Time-out Components Research Articles

Effect of Simulation-Based Training and Neurofeedback Interventions on Radiation Technologists’ Workload, Situation Awareness, and Performance

PurposeOur purpose was to assess the effect of a combined intervention – simulation-based training supported by neurofeedback sessions – on radiation technologists’ (RTs’) workload, situation awareness, and performance during routine quality assurance and treatment delivery tasks. Methods and MaterialsAs part of a prospective institutional review board approved study, 32 RTs previously randomized to receive versus not receive simulation-based training focused on patient safety were again randomized to receive versus not receive a 3-week neurofeedback intervention (8 sessions of alpha-theta protocol) focused on stress reduction as well as conscious precision, strong focus, and ability to solve arising problems. Perceived workload was quantified using the NASA Task Load Index. Situation awareness was quantified using the situation awareness rating technique. Performance score was calculated using procedural compliance with time-out components and error detection. ResultsRTs randomized to simulation-based training followed by neurofeedback sessions demonstrated no significant changes in perceived workload or situation awareness scores, but did have better performance compared with other study groups (P < .01). ConclusionsThis finding is encouraging and provides basis for using neurofeedback as means to possibly augment performance improvements gained during simulation-based training.

Safety Stop: A Valuable Addition to the Pediatric Universal Protocol

The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk. The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption. In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice. Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

The impact of a multidisciplinary safety checklist on adverse procedural events during bedside bronchoscopy-guided percutaneous tracheostomy.

Bedside procedures are seldom subject to the same safety precautions as operating room (OR) procedures. Since July 2013, we have performed a multidisciplinary checklist before all bedside bronchoscopy-guided percutaneous tracheostomy insertions (BPTIs). We hypothesized that the implementation of this checklist before BPTI would decrease adverse procedural events. A prospective study of all patients who underwent BPTI after checklist implementation (PostCL, 2013-2014, n = 63) at our Level I trauma center were compared to all patients (retrospectively reviewed historical controls) who underwent BPTI without the checklist (PreCL, 2010-2013, n = 184). Exclusion criteria included age less than 16 years, OR, and open tracheostomy. The checklist included both a procedural and timeout component with the trauma technician, respiratory therapist, nurse, and surgeon. Demographics and variables focusing on BPTI risk factors were compared. Variables associated with the primary end point, adverse procedural events, during univariate analysis were used in the multiple variable logistic regression model. A p ≤ 0.05 was significant. Of 247 study sample patients, no difference existed in body mass index, baseline mean arterial pressure, duration or mode of mechanical ventilation, cervical spine or maxillofacial injury, or previous neck surgery between PreCL and PostCL BPTI patients. PreCL patients were younger (48 [20] years vs. 57 [21] years, p < 0.01) but more often had adverse procedural events compared with PostCL patients (PreCL,14.1% vs. PostCL,3.2%, p = 0.020). After adjusting for age, vitals, BPTI risk factors, and intensive care unit duration after BPTI, multiple variable logistic regression determined that performing the safety checklist alone was independently associated with a 580% reduction in adverse procedural events (odds ratio, 5.8; p = 0.022). Our results suggest that the implementation of a multidisciplinary safety checklist similar to those used in the OR would benefit patients during invasive bedside procedures. Therapeutic/care management study, level IV.

Literatur-Review zur Validität des präventiven Elterntrainings Stepping Stones Triple P

The preventive parent training program Stepping Stones Triple P (SSTP) (Sanders et al., 2004a), which was originally developed in Australia, is currently being examined in German-speaking countries. The object of this paper is to review the actual status of research on the validity of the SSTP program. Within this context, aspects of theoretical, internal and external (social) validity are examined. Based on two controlled-randomized primary studies on the effectiveness of SSTP, a secondary analysis was carried out in order to calculate effect sizes. The findings indicate (a) a positive internal validity, shown by replicated substantial and stable effects of the program onto child problem behavior as well as parental behavior; (b) a generally positive theoretical validity which has however certain restrictions regarding the shaping of the timeout component as well as the role of operant methods, and (c) a generally positive external validity which has however certain restrictions, in particular regarding the controversial social evaluation of the time-out component. From the results conclusions were drawn for a selective adaptation of the program as well as implementing SSTP as a preventive intervention method in families with children with developmental disabilities in German-language regions in the future.

Local pharmacological manipulations of prefrontal dopamine affect conflict behaviour in rats

Several lines of research have implicated the prefrontal cortex (PFC) and its dopaminergic (DA) innervation in an animal's response to stress and anxiety. To extend these findings we evaluated the effects of bilateral infusions of DA drugs into the medial PFC of rats, in a modified conflict test, consisting of Reward, Conflict and Time-out components. In experiment 1, the effects of infusions of the DA receptor agonist apomorphine (APO) were compared to the effects of systemic injections of the same drug. APO infusions induced a dose-dependent decrease of responding in the Conflict component, indicative of an anxiogenic-like effect. However, response rates in the Reward component were simultaneously decreased, casting some doubt on the specificity of the effect. In comparison, i.p injections of APO in a second group of animals did not affect responding in the Conflict component, but dose-dependently decreased response rates during Time-out and Reward components. In experiment 2, we evaluated the effects of infusions of APO and the DA receptor antagonist cis-flupenthixol (FLU) into the medial PFC in the conflict test, and in one of its variants, the extinction of conflict test. Although both APO and FLU decreased response rates during Reward components, responding in the Conflict components of both tests was differentially affected. APO infusions decreased Conflict responses, the effect being more pronounced in the extinction of conflict test. In contrast, infusions of FLU increased responding in the Conflict components. The respective pro- and anti-conflict effects of APO and FLU infusions are in favour of a direct involvement of prefrontal DA in anxiety-related behavioural responses.

Differential interaction of cholecystokinin with morphine and phencyclidine: Effects on operant behavior in pigeons

To extend previous operant research in rats with morphine and cholecystokinin (CCK), these two substances were given alone and in combination to pigeons. In one component of a multiple schedule, responding of pigeons (key pecking) was reinforced under a fixed-ratio (FR 50) schedule of food presentation. In the other component, responding had no programmed consequence (timeout). Each session consisted of four 10-min timeout components alternating with four 5-min FR components. In Experiment 1, cumulative dose-effect curves for morphine were obtained by giving an IM injection before each of four FR components; successive injections increased the cumulative dose by 1 4 log-unit steps. In general, as the cumulative dose of morphine increased, the overall response rate in each FR component decreased. Dose-dependent decreases in response rate also occurred when single noncumulative doses of CCK were administered alone 20 min prior to the start of the session. This effect of CCK alone diminished as the session progressed. When CCK was given as a pretreatment before cumulative doses of morphine, the morphine dose-effect curve for response rate shifted to the left. At intermediate doses of CCK, the “potentiation” was so complete that two of three subjects failed to respond during any of the four FR components (i.e., the dose-effect curve for morphine had shifted approximately 1 log-unit to the left). In order to evaluate the pharmacological specificity of this effect, cumulative doses of phencyclidine were administered in combination with CCK (Experiment 2). Unlike the interaction between morphine and CCK, the interaction between phencyclidine and CCK was reciprocal. After pretreatment with each dose of CCK, high doses of phencyclidine tended to produce smaller rate-decreasing effects than those obtained with phencyclidine alone. Moreover, low doses of phencyclidine attenuated the rate-decreasing effects of the higher doses of CCK in the initial FR components. The results of Experiment 1 extend the generality of previous findings in rats with morphine and CCK on schedule-controlled behavior, while the results of Experiment 2 indicate distinct differences in the way in which CCK interacts with morphine and phencyclidine.

Cholecystokinin potentiates the rate-decreasing effects of morphine on schedule-controlled behavior in rats

In one component of a multiple schedule, responding (licking in rats) was reinforced under a fixed-ratio (FR 50) schedule of water presentation. In the other component, responding had no programmed consequences (timeout). Each session consisted of four 10-min timeout components alternating with four FR components. In general, increasing cumulative doses of morphine (3.2–18 mg/kg) produced a dose-dependent decrease in the overall rate of responding. In one subject, cholecystokinin (CCK) alone (10–32 μg/kg) produced dose-dependent decreases in rate in the first component, while in the other two subjects relatively little decrease in rate occurred. When these doses of CCK were given as a pretreatment before morphine, the decrease in overall response rate was greater than that found with morphine alone. This interaction was most noticeable at the lowest dose of morphine where CCK produced a dose-dependent “potentiation” of the rate-decreasing effects. Although the potentiation by CCK was not as evident at the intermediate doses of morphine, there were instances in which the rate-decreasing effects produced by the combination were greater than those expected from addition of the effects of CCK and morphine alone. In contrast, when naltrexone (1 mg/kg) was given as a pretreatment, little or no rate-decreasing effects were produced by the cumulative doses of morphine. Furthermore, pretreatment with naltrexone and the administration of a higher dose range of morphine indicated the dose-effect curve for morphine had shifted approximately 34 log-units to the right. The CCK-morphine potentiation found in the present study with schedule-controlled behavior is in contrast to the CCK-morphine antagonism previously reported using measures such as analgesia and feeding.

Pulse modulated and continuous wave microwave radiation yield equivalent changes in operant behavior of rodents

Long-Evans rats were trained to the point of stable performance on a multicomponent (fixed-ratio, timeout) operant task. Different groups were exposed to continuous wave (CW) and to pulse modulated (PM) microwave radiation (MWR) during daily three-hour behavioral sessions. The rates of responding under actual and sham exposure conditions were noted. With comparable MWR dose rates, CW and PM MWR (5.8 and 6.7 mW/g, respectively) were equally effective in reducing response rates during both the fixed-ratio and the timeout components of the operant sessions. Dose rates of this order were associated with an elevation in body temperature of 0.5 to 1.0°C. At 3.6 mW/g, whereas the mean rates of fixed-ratio responding were unchanged, the rates of responding during timeout were reduced significantly. Again, CW and PM MWR yielded essentially equivalent results. This MWR dose rate was not accompanied by a measurable increment in whole body temperature. It appears that (1) fixed-ratio operant responding of rats for food reward was more robust, that is, less subject to suppression by concurrent exposure to MWR than was bar-pressing during timeout, (2) PM and CW MWR, especially at the higher dose rate, effectively enhanced operant control over timeout responding and (3) the equivalent effects of CW and PM MWR support the hypothesis of a thermal basis for their effect despite the apparent inability to detect changes in whole body temperature.

Operant aversive control and Pavlovian higher order conditioning

Pigeons pecked a key for food on a multiple schedule, while pecking in one component also produced time-outs intermittently. The time-outs could be avoided by withholding responses appropriately, and they could be escaped either by responding or by not responding (in separate conditions). Partial suppression of responding during the time-out component was evidence for moderate punishment, and every time-out was escaped successfully. The escape behavior transferred to the warning signal signifying when responses would produce the time-out. The transfer occurred even if this behavior during the signal produced the aversive consequence. The result was that avoidance occurred only if the escape response was the omission of pecking. Responding during the signal was determined neither by its consequences nor by species-specific responses to a salient stimulus, but, rather, by the behavior occurring in the aversive environment itself.

INTERACTIONS IN MULTIPLE SCHEDULES: NEGATIVE INDUCTION WITH SQUIRREL MONKEYS1

In Experiment I, lever pressing by squirrel monkeys was maintained under a sequence of variable-interval, multiple variable-interval variable-interval, and multiple variable-interval extinction schedules of food presentation. Negative induction (decreased responding in the unchanged component) occurred when one component of the multiple variable-interval variable-interval schedule was changed to extinction. Negative induction was transient over sessions; responding in the unchanged component usually recovered to a rate similar to that under the multiple variable-interval variable-interval schedule. Negative induction was not accompanied by consistent changes in the patterns of local responding within the unchanged component, and did not depend on whether component schedules were associated with localized (lever lights) or diffuse visual stimuli (houselights), or on whether the unchanged component was a 60- or 180-sec variable-interval schedule. In Experiment II, responding was maintained under a sequence of variable-interval and multiple variable-interval timeout schedules of food presentation. Negative induction occurred when responding declined gradually in the timeout component but not when responding declined abruptly. The nature of interactions in multiple schedules may depend on the species; negative induction was observed with squirrel monkeys under conditions similar to those that produce positive contrast with pigeons.

The effects of time-out duration during fixed-ratio reinforcement

Pigeon’s keypecking was reinforced on a multiple fixed-ratio (FR) schedule. All three components were maintained at a FR 50 response requirement with two components containing timeouts. A 2.5-sec time-out appeared regularly after the 30th response in one of these components, while a 10-sec time-out appeared after the 30th response in the second time-out component. Pauses following reinforcement were shortest in the non-time-out component, while longest duration pausing accompanied the 10-sec time-out component. The 2.5-sec time-out generated intermediate duration pauses. In time-out components, response rate was low preceding the time-out, and high immediately following it. The total time from response initiation to subsequent reinforcement was highly predictive of pause duration.

The effects of time-out locus during fixed-ratio reinforcement

Pigeon’s keypecking was reinforced on a multiple fixed-ratio schedule. All three components were fixed ratio 60; a 10-sec time-out regularly appeared after the tenth response in one component and after the fiftieth response in another. Pause duration was shortest with no time-out, longest with the time-out late in the ratio. In time-out components, response rate was low preceding the timeout, high immediately following it. The total time from rsponse initiation to subsequent reinforcement was highly predictive of pause duration. Immediate repetition of a component generally produces shorter pausing than when it was preceded by a different component.

THE EFFECTS OF NUMBER OF RESPONSES ON PAUSE LENGTH WITH TEMPORAL VARIABLES CONTROLLED1

A change in the size of a fixed-ratio schedule involves a simultaneous change in number of responses, in time to complete the ratio (work time), and in the interval between successive reinforcements (interreinforcement interval). Previous studies have suggested the importance of work time and the interreinforcement interval in controlling the length of the post-reinforcement pause. The present study sought to determine whether number of responses is also a significant factor. Pigeons were trained on a multiple fixed-ratio x fixed-ratio 2 plus timeout schedule in which the size of the fixed-ratio x was manipulated. When the work times (Experiment I) or interreinforcement intervals (Experiment II) were equated for the two components, the pause before the fixed-ratio x was longer than the pause before the fixed-ratio 2 plus timeout. As fixed-ratio x size increased, the relative difference in the lengths of the two types of pauses also increased. Because the fixed-ratio x component contained a larger number of responses than the fixed-ratio 2 plus timeout component, the relatively longer pause preceding the fixed-ratio x indicates that number of responses played a significant role in determining the length of the post-reinforcement pause.

Varying temporal relationship of an intruded aversive stimulus with time-out from responding

Four groups of rats were trained on a random-interval schedule of positive reinforcement. During daily sessions successive 2-min exposures to the schedule were interrupted by 2-min time-outs during which the lever operandum was withdrawn from the chamber. Response-independent shock was superimposed in different portions of the behavior stream for differ en t groups so that one group was shocked in the middle of the reinforced periods, one at the end of the reinforced components, one group in the middle, and one group at the end of the time-out components. Animals shocked during or at the end of the reinforced component were suppressed by lower intensity shocks than were rats shocked outside the periods of bar-pressing. The results are consistent with several different conceptual schemes.