In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments.

OBJECTIVES: The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality. METHODS: This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality. RESULTS: The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons. CONCLUSIONS: We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

Access to Care: End-to-End Digital Response for COVID-19 Care Delivery.

The coronavirus disease 2019 pandemic disrupted health care, requiring organizational leaders to act quickly to manage the health-related concerns of individuals and communities. The ability to offer a variety of digitally enabled telehealth services with 24/7 access to nurse practitioners and physician assistants allowed us to care for patients in their homes. It reduced the spread of the virus, protected our employees from further disease spread, and provided early interventions to those in need. The roles of nurse practitioner leaders, the enacted strategies, and patient outcomes demonstrate the impact of an innovative digital care delivery model on care across the continuum.

There's an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application.

BACKGROUND: Clear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training. OBJECTIVE: To evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery. PATIENT INVOLVEMENT: The app under study is designed to improve doctor-patient communication. METHODS: The study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants' use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill. RESULTS: Among 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91-4.84)]. DISCUSSION: Despite positive reviews of app use, overall use was low and there was no association with achieving mastery. PRACTICAL VALUE: Offering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn't be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated. AVAILABILITY OF DATA AND MATERIALS: The datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.

A novel in situ simulation framework for introduction of a new technology: the 3-Act-3-Debrief model.

BACKGROUND: New technologies for clinical staff are typically introduced via an "in-service" that focuses on knowledge and technical skill. Successful adoption of new healthcare technologies is influenced by multiple other factors as described by the Consolidated Framework in Implementation Research (CFIR). A simulation-based introduction to new technologies provides opportunity to intentionally address specific factors that influence adoption. METHODS: The new technology proposed for adoption was a telehealth cart that provided direct video communication with electronic intensive care unit (eICU) staff for a rural Emergency Department (ED). A novel 3-Act-3-Debrief in situ simulation structure was created to target predictive constructs from the CFIR and connect debriefing to specific workflows. The structure and content of the simulation in relation to the framework is described. Participants completed surveys pre-simulation/post-simulation to measure change in their readiness to adopt the new technology. RESULTS: The scenario was designed and pilot tested before implementation at two rural EDs. There were 60 interprofessional participants across the 2 sites, with 58 pre-simulation and 59 post-simulation surveys completed. The post-simulation mean ratings for each readiness measure (feasibility, quality, resource availability, role clarity, staff receptiveness, and tech usability) increased significantly as a result of the simulation experience. CONCLUSIONS: A novel 3-stage simulation-debriefing structure positively targets factors influencing the adoption of new healthcare technologies.

The Equivalence of Video Self-review Versus Debriefing After Simulation: Can Faculty Resources Be Reallocated?

INTRODUCTION: Traditional simulation debriefing is both time- and resource-intensive. Shifting the degree of primary learning responsibility from the faculty to the learner through self-guided learning has received greater attention as a means of reducing this resource intensity. The aim of the study was to determine if video-assisted self-debriefing, as a form of self-guided learning, would have equivalent learning outcomes compared to standard debriefing. METHODS: This randomized cohort study consisting of 49 PGY-1 to -3 emergency medicine residents compared performance after video self-assessment utilizing an observer checklist versus standard debriefing for simulated emergency department procedural sedation (EDPS). The primary outcome measure was performance on the second EDPS scenario. RESULTS: Independent-samples t-test found that both control (standard debrief) and intervention (video self-assessment) groups demonstrated significantly increased scores on Scenario 2 (standard-t(40) = 2.20, p < 0.05; video-t(45) = 3.88, p < 0.05). There was a large and significant positive correlation between faculty and resident self-evaluation (r = 0.70, p < 0.05). There was no significant difference between faculty and residents self-assessment mean scores (t(24) = 1.90, p = 0.07). CONCLUSIONS: Residents receiving feedback on their performance via video-assisted self-debriefing improved their performance in simulated EDPS to the same degree as with standard faculty debriefing. Video-assisted self-debriefing is a promising avenue for leveraging the benefits of simulation-based training with reduced resource requirements.

A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation.

INTRODUCTION: With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU. METHODS: The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t test. RESULTS: We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05). CONCLUSIONS: We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.

Clinician behaviors in telehealth care delivery: a systematic review.

Literature on telehealth care delivery often addresses clinical, cost, technological, system, and organizational impacts. Less is known about interpersonal behaviors such as communication patterns and therapeutic relationship-building, which may have workforce development considerations. The purpose of this study was to conduct a systematic literature review to identify interpersonal health care provider (HCP) behaviors and attributes related to provider-patient interaction during care in telehealth delivery. Electronic searches were conducted using five indexes/databases: CINAHL, ERIC, PsychInfo, ProQuest Dissertations, PubMed; with hand-searching of the immediate past 10 years of five journals. Search concepts included: communication, telehealth, education, and health care delivery. Of 5261 unique article abstracts initially identified, 338 full-text articles remained after exclusion criteria were applied and these were reviewed for eligibility. Finally, data were extracted from 45 articles. Through qualitative synthesis of the 45 articles, we noted that papers encompassed many disciplines and targeted care to people in many settings including: home care, primary and specialist care, mental health/counseling, and multi-site teams. Interpersonal behaviors were observed though not manipulated through study designs. Six themes were identified: HCP-based support for telehealth delivery; provider-patient interactions during the telehealth event; environmental attributes; and guidelines for education interventions or evaluation of HCP behaviors. Although unable to identify current best practices, important considerations for practice and education did emerge. These include: perceptions of the utility of telehealth; differences in communication patterns such as pace and type of discourse, reliance on visual cues by both provider and patient especially in communicating empathy and building rapport; and confidentiality and privacy in telehealth care delivery.

Patients' views of teamwork in the emergency department offer insights about team performance.

BACKGROUND: Research into efforts to engage patients in the assessment of health-care teams is limited. OBJECTIVE: To explore, through qualitative methods, patient awareness of teamwork-related behaviours observed during an emergency department (ED) visit. DESIGN: Researchers used semi-structured question guides for audio-recorded interviews and analysed their verbatim transcripts. SETTING AND PARTICIPANTS: Researchers conducted individual phone interviews with 6 teamwork subject matter experts (SMEs) and held 5 face-to-face group interviews with patients and caregivers (n = 25) about 2 weeks after discharge from the emergency department (ED). RESULTS: SMEs suggested that a range of factors influence patient perspectives of teams. Many patients perceived the health-care team within the context of their expectations of an ED visit and their treatment plan. Four themes emerged: (i) patient-centred views highlight gaps in coordination and communication; (ii) team processes do concern patients; (iii) patients are critical observers of ways that team members present their team roles; (iv) patients' observations of team members relate to patients' views of team effectiveness. Analysis also indicated that patients viewed health-care team members' interactions with each other as proxy for how team members actually felt about patients. DISCUSSION: Results from both sets of interviews (SME and patient) indicated that patient observations of teamwork could add to assessment of team processes/frameworks. Patients' understanding about teamwork organization seemed helpful and witnessed interteam communication appeared to influence patient confidence in the team. CONCLUSION: Patients perspectives are an important part of assessment in health care and suggest potential areas for improvement through team training.

Implementation of unit-based interventions to improve teamwork and patient safety on a medical service.

In a prior study involving 2 medical units, Structured Interdisciplinary Rounds (SIDRs) improved teamwork and reduced adverse events (AEs). SIDR was implemented on 5 additional units, and a pre- versus postintervention comparison was performed. SIDR combined a structured format for communication with daily interprofessional meetings. Teamwork was assessed using the Safety Attitudes Questionnaire (score range = 0-100), and AEs were identified using queries of information systems confirmed by 2 physician researchers. Paired analyses for 82 professionals completing surveys both pre and post implementation revealed improved teamwork (mean 76.8 ± 14.3 vs 80.5 ± 11.6; P = .02), which was driven mainly by nurses (76.4 ± 14.1 vs 80.8 ± 10.4; P = .009). The AE rate was similar across study periods (3.90 vs 4.07 per 100 patient days; adjusted IRR = 1.08; P = .60). SIDR improved teamwork yet did not reduce AEs. Higher baseline teamwork scores and lower AE rates than the prior study may reflect a positive cultural shift that began prior to the current study.

Testing of the Patients' Insights and Views of Teamwork (PIVOT) Survey: a validity study.

OBJECTIVE: To explore patient observations of teamwork-related behaviors such as inter-team communication through a newly designed survey. METHODS: In this cross-sectional study, 101 patients (N=86) and caregivers (N=15) recruited from the emergency department (ED) of an urban, academic medical center (>85,000 visits/year) completed the 16-item Patients' Insights and Views Observing Teams (PIVOT) Survey. We evaluated validity evidence through descriptive statistics and analysis including a Many-facet Rasch model to determine associations between questionnaire items and sociodemographic characteristics. RESULTS: Participant responses provided evidence survey items performed well and reflected patients' awareness of team behaviors such as inter-team communication, coordination, and keeping teammates informed. Also, participants responded about the consistency of information from team members and knowing what people's jobs were on the team. Rasch analysis largely supported that the PIVOT items reflected the intended content area and adequacy of ratings scales supporting evidence of response processes. High internal consistency (Cronbach alpha, r=.87) supported evidence of internal structure. As expected, response patterns differed by ED visit acuity level and length of stay. CONCLUSIONS: The PIVOT survey offered a means to collect patient and caregiver observations of health care teams. PRACTICE IMPLICATIONS: PIVOT survey responses may contribute to evaluation of teamwork behaviors.

Specialty milestones and the next accreditation system: an opportunity for the simulation community.

The Accreditation for Graduate Medical Education has developed a new process of accreditation, the Next Accreditation System (NAS), which focuses on outcomes. A key component of the NAS is specialty milestones-specific behavior, attributes, or outcomes within the general competency domains. Milestones will mark a level of proficiency of a resident within a competency domain. Each specialty has developed its own set of milestones, with semiannual reporting to begin July 2013, for 7 specialties, and the rest in July 2014.Milestone assessment must be based on objective data. Each specialty will determine optimal methods of measuring milestones, based on ease, cost, validity, and reliability. The simulation community has focused many graduate medical education efforts at training and formative assessment. Milestone assessment represents an opportunity for simulation modalities to offer summative assessment of milestone proficiencies, adding to the potential methods that residency programs will likely use or adapt. This article discusses the NAS, milestone assessment, and the opportunity to the simulation community to become involved in this next stage of graduate medical education assessment.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

BACKGROUND: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

Language use in the informed consent discussion for emergency procedures.

BACKGROUND: The field of health literacy has closely examined the readability of written health materials to optimize patient comprehension. Few studies have examined spoken communication in a way that is comparable to analyses of written communication. PURPOSE: The study objective was to characterize the structural elements of residents' spoken words while obtaining informed consent. METHODS: Twenty-six resident physicians participated in a simulated informed consent discussion with a standardized patient. Audio recordings of the discussions were transcribed and analyzed to assess grammar statistics for evaluating language complexity (e.g., reading grade level). Transcripts and time values were used to assess structural characteristics of the dialogue (e.g., interactivity). RESULTS: Discussions were characterized by physician verbal dominance. The discussions were interactive but showed significant differences between the physician and patient speech patterns for all language complexity metrics. CONCLUSIONS: In this study, physicians spoke significantly more and used more complex language than the patients.

Melanoma trainer using simulated back skin: an innovative design.

INTRODUCTION: The method used to create a melanoma trainer using simulated back skin is presented. The trainer is intended to be used to teach medical students to identify benign and malignant cutaneous pigmented lesions. METHODS: Non-Hispanic and Hispanic white melanoma trainers were created using flexible polyurethane foam and pigmented silicone rubber. The models were reviewed by board-certified dermatologists and dermatology residents to determine the reliability and fidelity of the models. RESULTS: The models were deemed an accurate representation of the skin of human backs containing multiple normal nevi and clinically suspicious pigmented lesions, which were melanomas. Among 33 dermatologists and dermatology residents, there was good reliability for all clinically suspicious lesions (κ = 0.64), excellent reliability for melanomas (κ = 0.97), and excellent reliability for selecting melanomas for biopsy (κ = 0.96). Reliability in selecting lesions to monitor for change varied depending on the physicians preference to perform biopsy on all melanomas and follow all other clinically suspicious lesions (κ = 0.86) or to perform biopsy on all melanomas and 1 other abnormal nevus and monitor all other abnormal lesions (κ = 0.61). CONCLUSIONS: The melanoma trainer using simulated back skin is a reliable model that can be stored and used frequently over a long period. The trainer will allow students to assess a range of pigmented lesions that would not be found on 1 patient.

Self-reported use of communication techniques in the emergency department.

BACKGROUND: Communication is considered a core competency for physicians. However, the Emergency Department setting poses significant and unique communication challenges. OBJECTIVE: The objective of this study was to explore self-reported use and perceptions of effectiveness and feasibility of communication techniques used by Emergency Physicians for communication with patients. METHODS: This cross-sectional study utilized a previously published survey on eight communication techniques. Respondents were asked to quantify their personal use and perceptions of effectiveness and feasibility of each technique. Responses were analyzed for differences based on practice setting (community, academic) and provider role (attending, resident). The survey was administered to a convenience sample recruited at the national meeting of the American College of Emergency Physicians. RESULTS: One hundred and sixty-nine participants were enrolled (70.5% male; 55.8% attending physicians, 44.2% residents; 66.2% practiced in academic settings). Using simple language and speaking slowly to patients were the only techniques identified as being used routinely by a majority of the sample (92.2% and 61.3%, respectively). A majority of the sample ranked seven of the techniques as effective; all techniques were considered feasible in the Emergency Department. No differences were noted across provider role or practice setting. CONCLUSION: The majority of respondents are not utilizing communication techniques, despite their own beliefs that the techniques are effective and easy to implement in the Emergency Department. Additional research is needed to determine the effectiveness of these techniques and relevant barriers to their use.

Simulation-based education with mastery learning improves paracentesis skills.

BACKGROUND: Paracentesis is a commonly performed bedside procedure that has the potential for serious complications. Therefore, simulation-based education for paracentesis is valuable for clinicians. OBJECTIVE: To assess internal medicine residents' procedural skills before and after simulation-based mastery learning on a paracentesis simulator. METHODS: A team with expertise in simulation and procedural skills developed and created a high fidelity, ultrasound-compatible paracentesis simulator. Fifty-eight first-year internal medicine residents completed a mastery learning-based intervention using the paracentesis simulator. Residents underwent baseline skill assessment (pretest) using a 25-item checklist. Residents completed a posttest after a 3-hour education session featuring a demonstration of the procedure, deliberate practice, ultrasound training, and feedback. All residents were expected to meet or exceed a minimum passing score (MPS) at posttest, the key feature of mastery learning. We compared pretest and posttest checklist scores to evaluate the effect of the educational intervention. Residents rated the training sessions. RESULTS: Residents' paracentesis skills improved from an average pretest score of 33.0% (SD  =  15.2%) to 92.7% (SD  =  5.4%) at posttest (P < .001). After the training intervention, all residents met or exceeded the MPS. The training sessions and realism of the simulation were rated highly by learners. CONCLUSION: This study demonstrates the ability of a paracentesis simulator to significantly improve procedural competence.

A new tool for testing and training ophthalmoscopic skills.

INTRODUCTION: The direct fundoscopic examination is an important clinical skill, yet the examination is difficult to teach and competency is difficult to assess. Currently there is no defined proficiency assessment for this physical examination, and the objective of this study was to assess the feasibility of a simulation model for evaluating the fundoscopic skills of residents. METHODS: Emergency medicine and ophthalmology residents participated in simulation sessions using a commercially available eye simulator that was modified with customized slides. The slides were designed with the goal of having a quantifiable measure of visualization in addition to a more traditional descriptive outcome. To assess feasibility, participants' ease of use, time to perform the examination, and user satisfaction were assessed. RESULTS: The simulation could be completed in a timely fashion (mean time per slide, 61-95 seconds), and there were no significant differences in performance between emergency medicine and ophthalmology residents in completion of this task. Residents expressed an interest in fundoscopy through simulation but found this model technically challenging. CONCLUSIONS: This simulation model has potential as a means of training and testing fundoscopy. A concern was low user satisfaction, and further refinement of the model is needed.

Is it the athlete or the equipment? An analysis of the top swim performances from 1990 to 2010.

O'Connor, LM and Vozenilek, JA. Is it the athlete or the equipment? An analysis of the top swim performances from 1990 to 2010. J Strength Cond Res 25(12): 3239-3241, 2011-Forty-three world record swims were recorded at the 2009 Fédération Internationale de Natation (FINA) World Championship meet in Rome. Of the 20 FINA recognized long-course (50-m pool) swimming events, men set new world records in 15 of those events, whereas women did the same in 17 events. Each of the men's world records and 14 of the 17 women's records still stand. These performances were unprecedented; never before had these many world records been broken in such a short period of time. There was much speculation that full-body, polyurethane, technical swimsuits were the reason for the conspicuous improvement in world records. Further analysis led the FINA to institute new rules on January 1, 2010, that limited the types of technical swimsuits that could be worn by athletes. No long-course world record has been broken since then. We sought to understand this phenomenon by analyzing publicly available race data and exploring other possible causes including improvements in other sports, improvements in training science, changes in rules and regulations, gender differences, anaerobic vs. aerobic events, unique talent, and membership data.

Comparison of checklist and anchored global rating instruments for performance rating of simulated pediatric emergencies.

PURPOSE: To compare the psychometric performance of two rating instruments used to assess trainee performance in three clinical scenarios. METHODS: This study was part of a two-phase, randomized trial with a wait-list control condition assessing the effectiveness of a pediatric emergency medicine curriculum targeting general emergency medicine residents. Residents received 6 hours of instruction either before or after the first assessment. Separate pairs of raters completed either a dichotomous checklist for each of three cases or the Global Performance Assessment Tool (GPAT), an anchored multidimensional scale. A fully crossed person×rater×case generalizability study was conducted. The effect of training year on performance is assessed using multivariate analysis of variance. RESULTS: The person and person×case components accounted for most of the score variance for both instruments. Using either instrument, scores demonstrated a small but significant increase as training level increased when analyzed using a multivariate analysis of variance. The inter-rater reliability coefficient was >0.9 for both instruments. CONCLUSIONS: We demonstrate that our checklist and anchored global rating instrument performed in a psychometrically similar fashion with high reliability. As long as proper attention is given to instrument design and testing and rater training, checklists and anchored assessment scales can produce reproducible data for a given population of subjects. The validity of the data arising for either instrument type must be assessed rigorously and with a focus, when practicable, on patient care outcomes.

Simulation center accreditation and programmatic benchmarks: a review for emergency medicine.

Simulation-based education has grown significantly over the past 10 years. As a result, more professional organizations are developing or implementing accreditation processes to help define minimum standards and best practices in simulation-based training. However, the benefits and potential pitfalls of sponsoring and implementing such programs have yet to be fully evaluated across specialties. The board of directors of the Society for Academic Emergency Medicine (SAEM) requested an evaluation of the potential to create an emergency medicine (EM)-based Simulation Consultation and Accreditation Service. In response to this request, the Simulation Accreditation and Consultation Work Group, a subgroup of the Committee on Technology in Medical Education (now Simulation Academy), was created. The work group was charged with: 1) reviewing current benchmarks and standards set by existing simulation accreditation programs; 2) analyzing current EM simulation program structures, including leadership, administrative, and financial components; and 3) proposing a potential model for EM-based simulation accreditation. This article outlines currently existing and proposed accreditation models and identifies components that support best practices. It then goes on to describe three general programmatic models to better understand how simulation training can be operationalized in EM. Finally, the work group uses this collective information to propose how an accreditation process, in concert with the SAEM Simulation Consultation Service, can enhance and advance EM simulation training.