Medical Emergency Management in the Dental Office (MEMDO): A Pilot Study Assessing a Simulation-Based Training Curriculum for Dentists.

In the event of a medical emergency in the dental office, the dentist must be able to identify a patient in distress, assess the situation, and institute proper management. This study assessed the impact of a simulation-based medical emergency preparedness curriculum on a resident's ability to manage medical emergencies. This interventional and pre-post educational pilot study included 8 participants who completed a standard curriculum and 8 who completed a modified curriculum (N = 16). The intervention consisted of a comprehensive medical emergency preparedness curriculum that replaced lecture sessions in a standard curriculum. Participants completed performance assessments using scenario-based objective structured clinical examinations (OSCEs) that were recorded and evaluated by calibrated faculty reviewers using a customized scoring grid. The intervention group performed significantly better than the control group on their summative OSCEs, averaging 90.9 versus 61.2 points out of 128 (p = .0009). All participants from the intervention group passed their summative OSCE with scores >60%, while none from the control group received passing scores. Completion of a simulation-based medical emergency preparedness curriculum significantly improved resident performance during simulated medical emergencies.

Perioperative do-not-resuscitate orders: Trainee experiential learning in preserving patient autonomy and knowledge of professional guidelines.

ABSTRACT: Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical "buy-in," that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order.Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes.Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention.Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training.

The effect of supplemental high Fidelity simulation training in medical students.

BACKGROUND: Simulation-based education (SBE) with high-fidelity simulation (HFS) offers medical students early exposure to the clinical environment, allowing development of clinical scenarios and management. We hypothesized that supplementation of standard pulmonary physiology curriculum with HFS would improve the performance of first-year medical students on written tests of pulmonary physiology. METHODS: This observational pilot study included SBE with three HFS scenarios of patient care that highlighted basic pulmonary physiology. First-year medical students' test scores of their cardio-pulmonary curriculum were compared between students who participated in SBE versus only lecture-based education (LBE). A survey was administered to the SBE group to assess their perception of the HFS. RESULTS: From a class of 188 first-year medical students, 89 (47%) participated in the SBE and the remaining 99 were considered as the LBE group. On their cardio-pulmonary curriculum test, the SBE group had a median score of 106 [IQR: 97,110] and LBE group of 99 [IQR: 89,105] (p < 0.001). For the pulmonary physiology subsection, scores were also significantly different between groups (p < 0.001). CONCLUSIONS: Implementation of supplemental SBE could be an adequate technique to improve learning enhancement and overall satisfaction in preclinical medical students.

Exposure to incivility hinders clinical performance in a simulated operative crisis.

BACKGROUND: Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage. METHODS: This is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or 'rude' environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups. RESULTS: 76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112). CONCLUSION: Although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

Physiologically Triggered Digital Cognitive Aid Facilitates Crisis Management in a Simulated Operating Room: A Randomized Controlled Study.

INTRODUCTION: Although the benefits of using cognitive aids in anesthesia care have previously been demonstrated, several challenges remain. It must be presented in a timely manner, and providers must be amenable to using the tool once it is available. We hypothesized that anesthesia residents would perform superiorly when presented with a digital cognitive aid (DCogA) that is automatically triggered by a set vital sign aberration. METHODS: Thirty anesthesia residents were randomized to either control (with access to hard copy of the cognitive aid) or receive a DCogA projected on their anesthesia information management system with the onset of heart block and associated hypotension. The scenario ended upon commencement of pacing, and the times to interventions were recorded. RESULTS: Fourteen participants were randomized to the control group and 16 to the intervention group DCogA. In the control group, 6 of 14 participants failed to pace, and in the DCogA group, all participants initiated pacing (P < 0.01). Those in the DCogA group were also faster to pace [260.1 (137.5) s vs. 405.1 (201.8) s, P = 0.03]. Both groups were similar with respect to their knowledge of advanced cardiovascular life support as measured by a pretest (P = 0.92). CONCLUSIONS: We found those participants who were presented with electronic, physiologically triggered cognitive aids were more likely to appropriately treat heart block by initiating transcutaneous pacing. We believe that adoption of a high-functioning anesthesia information management system designed to detect physiologic perturbations and present appropriate decision support tools would lead to safer intraoperative care.

Initiation of labor analgesia with injection of local anesthetic through the epidural needle compared to the catheter.

BACKGROUND: The rationale for injection of epidural medications through the needle is to promote sooner onset of pain relief relative to dosing through the epidural catheter given that needle injection can be performed immediately after successful location of the epidural space. Some evidence indicates that dosing medications through the epidural needle results in faster onset and improved quality of epidural anesthesia compared to dosing through the catheter, though these dosing techniques have not been compared in laboring women. This investigation was performed to determine whether dosing medication through the epidural needle improves the quality of analgesia, level of sensory blockade, or onset of pain relief measured from the time of epidural medication injection. METHODS: In this double-blinded prospective investigation, healthy term laboring women (n=60) received labor epidural placement upon request. Epidural analgesia was initiated according to the assigned randomization group: 10 mL loading dose (0.125% bupivacaine with fentanyl 2 µg/mL) through either the epidural needle or the catheter, given in 5 mL increments spaced 2 minutes apart. Verbal rating scale (VRS) pain scores (0-10) and pinprick sensory levels were documented to determine the rates of analgesic and sensory blockade onset. RESULTS: No significant differences were observed in onset of analgesia or sensory blockade from the time of injection between study groups. The estimated difference in the rate of pain relief (VRS/minute) was 0.04 (95% CI: -0.01 to 0.11; p=0.109), and the estimated difference in onset of sensory blockade (sensory level/minute) was 0.63 (95% CI: -0.02 to 0.15; p=0.166). The time to VRS ≤3 and level of sensory block 20 minutes after dosing were also similar between groups. No differences in patient satisfaction, or maternal or fetal complications were observed. CONCLUSION: This investigation observed that epidural needle and catheter injection of medications result in similar onset of analgesia and sensory blockade, quality of labor analgesia, patient satisfaction, and complication rates.

Development of an Assessment for Entrustable Professional Activity (EPA) 10: Emergent Patient Management.

INTRODUCTION: Medical schools in the United States are encouraged to prepare and certify the entrustment of medical students to perform 13 core entrustable professional activities (EPAs) prior to graduation. Entrustment is defined as the informed belief that the learner is qualified to autonomously perform specific patient-care activities. Core EPA-10 is the entrustment of a graduate to care for the emergent patient. The purpose of this project was to design a realistic performance assessment method for evaluating fourth-year medical students on EPA-10. METHODS: First, we wrote five emergent patient case-scenarios that a medical trainee would likely confront in an acute care setting. Furthermore, we developed high-fidelity simulations to realistically portray these patient case scenarios. Finally, we designed a performance assessment instrument to evaluate the medical student's performance on executing critical actions related to EPA-10 competencies. Critical actions included the following: triage skills, mustering the medical team, identifying causes of patient decompensation, and initiating care. Up to four students were involved with each case scenario; however, only the team leader was evaluated using the assessment instruments developed for each case. RESULTS: A total of 114 students participated in the EPA-10 assessment during their final year of medical school. Most students demonstrated competence in recognizing unstable vital signs (97%), engaging the team (93%), and making appropriate dispositions (92%). Almost 87% of the students were rated as having reached entrustment to manage the care of an emergent patient (99 of 114). Inter-rater reliability varied by case scenario, ranging from moderate to near-perfect agreement. Three of five case-scenario assessment instruments contained items that were internally consistent at measuring student performance. Additionally, the individual item scores for these case scenarios were highly correlated with the global entrustment decision. CONCLUSION: High-fidelity simulation showed good potential for effective assessment of medical student entrustment of caring for the emergent patient. Preliminary evidence from this pilot project suggests content validity of most cases and associated checklist items. The assessments also demonstrated moderately strong faculty inter-rater reliability.

Presence of an arterial line improves response to simulated hypotension and pulseless electrical activity.

With pulseless electrical activity (PEA) emerging as one of the leading cardiac arrest arrhythmias, the rapid response and accurate diagnosis of PEA is essential to improve survival rates. Although the use of invasive blood pressure monitoring to more quickly detect changes in blood pressure is widespread, evidence for its use is largely anecdotal and placement is not without risk. This is a prospective, multi-center, randomized controlled trial involving 58 senior anesthesiology residents undergoing a simulation of intraoperative PEA using high-fidelity simulation. Of the total 58 participants, 28 subjects were randomized to invasive blood pressure monitoring and 30 to non-invasive blood pressure monitoring in order to investigate the effects of arterial line information on the response time of ACLS-trained anesthesiology residents. Response times of subjects in the group provided with invasive blood pressure monitoring were faster to palpate pulses (6.5 s faster, p = .0470), initiate chest compressions (17 s faster, p = .004), and administer 1 mg of epinephrine (21 s faster, p = .0005. The absolute number of pharmacologic interventions was increased in the group with invasive blood pressure monitoring (p = .020). These findings suggest that noninvasive blood pressure monitoring and other readily available monitors are not as powerful as invasive blood pressure monitoring in influencing decision-making during a PEA event. As there is currently no specific blood pressure at which the patient is considered to be in PEA, future studies are necessary to clarify the correlation between the arterial line tracing and the appropriate trigger for ACLS initiation.