ("mock codes") in a tertiary care, academic pediatric hospital. Responders were code team members, including pediatric residents and interns (MDs), respiratory therapists (RTs), and nurses (RNs). All sessions were video-recorded and reviewed for the rate of BVM ventilation, rate of chest compressions, and the team members performing these tasks. The type of emergency, location of the code, and training level of the team leader were also recorded. Hyperventilation was present in every mock code reviewed. The mean rate of BVM ventilation for all providers in all scenarios was 40.6 ± 11.8 breaths per minute (BPM). The mean ventilation rates for RNs, RTs, and MDs were 40.8 ± 14.7, 39.9 ± 11.7, and 40.5 ± 10.3 BPM, respectively, and did not differ among providers (P = .94). All rates were significantly higher than the recommended rate of 8 to 20 BPM (per Pediatric Advanced Life Support guidelines, varies with patient age) (P < .001). The mean ventilation rate in cases of isolated respiratory arrest was 44.0 ± 13.9 BPM and was not different from the mean BVM ventilation rate in cases of cardiopulmonary arrest (38.9 ± 14.4 BPM; P = .689). Hyperventilation occurred in simulated pediatric resuscitation and did not vary according to provider type. Future educational interventions should focus on avoidance of excessive ventilation.

Hyperventilation in Pediatric Resuscitation: Performance in Simulated Pediatric Medical Emergencies

Hyperventilation in Pediatric Resuscitation: Performance in Simulated Pediatric Medical Emergencies

Supporting collaboration with technology: does shared cognition lead to co-regulation in medicine?

The theoretical distinctions between metacognition, self-regulation and self-regulated learning are often blurred which makes the definition of co-regulation in group learning situations even more difficult. We have started to explore co-regulation in the context of decision making in simulated emergencies where medical teams work together to manage patient cases. Our earlier work has described the relationship between collaborative decision-making in this context as well as discourse patterns that emerge in a simulated medical emergency (Lu & Lajoie, 2008). This paper examines the interactions that occur during this simulation that reflect the relationship between co-regulation and medical decision-making. There are two collaborative learning conditions, a traditional situation where the instructor facilitates collaboration by using a whiteboard to document the group’s construction of a medical argument (the traditional whiteboard condition, TW). The second condition uses technology to facilitate the collaboration, where individuals use laptops and an interactive whiteboard (IW) where they can interact with the problem list as it is being created. Our assumption was that the IW would facilitate communication beyond the teacher–student, to include student–student both within and between the various subgroups. The IW group could document their medical arguments by using a structured template for constructing, annotating and sharing arguments. We found that participants in the IW condition differed from the TW condition in that they engaged in more adaptive decision-making behavior early on in the intervention. Similar overall levels of metacognitive activity were found in both conditions but the pattern and timing of metacognitive categories varied. Specifically, the IW group engaged in more planning and orienting than the TW group at the outset of the problem. Early engagement and co-regulation occurred in the IW group which led to shared understandings and subsequently to effective patient management in latter sessions (11.5% vs. 3.6% in TW). Technology supported greater metacognitive activity overall (44% vs 29% in the non supported group). Furthermore, technology facilitated greater planning (23% vs. 10%) and orienting (10% vs 1%) early in the medical problem solving activity. We refer to specific indicators in the discourse that help operationalize the concept of co-regulation.

A randomised control trial to determine if use of the iResus©application on a smart phone improves the performance of an advanced life support provider in a simulated medical emergency*

This study sought to determine whether using the Resuscitation Council UK's iResus© application on a smart phone improves the performance of doctors trained in advanced life support in a simulated emergency. Thirty-one doctors (advanced life support-trained within the previous 48 months) were recruited. All received identical training using the smart phone and the iResus application. The participants were randomly assigned to a control group (no smart phone) and a test group (access to iResus on smart phone). Both groups were tested using a validated extended cardiac arrest simulation test (CASTest) scoring system. The primary outcome measure was the overall cardiac arrest simulation test score; these were significantly higher in the smart phone group (median (IQR [range]) 84.5 (75.5-92.5 [64-96])) compared with the control group (72 (62-87 [52-95]); p=0.02). Use of the iResus application significantly improves the performance of an advanced life support-certified doctor during a simulated medical emergency. Further studies are needed to determine if iResus can improve care in the clinical setting.

What were the perceptions of primary care teams on learning from a single multidisciplinary simulation-based training intervention?

Medical emergencies in general practice are uncommon and their management requires good teamwork, communication and effective use of the available resources by the whole primary care team. To address this need the Montagu Clinical Simulation Centre developed and delivered a half-day simulation-based medical emergencies course for primary care teams (GPs, practice nurses and administrative staff). Each half-day course comprises two simulated medical emergencies, which are video-taped and then debriefed. The course was evaluated using a multi-level approach by seeking the staff's reactions to the course, their learning, the behaviour changes produced and the results for the organisation. We gained this information through self-reporting using end-of-course and follow-up questionnaires. The immediate feedback was very positive, showing they had learnt the objectives set. We then surveyed all those who had attended training between 2003 and 2007. A follow-up questionnaire was developed and sent to the practice managers who then co-ordinated their completion and return using a pre-paid return envelope. The survey was carried out in two cohorts. The first set of follow-up questionnaires was sent out in September 2004 to all those that had attended up to the end of May 2004 and the second set sent out in May 2008 to those who had attended between June 2004 and May 2007. Of the 338 available to complete the follow-up questionnaire, 208 responded, giving a response rate of 62%. Eighty percent of practices had made changes to equipment, emergency protocols or training and 20% of the participants had been involved in managing a medical emergency since attending the course. Of those, 86% indicated that their management and confidence had improved, that they were better able to take a lead role, give instruction and delegate tasks as required. Based on the self-reported perceptions of learning, we believe that the lessons learnt have been translated into positive changes at a personal and practice level for all members of the primary care team. The participants valued the chance to train as a complete unit. We plan to evaluate simulation-based training in the workplace to see if this has a greater impact.

Design, validation and dissemination of an undergraduate assessment tool using SimMan® in simulated medical emergencies

Background: Increasingly, medical students are being taught acute medicine using whole-body simulator manikins.Aim: We aimed to design, validate and make widely available two simple assessment tools to be used with Laerdal SimMan® for final year students.Methods: We designed two scenarios with criterion-based checklists focused on assessment and management of two medical emergencies. Members of faculty critiqued the assessments for face validity and checklists revised. We assessed three groups of different experience levels: Foundation Year 2 doctors, third and final year medical students. Differences between groups were analysed, and internal consistency and interrater reliability calculated. A generalisability analysis was conducted using scenario and rater as facets in design.Results: A maximum of two items were removed from either checklist following the initial survey. Significantly different scores for three groups of experience for both scenarios were reported (p < 0.001). Interrater reliability was excellent (r > 0.90). Internal consistency was poor (α < 0.5). Generalizability study results suggest that four cases would provide reliable discrimination between final year students.Conclusions: These assessments proved easy to administer and we have gone some way to demonstrating construct validity and reliability. We have made the material available on a simulator website to enable others to reproduce these assessments.

Human factors in resuscitation: Lessons learned from simulator studies.

Medical algorithms, technical skills, and repeated training are the classical cornerstones for successful cardiopulmonary resuscitation (CPR). Increasing evidence suggests that human factors, including team interaction, communication, and leadership, also influence the performance of CPR. Guidelines, however, do not yet include these human factors, partly because of the difficulties of their measurement in real-life cardiac arrest. Recently, clinical studies of cardiac arrest scenarios with high-fidelity video-assisted simulations have provided opportunities to better delineate the influence of human factors on resuscitation team performance. This review focuses on evidence from simulator studies that focus on human factors and their influence on the performance of resuscitation teams. Similar to studies in real patients, simulated cardiac arrest scenarios revealed many unnecessary interruptions of CPR as well as significant delays in defibrillation. These studies also showed that human factors play a major role in these shortcomings and that the medical performance depends on the quality of leadership and team-structuring. Moreover, simulated video-taped medical emergencies revealed that a substantial part of information transfer during communication is erroneous. Understanding the impact of human factors on the performance of a complex medical intervention like resuscitation requires detailed, second-by-second, analysis of factors involving the patient, resuscitative equipment such as the defibrillator, and all team members. Thus, high-fidelity simulator studies provide an important research method in this challenging field.

Supporting medical decision making with argumentation tools

This study investigated the collaborative decision-making and communicative discourse of groups of learners engaged in a simulated medical emergency in two conditions. In one condition subgroups used a traditional whiteboard (TW group) to document medical arguments on how to solve a medical emergency. In the other condition subgroups used interactive whiteboards (IW group) where they could document their medical arguments by using a structured template for constructing, annotating and sharing arguments. The discourse of each group was coded with respect to decision-making and communicative activities. The research goal was to identify relationships between the decision-making and collaborative discourse under the two conditions. The IW condition differed from the TW condition in that participants engaged in more adaptive decision-making behavior early on in the intervention. This early engagement led to shared understandings and subsequently to more effective patient management. Group differences were also found in the types of collaborative discourse and the IW groups produced more productive argumentation.

Simulation of In-Hospital Pediatric Medical Emergencies and Cardiopulmonary Arrests: Highlighting the Importance of the First 5 Minutes

Outcomes of in-hospital pediatric cardiopulmonary arrest are dismal. Recent data suggest that the quality of basic and advanced life support delivered to adults is low and contributes to poor outcomes, but few data regarding pediatric events have been reported. The objectives of this study were to (1) measure the median elapsed time to initiate important resuscitation maneuvers in simulated pediatric medical emergencies (ie, "mock codes") and (2) identify the types and frequency of errors committed during pediatric mock codes. A prospective, observational study was conducted of 34 consecutive hospital-based mock codes. A mannequin or computerized simulator was used to enact unannounced, simulated crisis situations involving children with respiratory distress or insufficiency, respiratory arrest, hemodynamic instability, and/or cardiopulmonary arrest. Assessment included time elapsed to initiation of specific resuscitation maneuvers and deviation from American Heart Association guidelines. Among the 34 mock codes, the median time to assessment of airway and breathing was 1.3 minutes, to administration of oxygen was 2.0 minutes, to assessment of circulation was 4.0 minutes, to arrival of any physician was 3.0 minutes, and to arrival of first member of code team was 6.0 minutes. Among cardiopulmonary arrest scenarios, elapsed time to initiation of compressions was 1.5 minutes and to request for defibrillator was 4.3 minutes. In 75% of mock codes, the team deviated from American Heart Association pediatric basic life support protocols, and in 100% of mock codes there was a communication error. Alarming delays and deviations occur in the major components of pediatric resuscitation. Future educational and organizational interventions should focus on improving the quality of care delivered during the first 5 minutes of resuscitation. Simulation of pediatric crises can identify targets for educational intervention to improve pediatric cardiopulmonary resuscitation and, ideally, outcomes.