Tracheal intubation in microgravity: a simulation study comparing direct laryngoscopy and videolaryngoscopy†.

BACKGROUND: The risk of severe medical and surgical events during long-duration spaceflight is significant. In space, many environmental and psychological factors may make tracheal intubation more difficult than on Earth. We hypothesised that, in microgravity, tracheal intubation may be facilitated by the use of a videolaryngoscope compared with direct laryngoscopy. METHODS: In a non-randomised, controlled, cross-over simulation study, we compared intubation performance of novice operators and experts, using either a direct laryngoscope or a videolaryngoscope, in weightlessness and in normogravity. The primary outcome was the success rate of tracheal intubation. Time to intubation and the confidence score into the success of tube placement were also recorded. RESULTS: When novices attempted to intubate the trachea in microgravity, the success rate of tracheal intubation using a videolaryngoscope was significantly higher (20/25 [80%]; 95% confidence interval [CI], 64.3-95.7 vs eight/20 [40%]; 95% CI, 18.5-61.5; P=0.006), and intubation time was shorter, compared with using a direct laryngoscope. In normogravity, the success rate of tracheal intubation by experts was significantly higher than that by novices (16/20 [80%]; 95% CI, 62.5-97.5 vs seven/25 [28%]; 95% CI, 10.4-45.6; P=0.001), but in microgravity, there was no significant difference between the experts and novices (19/20 [95%]; 95% CI, 85.4-100 vs 20/25 [80%]; 95% CI, 64.3-95.7; P=0.113). Higher confidence scores were achieved with videolaryngoscopy compared with direct laryngoscopy by both experts and novices in both microgravity and normogravity. CONCLUSIONS: Videolaryngoscopy was associated with higher intubation success rate and speed, and higher confidence for correct tube placement by novice operators in microgravity, and as such may represent the best technique for advanced airway management during long-duration spaceflight.

The heuristic version of Cognitive Work Analysis: A first application to medical emergency situations.

Cognitive Work Analysis is an original method that seeks to describe work systems made up of nested sets of constraints, from ecological constraints imposed by the work domain to cognitive constraints. This top-down approach starts with a work domain model in order to analyze and specify contexts of activity. To complement this method, we propose a bottom-up version of Cognitive Work Analysis focusing on contexts of activity and depicting how operators adapt to the ecological constraints. Based on Rasmussen's Dynamic Safety Model, the ecological constraints involved are those bounding the workspace in which operators dynamically navigate with control loops, strategies, work organization, and competencies. This analysis relies on the simulation of specific contexts of activity. A first illustrative application of this framework to a simulated medical emergency situation with a team of nurses and nursing aids shows that this framework can help identify design issues.

Fields of promoted actions for facilitating multitasking activity during a medical emergency.

Background: An adverse clinical event requires emergency team coordination and multitasking activity. Based on studies in ecological psychology, we propose that a structured ambient environment can implicitly facilitate these requirements. Method: We designed a new configuration of work in which spatial zones were specified as fields of promoted actions for doctors, nurses and nursing auxiliaries. 6 emergency teams were confronted with scenarios in a simulation setting, either with a traditional configuration of work or with the new configuration. Results: Significantly, each kind of caregiver respected the delimited spatial zones: 91.5% of occupation time for doctors, 97.1% for nurses and 95.3% for nursing auxiliaries. The mean durations of occupation of a same zone by the nursing auxiliaries and another caregiver decreased significantly, thus reducing the likelihood of mutual disturbance. Readiness for multitasking activity measured before and after experiencing the work configuration increased significantly among caregivers. An ergonomic evaluation scale showed a high level of satisfaction among caregivers (68.5 points out of 100). Participants also indicated the advantages and disadvantages of this new work configuration. Conclusions: This study is a first step towards recommendations to standardise the positioning of emergency team members and for a new spatial arrangement of equipment.

Cognitive control level of action for analyzing verbal reports in educative clinical simulation situations.

BACKGROUND: Several methods and theoretical frameworks have been proposed for efficient debriefing after clinical simulation sessions. In these studies, however, the cognitive processes underlying the debriefing stage are not directly addressed. Cognitive control constitutes a conceptual link between behavior and reflection on behavior to apprehend debriefing cognitively. OBJECTIVES: Our goal was to analyze cognitive control from verbal reports using the Skill-Rule-Knowledge model. This model considers different cognitive control levels from skill-based to rule-based and knowledge-based control. DESIGN: An experiment was conducted with teams of nursing students who were confronted with emergency scenarios during high-fidelity simulation sessions. SETTINGS: Participants' descriptions of their actions were asked in the course of the simulation scenarios or during the debriefing stage. PARTICIPANTS: 52 nursing students working in 26 pairs participated in this study. METHODS: Participants were divided into two groups: an "in situ" group in which they had to describe their actions at different moments of a deteriorating patient scenario, and a "debriefing" group, in which, at the same moments, they had to describe their actions displayed on a video recording. In addition to a cognitive analysis, the teams' clinical performance was measured. RESULTS: The cognitive control level in the debriefing group was generally higher than in the in situ group. Good team performance was associated with a high level of cognitive control after a patient's significant state deterioration. CONCLUSIONS: These findings are in conformity with the "Skill-Rule-Knowledge" model. The debriefing stage allows a deeper reflection on action compared with the in situ condition. If an abnormal event occurs as an adverse event, then participants' mental processes tend to migrate towards knowledge-based control. This migration particularly concerns students with the best clinical performance. Thus, this cognitive framework can help to strengthen the analysis of verbal reports.

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

OBJECTIVES: 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. RESEARCH METHODOLOGY/DESIGN: A post hoc qualitative behavioural analysis was performed of recordings made of professional training sessions based upon simulated scenarios. SETTING: 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. MAIN OUTCOMES MEASURES: 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. RESULTS: 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. CONCLUSION: 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.

Effects of communication on the performance of nursing students during the simulation of an emergency situation.

AIM: To explore how nursing performance is impacted by different forms of team communication including a message transmitted through an earpiece which triggers reflective thinking in the simulation of a deteriorating patient situation. BACKGROUND: Communication can either support team performance or produce interruptions potentially leading to error. Today, technology offers the opportunity to use devices that can permit communication. DESIGN: An experimental protocol was used with quantitative and qualitative analyses. METHODS: Pairs of nursing students (N = 26) were dispatched to either an experimental group having to wear an earpiece priming reflective thinking, or to a control group. The study was conducted between October 2013-April 2014. RESULTS: The number of spontaneous information exchanges between pairs of participants was positively correlated with overall performance (actions performed and physician call) and with actions performed at the right moment. The number of questions in the team was positively correlated with overall action performance. No quantitative effect of the earpiece message on the performance indicators was found. But, a qualitative observation showed that this message can allow for error avoidance. Subjective evaluation of the earpiece as an aid was negatively correlated with overall action performance. Its evaluation as a disturbance was also negatively correlated with the measurement of actions performed at the right moment. CONCLUSION: The ability to exchange information and to ask questions seems to contribute to performance in care delivery. The use of communication devices to trigger reflective thinking must be studied in more depth to assess their capacity to improve performance.

Work domain constraints for modelling surgical performance.

PURPOSE: Three main approaches can be identified for modelling surgical performance: a competency-based approach, a task-based approach, both largely explored in the literature, and a less known work domain-based approach. The work domain-based approach first describes the work domain properties that constrain the agent's actions and shape the performance. This paper presents a work domain-based approach for modelling performance during cervical spine surgery, based on the idea that anatomical structures delineate the surgical performance. This model was evaluated through an analysis of junior and senior surgeons' actions. METHOD: Twenty-four cervical spine surgeries performed by two junior and two senior surgeons were recorded in real time by an expert surgeon. According to a work domain-based model describing an optimal progression through anatomical structures, the degree of adjustment of each surgical procedure to a statistical polynomial function was assessed. RESULTS: Each surgical procedure showed a significant suitability with the model and regression coefficient values around 0.9. However, the surgeries performed by senior surgeons fitted this model significantly better than those performed by junior surgeons. Analysis of the relative frequencies of actions on anatomical structures showed that some specific anatomical structures discriminate senior from junior performances. CONCLUSION: The work domain-based modelling approach can provide an overall statistical indicator of surgical performance, but in particular, it can highlight specific points of interest among anatomical structures that the surgeons dwelled on according to their level of expertise.

Decision making during preoperative surgical planning.

OBJECTIVE: This study analyzes decision making during preoperative surgical planning through two cognitive indicators: conflict and cognitive control. BACKGROUND: Planning is a critical stage in naturalistic decision making, and there is some evidence suggesting that this activity depends on the level of expertise and the demands of the task. The specificity of surgery resides in the necessity to cope with (potential) conflicts between the purpose of the surgical intervention and the biological laws governing the patient's body. METHOD: Six neurosurgeons (two board-certified neurosurgeons, two chief residents, and two residents) described the operative procedure envisaged on nine surgical cases of increasing surgical complexity. A detailed analysis of one surgical case described by one expert was performed. Moreover, we measured the number of conflicts and controls reported by each surgeon. RESULTS: Two experts were the only ones for which the report of conflicts increased with surgical complexity (respectively, 75% and 73% of the conflict variance predicted by complexity). The two experts significantly activated a higher proportion of knowledge-based control (respectively, 43% and 38%) than did intermediates and residents. The residents significantly activated more motor skill-based controls (respectively, 40% and 44%) than did intermediates and experts. CONCLUSION: It seems that expert surgical decision making to cope with task demands is significantly associated with conflict monitoring. Knowledge-based control to regulate conflict is mainly produced by experts. APPLICATION: Conflicts and controls analyzed through verbal reports can be used as relevant indicators to highlight critical moments in decision making that potentially require assistance from information systems.

Sound level of environmental music and drinking behavior: a field experiment with beer drinkers.

OBJECTIVE: It had been found that environmental music was associated with an increase in alcohol consumption. The presence versus absence of music, high versus slow tempo and the different styles of environmental music is associated with different level of alcohol consumption. However, the effect of the level of the environmental music played in a bar still remained in question. METHODS: Forty male beer drinkers were observed in a bar. According to a random distribution, patrons were exposed to the usual level of environmental music played in 2 bars where the experiment was carried out or were exposed to a high level. RESULTS: The results show that high level volume led to increase alcohol consumption and reduced the average amount of time spent by the patrons to drink their glass. CONCLUSIONS: The impact of environmental music on consumption was discussed and the "arousal" hypothesis and the negative effect of loud music on social interaction were used to explain our results.

Request solicitation and semantic evocation of freedom: an evaluation in a computer-mediated communication context.

The "But you are free of..." technique is a compliance procedure which solicits someone to comply with a request by simply telling him that he is free to accept or to refuse the request. This semantic evocation leads to increased compliance with the request. A new evaluation of the generality of this technique was tested in an experiment in which subjects received an anonymous electronic mail which asked them to consult the site of a humanitarian association for children. Analysis showed that, when the semantic evocation of freedom is included in the message, a higher compliance rate was observed than in a situation in which this evocation was omitted.