Practice Makes Perfect: Simulation in Emergency Medicine Risk Management.

Simulation has been steadily changing the safety culture in the healthcare industry and allowing individual clinicians and interdisciplinary teams to be proactive in the culture of risk reduction and improved patient safety. Literature has demonstrated improved patient outcomes, improved team based skills, systems testing and mitigation of latent safety threats. Simulation may be incorporated into practice via different modalities. The simulation lab is helpful for individual procedures, in situ simulation (ISS) for system testing and teamwork, community outreach ISS for sharing of best practices and content resource experts. Serious medical gaming is developing into a useful training adjunct for the future.

Training for Failure: A Simulation Program for Emergency Medicine Residents to Improve Communication Skills in Service Recovery.

OBJECTIVES: Service failures such as long waits, testing delays, and medical errors are daily occurrences in every emergency department (ED). Service recovery refers to the immediate response of an organization or individual to resolve these failures. Effective service recovery can improve the experience of both the patient and the physician. This study investigated a simulation-based program to improve service recovery skills in postgraduate year 1 emergency medicine (PGY-1 EM) residents. METHODS: Eighteen PGY-1 EM residents participated in six cases that simulated common ED service failures. The patient instructors (PIs) participating in each case and two independent emergency medicine (EM) faculty observers used the modified Master Interview Rating Scale to assess the communication skills of each resident in three simulation cases before and three simulation cases after a service recovery debriefing. For each resident, the mean scores of the first three cases and those of the last three cases were termed pre- and postintervention scores, respectively. The means and standard deviations of the pre- and postintervention scores were calculated by the type of rater and compared using paired t-tests. Additionally, the mean scores of each case were summarized. In the framework of the linear mixed-effects model, the variance in scores from the PIs and faculty observers was decomposed into variance contributed by PIs/cases, the program effect on individual residents, and the unexplained variance. In reliability analyses, the intraclass correlation coefficient between rater types and the 95% confidence interval were reported before and after the intervention. RESULTS: When rated by the PIs, the pre- and postintervention scores showed no difference (p = 0.852). In contrast, when scored by the faculty observers, the postintervention score was significantly improved compared to the preintervention score (p < 0.001). In addition, for the faculty observers, the program effect was a significant contributor to the variation in scores. Low intraclass correlation was observed between rater groups. CONCLUSIONS: This innovative simulation-based program was effective at teaching service recovery communication skills to residents as evaluated by EM faculty, but not PIs. This study supports further exploration into programs to teach and evaluate service recovery communication skills in EM residents.

Procedural sedation and analgesia in the emergency department.

PURPOSE OF REVIEW: Procedural sedation and analgesia is frequently administered outside of the operating room in emergency departments (EDs) and ICUs. Evidence was sought concerning patients' safety in the ED. RECENT FINDINGS: Procedural sedation, when administered in the ED by trained personnel, is safe. Extensive literature demonstrates that propofol, ketamine, midazalam, and fentanyl are appropriate medications with proper monitoring and the presence of appropriate personnel. Preprocedural fasting may not be necessary in many cases. SUMMARY: With appropriately trained personnel, proper equipment, and the studied drugs ED sedation and analgesia is safe and an appropriate procedure.

Comparison of nitrile gloves and nitrile over Nomex gloves.

OBJECTIVES: Aeromedical flight crews must perform many tasks in flight requiring manual dexterity and fine precision. A common perception is that safety-enhancing fire-retardant gloves compromise patient care if worn during such tasks by providing added bulk and barrier to the hand. This study is a quantitative and qualitative analysis of this possible compromise to patient care. METHODS: Sixteen practicing flight nurses and respiratory therapists were asked to perform 10 different standard patient care tasks while wearing either nitrile gloves or a nitrile-Nomex glove pair. Tasks were timed, rated as completed successfully or not, and were subsequently judged subjectively by the participants. RESULTS: Whereas the time required to insert an intravenous catheter and to insert a central line while wearing only nitrile gloves was significantly faster than when wearing both gloves, the time to perform all other tasks was not significantly different. In subjective ratings, the nitrile glove alone was scored significantly better than the two-glove combination by the study participants. CONCLUSIONS: Comfort, dexterity, tactile discrimination, and ease of use were all adversely affected by wearing a Nomex glove under a nitrile glove. Although the differences in times for most tasks may not be clinically significant, the difference in the subjective parameters may be great enough to cause helicopter emergency medical services (HEMS) practitioners to not wear Nomex gloves under nitrile gloves while performing procedures.

Comparison of use of the the Airtraq with direct laryngoscopy by paramedics in the simulated airway.

INTRODUCTION: Paramedics often encounter patients with difficult airways requiring emergent airway management. OBJECTIVE: The purpose of this study was to compare intubation utilizing the Airtraq with direct laryngoscopy (DL) in the manikin model. We evaluated the number of attempts, the time to successful intubation, and the Airtraq's learning curve. METHODS: This was a randomized, crossover study involving paramedics. Each participant was given a standardized lecture and a demonstration of the Airtraq device. After a 5-minute practice session on a Laerdal Airway Management Trainer with the Airtraq and DL, participants managed the following four scenarios on a Laerdal SimMan manikin: 1) normal airway; 2) tongue edema; 3) cervical spine immobilization; and 4) repeated normal airway. Results were analyzed using the Wilcoxon signed rank test. RESULTS: Thirty paramedics participated in this study. For scenario 1, there were no significant differences in either the number of attempts or the time to ventilation between the devices. For scenario 2, the mean time to ventilation was significantly faster, and fewer intubation attempts were observed with the Airtraq when compared with DL. For scenario 3, there were no significant differences in number of attempts and time to ventilation. Scenario 4 demonstrated significantly less time to ventilation and fewer intubation attempts with the Airtraq. A significant decrease in time to ventilation was observed with the Airtraq when comparing scenarios 1 and 4. CONCLUSIONS: The Airtraq was shown to be equal to or faster than DL. The Airtraq has a rapid learning curve demonstrated by a significantly decreased time to ventilation between scenarios 1 and 4.

Simulation in graduate medical education 2008: a review for emergency medicine.

Health care simulation includes a variety of educational techniques used to complement actual patient experiences with realistic yet artificial exercises. This field is rapidly growing and is widely used in emergency medicine (EM) graduate medical education (GME) programs. We describe the state of simulation in EM resident education, including its role in learning and assessment. The use of medical simulation in GME is increasing for a number of reasons, including the limitations of the 80-hour resident work week, patient dissatisfaction with being "practiced on," a greater emphasis on patient safety, and the importance of early acquisition of complex clinical skills. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. This article also discusses the design of simulation centers and the resources available for developing simulation programs in graduate EM education. The level of interest in these resources is evident by the numerous national EM organizations with internal working groups focusing on simulation. In the future, the health care system will likely follow the example of the airline industry, nuclear power plants, and the military, making rigorous simulation-based training and evaluation a routine part of education and practice.

Sedation in the emergency department.

PURPOSE OF REVIEW: The recent year's literature is reviewed concerning the use of sedation in the emergency department. The use of moderate to deep sedation is becoming common in emergency medicine for many reasons, including progressive hospital crowding, limited availability of anesthesia, and increased training in residency. This is performed for a wide variety of procedures, most commonly orthopedic. RECENT FINDINGS: The literature discussed medications, monitoring, and the safety of current sedation practice in the emergency department. Emergency department procedural sedation and analgesia is performed with a number of medications, including propofol, etomidate, midazolam, fentanyl, ketamine, and nitrous oxide. Cardiac monitoring, pulse oximetry and capnography are used, often without strong evidence-based support of need. Complications do occur and are higher in prospective studies than in retrospective series. This suggests a degree of underreporting. Nevertheless, clinically important complications are uncommon. SUMMARY: The year's literature reflects the reality that the performance of sedation in the emergency department is advantageous. As the era of evidence-based medicine continues to provide us with more and better information, the combined efforts of both anesthesiology and emergency medicine can hopefully contribute to improving patient safety with respect to procedural sedation.

Pearls and pitfalls in the emergency department evaluation of abdominal pain.

Abdominal pain is a common complaint in the emergency department (ED), comprising approximately 5% of total visits. Although not typically serious, abdominal pain often presents many difficult situations for the clinician. Women of reproductive age and elderly individuals represent some of the most challenging patients to evaluate. Although there are general diagnostic and clinical principles that apply to the evaluation of all patients, these two groups deserve extra attention because of the broad differential diagnosis and potential for serious complications. This article outlines the epidemiology of abdominal pain in patients who present to the ED, and provides guidelines pertinent to the evaluation of all patients. In addition, the article discusses the approach to abdominal pain of pelvic origin in women of reproductive age and abdominal pain in elderly individuals.