Decision-Making During High-Risk Events: A Systematic Literature Review.

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

Acute Benefits After Liposomal Bupivacaine Abdominal Wall Blockade for Living Liver Donation: A Retrospective Review.

OBJECTIVE: To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. PATIENTS AND METHODS: We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. RESULTS: Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). CONCLUSION: Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

Factors that influence the selection of sterile glove brand: a randomized controlled trial evaluating the performance and cost of gloves.

PURPOSE: To determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand. METHODS: Forty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The manufacturer's suggested retail price was collected for each glove tested. RESULTS: There were statistically significant differences in touch sensitivity for all nerve distributions, with all glove types resulting in less sensitivity than a bare hand. When compared with the non-sterile glove, only the thickest glove tested (Ansell Perry Orthopaedic) was found to have less touch sensitivity. Fine motor dexterity testing revealed no statistically significant differences in time to completion amongst glove types or bare handed performance. In hand-eye coordination testing across treatment conditions, the thickest glove tested (Ansell Perry(®) Orthopaedic) was the only glove to show a statistically significant difference from a bare hand. There were statistically significant differences in glove comfort ratings across glove types, with latex-free, powder-free (Cardinal Esteem(®)), and latex powder-free (Mölnlycke-Biogel(®)) rated highest; however, there were no statistically significant differences in subjective performance ratings across glove types. CONCLUSIONS: Given the observed similarities in touch sensitivity and psychomotor performance associated with five different glove types, our results suggest that subjective provider preferences, such as glove comfort, should be balanced against material costs.

A 1-week simulated internship course helps prepare medical students for transition to residency.

INTRODUCTION: The transition from medical student to intern is inherently stressful, with potentially negative consequences for both interns and patients. METHODS: We describe Internship Boot Camp, an innovative course specifically designed to prepare fourth-year medical students for the transition from medical school to internship. An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns. RESULTS: In March 2007, 12 students participated in the course as an elective in their final year of medical school, and the other 28 students in their class did not. After beginning internship and 5 to 7 months after the completion of Internship Boot Camp, all 40 former students were asked to complete a blinded survey about their preparation for internship. The overall response rate for the survey was 80%. Of responders to an open-ended question about the aspects of medical school training that best prepared them for internship, 89% (8 of 9) of course participants listed "Internship Boot Camp." The next highest response ("subinternship") was given by 45% (9 of 20) of nonparticipants and 33% (3 of 9) of course participants. DISCUSSION: Internship Boot Camp is a unique learning environment that is recalled by participants as the most helpful, of all components of their medical school education, in preparation for internship.

Ultrasound machine comparison: an evaluation of ergonomic design, data management, ease of use, and image quality.

BACKGROUND AND OBJECTIVES: The use of ultrasound technology for vascular access and regional anesthesia is gaining widespread acceptance among anesthesia providers. As a result, many group practices and medical institutions are considering purchasing ultrasound equipment. Currently, comparative information regarding the ergonomic design, physical and adjustable features, data management, ease of use, cost, and image quality of various ultrasound machines is not available. The primary goal of this investigation was to develop an objective process of evaluating ultrasound equipment before purchase. The process of evaluation used in the current investigation may be used when comparing a variety of medical technologies. METHODS: A randomized, side-by-side comparative evaluation of 7 different ultrasound machine models was performed. Sixteen resident physicians without prior ultrasound experience (inexperienced providers) completed a formal evaluation of each machine model after performing a standardized machine configuration and performance checklist. Inexperienced providers and 10 faculty members experienced in ultrasound-guided regional anesthesia evaluated the image quality of 2 standardized images acquired from each machine model. RESULTS: Overall, evaluators rated questions on the machine evaluation form as "very good" or "outstanding" 70% or more of the time for all machine models. The largest, most complex ultrasound machine was rated as having the best image quality by both inexperienced and experienced providers. Ultrasound machine models with the simplest ergonomic design and user interface were rated highest by inexperienced study participants. CONCLUSIONS: Anesthesia providers considering an ultrasound equipment purchase should objectively evaluate machine models that have features most important to their own clinical practice. Ergonomic design, physical and adjustable features, data management, ease of use, image quality, and cost are important features to consider when evaluating an ultrasound machine.

An innovative team collaboration assessment tool for a quality improvement curriculum.

The success of quality improvement (QI) initiatives is significantly dependent on the effective functioning of the team responsible for the project. To our knowledge, there is no published literature on performance-based team assessment tools in the context of a QI curriculum. This study demonstrates the validity, feasibility, and acceptability of an objective structured clinical examination station designed to assess competency in teamwork at the completion of a QI curriculum taught in a graduate medical education program. Further research with multiple teams and during a longer period will be needed to better understand the psychometric properties and predictive validity of the teamwork objective structured clinical examination station.