Innovating for a Safe Simulation Challenge During a Pandemic: An Avatar Simulation Concept.

SUMMARY STATEMENT: We present a new simulation-based challenge (Sim'Cup) concept, created in response to the COVID-19 pandemic. It took place in 2020, during the European Society of Emergency Medicine and the Societé Française de Médecine d'Urgence (SFMU) conferences. Usually, during the conferences, a Sim'Cup is held with onsite participants who are involved in a consecutive series of face-to-face simulations organized in 2 qualifying rounds, followed by a final round. When congresses were transformed into online events, the Sim'Cup had to evolve into a virtual format as well. We developed the e-Sim'Cup concept as follows: participants staying safely at home, piloting the trainers, as if they were their own avatar, in a simulation room with a full-scale high-fidelity manikin (Gaumard, Laerdal) using real-time scenarios. Participants gave instructions to the avatars through a smartphone and via a website. Each team participated in 2 scenarios. At the end of each scenario, teams had to undergo a self-debriefing, followed by a short debriefing with the organizers. Twenty-seven participants divided into 9 teams participated in 1 of the 2 e-Sim'Cup events.We evaluated the impact of this approach using the Educational Practices Questionnaire, and we also analyzed the participants' perception of their satisfaction and their feelings of improvement with this virtual format. Moreover, we conducted qualitative analyses of the self-debriefings. Thirteen participants filled out the questionnaire, giving a combined high Educational Practices Questionnaire score [72 (66.5-77) of 80], which reflects the presence of educational best practices during the e-Sim'Cups. They appreciated the adjusted Sim'Cup format and believed that they were able to improve their communication, clinical skills, and self-confidence. The qualitative analysis suggested that the approach was perceived as immersive by the 27 participants, with some challenges due to technical problems but an overall feeling of improvement regarding their crisis resource management skills. The hybrid remote simulation concept satisfied the participants who believed that it improved important skills in emergency medicine. The increasing number of remote activities and conferences lead us to believe that our e-Sim'Cup concept can be easily reproducible in any simulation center, as it requires only the application of the educational concept and either the use of the website or the use of some widely available technical devices.

Factors associated with delayed revascularization in patients with ischemic stroke: a prospective study in one French region.

BACKGROUND AND IMPORTANCE: Optimizing the care pathway of stroke is crucial for the revascularization of ischemic stroke. OBJECTIVES: to identify factors associated with (1) a time interval over 4 h between the symptom onset and cerebral imaging in suspected stroke patients and (2) the absence of revascularization in patients with ischemic stroke. DESIGN, SETTINGS AND PARTICIPANTS: Patients over 18 years old with a suspected stroke admitted in 22 emergency rooms or stroke units in one French region between 1 March 2019 and 30 April 2019 were prospectively included by filling a dedicated form. OUTCOME MEASURES AND ANALYSIS: Factors associated with the previously mentioned outcome measures were identified using logistic regression models. MAIN RESULTS: In total 991 patients were included; 537 patients (64% of 845 with available time intervals) were admitted more than 4 h after symptom onset. Three predictors were identified: not calling emergency medical services (EMS) [odds-ratio (OR) 5.2; 95% confidence interval (3.4-8.1)], a preexisting autonomy loss [2.0 (1.3-2.9)] and atypical clinical presentation [2.0 (1.3-3.1)]. A total of 385 patients had an ischemic stroke of whom 93 underwent a revascularization procedure (24%). The same three predictors were associated with the absence of revascularization procedure, added to an initial admission in a hospital without stroke unit [3.1 (1.1-8.6)]. CONCLUSION: This study shows that efforts to organize the care chain for stroke need to be intensified in the region to reduce treatment time intervals, which could include information campaigns focused on the impact of EMS call and the clinical presentation recognition.

Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest: A Randomized Clinical Trial.

Importance: Bag-mask ventilation (BMV) is a less complex technique than endotracheal intubation (ETI) for airway management during the advanced cardiac life support phase of cardiopulmonary resuscitation of patients with out-of-hospital cardiorespiratory arrest. It has been reported as superior in terms of survival. Objectives: To assess noninferiority of BMV vs ETI for advanced airway management with regard to survival with favorable neurological function at day 28. Design, Settings, and Participants: Multicenter randomized clinical trial comparing BMV with ETI in 2043 patients with out-of-hospital cardiorespiratory arrest in France and Belgium. Enrollment occurred from March 9, 2015, to January 2, 2017, and follow-up ended January 26, 2017. Intervention: Participants were randomized to initial airway management with BMV (n = 1020) or ETI (n = 1023). Main Outcomes and Measures: The primary outcome was favorable neurological outcome at 28 days defined as cerebral performance category 1 or 2. A noninferiority margin of 1% was chosen. Secondary end points included rate of survival to hospital admission, rate of survival at day 28, rate of return of spontaneous circulation, and ETI and BMV difficulty or failure. Results: Among 2043 patients who were randomized (mean age, 64.7 years; 665 women [32%]), 2040 (99.8%) completed the trial. In the intention-to-treat population, favorable functional survival at day 28 was 44 of 1018 patients (4.3%) in the BMV group and 43 of 1022 patients (4.2%) in the ETI group (difference, 0.11% [1-sided 97.5% CI, -1.64% to infinity]; P for noninferiority = .11). Survival to hospital admission (294/1018 [28.9%] in the BMV group vs 333/1022 [32.6%] in the ETI group; difference, -3.7% [95% CI, -7.7% to 0.3%]) and global survival at day 28 (55/1018 [5.4%] in the BMV group vs 54/1022 [5.3%] in the ETI group; difference, 0.1% [95% CI, -1.8% to 2.1%]) were not significantly different. Complications included difficult airway management (186/1027 [18.1%] in the BMV group vs 134/996 [13.4%] in the ETI group; difference, 4.7% [95% CI, 1.5% to 7.9%]; P = .004), failure (69/1028 [6.7%] in the BMV group vs 21/996 [2.1%] in the ETI group; difference, 4.6% [95% CI, 2.8% to 6.4%]; P < .001), and regurgitation of gastric content (156/1027 [15.2%] in the BMV group vs 75/999 [7.5%] in the ETI group; difference, 7.7% [95% CI, 4.9% to 10.4%]; P < .001). Conclusions and Relevance: Among patients with out-of-hospital cardiorespiratory arrest, the use of BMV compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function, an inconclusive result. A determination of equivalence or superiority between these techniques requires further research. Trial Registration: clinicaltrials.gov Identifier: NCT02327026.

Family presence during cardiopulmonary resuscitation.

BACKGROUND: The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial. METHODS: We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with post-traumatic stress disorder (PTSD)-related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims. RESULTS: In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims. CONCLUSIONS: Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts. (Funded by Programme Hospitalier de Recherche Clinique 2008 of the French Ministry of Health; ClinicalTrials.gov number, NCT01009606.).