Adapting Cognitive Task Analysis Methods for Use in a Large Sample Simulation Study of High-Risk Healthcare Events.

Cognitive task analysis (CTA) methods are traditionally used to conduct small-sample, in-depth studies. In this case study, CTA methods were adapted for a large multi-site study in which 102 anesthesiologists worked through four different high-fidelity simulated high-consequence incidents. Cognitive interviews were used to elicit decision processes following each simulated incident. In this paper, we highlight three practical challenges that arose: (1) standardizing the interview techniques for use across a large, distributed team of diverse backgrounds; (2) developing effective training; and (3) developing a strategy to analyze the resulting large amount of qualitative data. We reflect on how we addressed these challenges by increasing standardization, developing focused training, overcoming social norms that hindered interview effectiveness, and conducting a staged analysis. We share findings from a preliminary analysis that provides early validation of the strategy employed. Analysis of a subset of 64 interview transcripts using a decompositional analysis approach suggests that interviewers successfully elicited descriptions of decision processes that varied due to the different challenges presented by the four simulated incidents. A holistic analysis of the same 64 transcripts revealed individual differences in how anesthesiologists interpreted and managed the same case.

Emergency in the clinic: a simulation curriculum to improve outpatient safety.

BACKGROUND: Emergency response skills are essential when events such as seizure, anaphylaxis, or hemorrhage occur in the outpatient setting. As services and procedures increasingly move outside the hospital, training to manage complications may improve outcomes. OBJECTIVE: The objective of this study was to evaluate a simulation-based curriculum in outpatient emergency management skills with the outcome measures of graded objective performance and learner self-efficacy. STUDY DESIGN: This pre- and postcurriculum study enrolled residents and fellows in Obstetrics and Gynecology and Family Medicine in a simulation-based, outpatient emergency management curriculum. Learners completed self-efficacy questionnaires and were videotaped managing 3 medical emergency scenarios (seizure, over-sedation/cardiopulmonary arrest, and hemorrhage) in the simulation laboratory both before and after completion of the curriculum. Evaluators who were blinded to training level scored the simulation performance videotapes using a graded rubric with critical action checklists. Scenario scores were assigned in 5 domains and globally. Paired t-tests were used to determine differences pre- and postcurriculum. RESULTS: Thirty residents completed the curriculum and pre- and postcurriculum testing. Subjects' objective performance scores improved in all 5 domains (P<.05) in all scenarios. When scores were stratified by level of training, all participants demonstrated global improvement. When scores were stratified by previous outpatient simulation experience, subjects with previous experience improved in all but management of excess sedation. Pre- and postcurriculum self-efficacy evaluations demonstrated improvement in all 7 measured areas: confidence, use of appropriate resources, communication skills, complex airway management, bag mask ventilation, resuscitation, and hemorrhage management. Self-efficacy assessment showed improvement in confidence managing outpatient emergencies (P=.001) and ability to communicate well in emergency situations (P<.001). CONCLUSION: A simulation-based curriculum improved both self-efficacy and objectively rated performance scores in management of outpatient medical emergencies. Simulation-based curricula should be incorporated into residency education.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

BACKGROUND: We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. METHODS: A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. RESULTS: Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. CONCLUSIONS: Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

A Taxonomy of Delivery and Documentation Deviations During Delivery of High-Fidelity Simulations.

INTRODUCTION: We developed a taxonomy of simulation delivery and documentation deviations noted during a multicenter, high-fidelity simulation trial that was conducted to assess practicing physicians' performance. Eight simulation centers sought to implement standardized scenarios over 2 years. Rules, guidelines, and detailed scenario scripts were established to facilitate reproducible scenario delivery; however, pilot trials revealed deviations from those rubrics. A taxonomy with hierarchically arranged terms that define a lack of standardization of simulation scenario delivery was then created to aid educators and researchers in assessing and describing their ability to reproducibly conduct simulations. METHODS: Thirty-six types of delivery or documentation deviations were identified from the scenario scripts and study rules. Using a Delphi technique and open card sorting, simulation experts formulated a taxonomy of high-fidelity simulation execution and documentation deviations. The taxonomy was iteratively refined and then tested by 2 investigators not involved with its development. RESULTS: The taxonomy has 2 main classes, simulation center deviation and participant deviation, which are further subdivided into as many as 6 subclasses. Inter-rater classification agreement using the taxonomy was 74% or greater for each of the 7 levels of its hierarchy. Cohen kappa calculations confirmed substantial agreement beyond that expected by chance. All deviations were classified within the taxonomy. CONCLUSIONS: This is a useful taxonomy that standardizes terms for simulation delivery and documentation deviations, facilitates quality assurance in scenario delivery, and enables quantification of the impact of deviations upon simulation-based performance assessment.

Adapting Simulation Curricula to the Future Needs of Anesthesiology.

We have discussed some examples of the types of program development strategies that are in common use and have presented examples of the type of performance gaps that can occur when a coordinated curriculum development process is not applied (or is applied in an uncoordinated fashion). We have outlined one method to develop a simulation-based curriculum focusing more on ways to identify how to "simulate what is needed" rather than using the "simulate what we know" style. We believe that curricula must be designed to continually evolve rather being conceived as a single finished program. We have attempted to illustrate what a designed simulation curriculum for training anesthesiology residents and faculty in the PSH might look like, and we have provided a sample scenario to illustrate how this process could be presented (Supplemental Digital Content 2, http://links.lww.com/AIA/A23, Supplemental Digital Content 3, http://links.lww.com/AIA/A24). Our hope is that this model may be applied to create simulation education curricula in a wide variety of areas. We suggest that it be a part of any attempt to create a standardized, longitudinal simulation-based assessment for residents or practitioners. A cohesive, strategic approach to simulation curriculum design and implementation will be required as we seek to create the same type of effective safety training in medicine that has been present in other high-risk professions.

Post-electroconvulsive therapy recovery and reorientation time with methohexital and ketamine: a randomized, longitudinal, crossover design trial.

OBJECTIVES: Methohexital, a barbiturate anesthetic commonly used for electroconvulsive therapy (ECT), possesses dose-dependent anticonvulsant properties, and its use can interfere with effective seizure therapy in patients with high seizure thresholds. Ketamine, an N-methyl-d-aspartate antagonist with epileptogenic properties not broadly used for ECT inductions, is a commonly used induction agent for general anesthesia. Recent studies suggest that the use of ketamine is effective in allowing successful ECT treatment in patients with high seizure thresholds without an increase in adverse effects. In this preliminary study, we directly compared the recovery and reorientation times of subjects receiving ketamine and methohexital for ECTs. METHODS: Twenty patients were randomized in a crossover design to receive methohexital and ketamine for ECT inductions in alternating fashion in 6 trials. Primary outcome measures were recovery time (voluntary movement, respiratory effort, blood pressure, consciousness, and O2 saturation) and reorientation time. Secondary outcome measures were individual recovery variables, adverse effect occurrence, and seizure duration. RESULTS: Overall recovery time was not significantly different between the 2 treatment arms (F(1, 17) = 0.72; P = 0.41). Reorientation time was faster in the methohexital arm (F(1, 17) = 9.23; P = 0.007). CONCLUSION: Ketamine inductions resulted in higher number of adverse effects, higher subject dropout rates, and a longer reorientation time with respect to methohexital inductions. No significant difference in postanesthesia recovery time was found between the ketamine and methohexital arms. Intolerability to ketamine affected a significant proportion of subjects and suggests that ketamine should remain as an alternative or adjunctive agent for patients with high seizure thresholds.

Physician communication in the operating room.

In this study, communication research was conducted with multidisciplinary groups of operating-room physicians. Theoretical frameworks from intercultural communication and rhetoric were used to (a) measure latent cultural communication variables and (b) conduct communication training with the physicians. A six-step protocol guided the research with teams of physicians from different surgical specialties: anesthesiologists, general surgeons, and obstetrician-gynecologists (n = 85). Latent cultural communication variables were measured by surveys administered to physicians before and after completion of the protocol. The centerpiece of the 2-hour research protocol was an instructional session that informed the surgical physicians about rhetorical choices that support participatory communication. Post-training results demonstrated scores increased on communication variables that contribute to collaborative communication and teamwork among the physicians. This study expands health communication research through application of combined intercultural and rhetorical frameworks, and establishes new ways communication theory can contribute to medical education.

Improved climate, culture, and communication through multidisciplinary training and instruction.

OBJECTIVE: The objective of the study was to determine the effectiveness of multidisciplinary team training on organizational culture and team communication. STUDY DESIGN: The training included a 6-step protocol: (1) a pretest survey assessing cultural attitudes and perceptions, (2) a baseline high-fidelity simulation session, (3) invitational medical rhetoric instruction, (4) a second high-fidelity simulation session, (5) a posttest survey assessing changed cultural attitudes and perceptions, and (6) a debriefing with participants. Teams of 4 physicians trained together: 2 obstetricians and 2 anesthesiologists. Forty-four physicians completed the training protocol during 2010 and 2011. RESULTS: Paired-sample t tests demonstrated significant decreases in autonomous cultural attitudes and perceptions (t = 8.23, P < .001) and significant increases in teamwork cultural attitudes and perceptions (t = -4.05, P < .001). Paired-sample t tests also demonstrated significant increases in communication climate that invited participation and integrated information from both medical services (t = -5.80, P < .001). CONCLUSION: The multidisciplinary team training program specified in this report resulted in increased teamwork among obstetricians and anesthesiologists.

Genetically-designed neural networks for error reduction in an optimized biomechanical model of the human elbow joint complex.

A real time dynamic biomechanical model of the human elbow joint has been used as the first step in the process of calculating time varying joint position from the electromyograms (EMGs) of eight muscles crossing the joint. Since calculation of position has a high sensitivity to errors in the model torque calculation, a genetic algorithm (GA) neural network (NN) has been developed for automatic error reduction in the dynamic model. Genetic algorithms are used to design many neural network structures during a preliminary trial effort, and then each network's performance is ranked to choose a trained network that represents the most accurate result. Experimental results from three subjects have shown model error reduction in 84.2% of the data sets from a subject on which the model had been trained, and 52.6% of the data sets from the subjects on which the model had not been trained. Furthermore, the GA networks reduced the error standard deviation across all subjects, showing that progress in error reduction was made evenly across all data sets.