Using quality improvement tools to enhance workplace learning in an anaesthesia unit.

BACKGROUND: In healthcare, quality improvement (QI) tools are predominantly used to address human, system and process factors to improve clinical care. We believe that QI tools can also be used to address similar factors in medical education, to facilitate improvement in learning outcomes and competencies for new junior doctors in a postgraduate medical education program in our anaesthesia and critical care unit. METHODS: A stepwise competency checklist was devised to guide the learning and monitor the percentage who had completed the required learning activities and tests at the end of each month. This was tabulated as monthly competency scores, and served as a measure of effectiveness of the education program. QI tools, namely the Fishbone diagram and Pareto chart, were used to identify modifiable root causes and prioritise interventions. RESULTS: Monthly competency scores ranged 30-50% at baseline, and improved to 60-75% after 6 months, with the implementation of a series of QI interventions. CONCLUSION: QI tools were utilised to guide education interventions, with consequent improvement in the monthly competency scores of our junior doctors. Focused improvement cycles that are aligned to learning outcomes are key to the success of using QI tools in medical education.

A BEME systematic review of teaching interventions to equip medical students and residents in early recognition and prompt escalation of acute clinical deteriorations: BEME Guide No. 62.

Background: Current educational interventions and teaching for acute deteriorations seem to address acute care learning in discreet segments. Technology enhanced and team training methodologies are in vogue though well studied in the nursing profession, teaching avenues for junior 'doctors in training' seem to be a lacuna.Aims: The BEME systematic review was designed to (1) appraise the existing published evidence on educational interventions that are intended for 'doctors in training' to teach early recognition and prompt escalation in acute clinical deteriorations (2) to synthesise evidence & to evaluate educational effectiveness.Methodology: The method applied was a descriptive, justification & clarification review. Databases searched included PubMed, PsycINFO, Science Direct and Scopus for original research and grey literature with no restrictions to year or language. Abstract review, full text decisions and data extraction were completed by two primary coders with final consensus by a third reviewer.Results: 5592 titles and abstracts were chosen after removal of 905 duplications. After exclusion of 5555 studies, 37 full text articles were chosen for coding. 22 studies met final criteria of educational effectiveness, relevance to acute care. Educational platforms varied from didactics to blended learning approaches, small group teaching sessions, simulations, live & cadaveric tissue training, virtual environments and insitu team-based training. Translational outcomes with reduction in long term (up to 3-6 years) morbidity & mortality with financial savings were reported by 18% (4/22) studies. Interprofessional training were reported in 41% (9/22) of studies. Recent evidence demonstrated effectiveness of virtual environment and mobile game-based learning.Conclusions: There were significant improvements in teaching initiatives with focus on observable behaviours and translational real patient outcomes. Serious game-based learning and virtual multi-user collaborative environments might enhance individual learners' cognitive deliberate practice. Acute care learning continuum with programmatic acute care portfolios could be a promise of the future.

Inherent variability in airway characteristics of simulation manikins: is it time we standardised assessments of crisis management skills?

Introduction: Learning of simulation-based crisis management skills involves technologically advanced manikins and use of automated scenarios. Progressions in preprogrammed scenarios require finite task completion such as successful airway intubations for achieving optimal learning outcomes aligned to curricular goals. The study was set to explore the existing variability among various simulation manikins in use at our institute for undergraduate medical education. Methods: 56 final-year undergraduate students, who had received prior training in airway management skills, performed intubations on each of the 5 different manikins (56×5=280 intubations). The manikins used were the Human Patient Simulator (HPS), iStan & Emergency Care Simulator (ECS) from CAE Healthcare and Mega Code Kelly (MCK) and Airway Trainer (AWTR) from Laerdal. The students' performances were compared for success rates, ease of intubation, grade of laryngeal visualisation and presence of tooth injury on the manikins, Data from the intubations were cross-tabulated and evaluated by general estimating equation analysis using the Poisson model. Results: iStan had the higher rates of failure to intubate (64.3%). iStan (62.5%) and HPS (57.1%) had statistically significant teeth injury (p<0.0001) compared to other manikins. HPS and AWTR had the least difficult grades of laryngeal visualisation (Cormack Lehane grades 1 and 2), while the most difficult grade of visualisation (Cormack Lehane grades 3 and 4) was reported in ECS (44.6%). Conclusions: Each of the high-technology manikins used in automated scenarios for crisis management teaching and learning has heterogeneity in airway features. Since frequent airway management is a critical component of simulation scenarios, this can affect student performance when these manikins are used for formative and summative high-stakes assessments.

Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: randomized controlled trial.

BACKGROUND: Virtual patient simulation has grown substantially in health care education. A virtual patient simulation was developed as a refresher training course to reinforce nursing clinical performance in assessing and managing deteriorating patients. OBJECTIVE: The objective of this study was to describe the development of the virtual patient simulation and evaluate its efficacy, by comparing with a conventional mannequin-based simulation, for improving the nursing students' performances in assessing and managing patients with clinical deterioration. METHODS: A randomized controlled study was conducted with 57 third-year nursing students who were recruited through email. After a baseline evaluation of all participants' clinical performance in a simulated environment, the experimental group received a 2-hour fully automated virtual patient simulation while the control group received 2-hour facilitator-led mannequin-based simulation training. All participants were then re-tested one day (first posttest) and 2.5 months (second posttest) after the intervention. The participants from the experimental group completed a survey to evaluate their learning experiences with the newly developed virtual patient simulation. RESULTS: Compared to their baseline scores, both experimental and control groups demonstrated significant improvements (P<.001) in first and second post-test scores. While the experimental group had significantly lower (P<.05) second post-test scores compared with the first post-test scores, no significant difference (P=.94) was found between these two scores for the control group. The scores between groups did not differ significantly over time (P=.17). The virtual patient simulation was rated positively. CONCLUSIONS: A virtual patient simulation for a refreshing training course on assessing and managing clinical deterioration was developed. Although the randomized controlled study did not show that the virtual patient simulation was superior to mannequin-based simulation, both simulations have demonstrated to be effective refresher learning strategies for improving nursing students' clinical performance. Given the greater resource requirements of mannequin-based simulation, the virtual patient simulation provides a more promising alternative learning strategy to mitigate the decay of clinical performance over time.

Experiential learning improves the learning and retention of endotracheal intubation.

CONTEXT: Simulators provide an effective platform for the learning of clinical motor skills such as endotracheal intubation, although the optimal learning technique remains unidentified. We hypothesised that, for novices, experiential learning would improve the learning and retention of endotracheal intubation compared with guided learning. METHODS: Year 4 medical students were randomised to either guided or experiential learning. Students in the guided group were taught using the conventional step-by-step technique. Students in the experiential group had to work out the correct technique for intubation on their own. Both groups had further opportunities to intubate manikins and patients during their postings. The students were recalled 3, 6, 9 and 12 months later, and their intubation skills assessed in four major categories: equipment preparation; intubation technique; successful intubation, and placement confirmation. RESULTS: A total of 210 students (107 guided, 103 experiential) participated in the study. At 3 months, 64.5% of the students in the experiential group successfully intubated the manikin, compared with 36.9% in the guided group (P < 0.001). The experiential group also had higher overall scores, signifying quality of intubation attempts, at 3 months (79% versus 70%; P < 0.001). Success rates and overall scores for both groups were comparable at 6 and 9 months, but were better in the experiential group at 12 months. Success rates improved with time, reaching 86% at 12 months. CONCLUSIONS: Novices learned and retained the skill of endotracheal intubation better with experiential learning. This study suggests that experiential learning should be adopted for the teaching of endotracheal intubation and that refresher tuition at 3-monthly intervals will prevent the decay of this skill in infrequent users.

Success of tracheal intubation with intubating laryngeal mask airways: a randomized trial of the LMA Fastrach and LMA CTrach.

BACKGROUND: The LMA CTrach system (The Laryngeal Mask Company, Singapore) is a development of the LMA Fastrach system (The Laryngeal Mask Company, Singapore), with integrated fiberoptic bundles and a detachable liquid crystal display viewer. This randomized study of 271 patients compared tracheal intubation with these two systems. METHODS: In both groups, ventilation was optimized after insertion of the laryngeal mask conduit before proceeding further: intubation with the LMA Fastrach, and optimizing the conduit placement and view and then intubation with the LMA CTrach. The first-attempt and overall success rates of tracheal intubation, and the times required, were recorded. RESULTS: Tracheal intubation was successful on the first attempt in 93.3% of patients with the LMA CTrach and 67.9% of patients with the LMA Fastrach (P < 0.001). The success rates within three attempts were 100% with the LMA CTrach and 96.4% with the LMA Fastrach (P = 0.06). The median (interquartile range) time for the complete tracheal intubation process was 116 (82-156) s with the LMA CTrachand 100 (74-121) s with the LMA Fastrach (P = 0.002). There was no correlation between the grade of conventional laryngoscopy and success of intubation with either system. CONCLUSIONS: The ability to view the glottis and optimize placement of the LMA CTrach under vision enabled a higher first-attempt success rate of tracheal intubation with the LMA CTrach. However, more time is required with the LMA CTrach, there are failed views in some patients, and its cost effectiveness remains unclear.

The impact of experiential learning on NUS medical students: our experience with task trainers and human-patient simulation.

INTRODUCTION: Experiential learning is one of the key methods for effective teaching of medical students. The use of simulation is ideal to achieve this goal. Simulation training allows the learner to be actively involved, and provides realism, self-direction, feedback and practice. We present 2 pilot projects in which the efficacy of experiential learning with simulation is demonstrated. MATERIALS AND METHODS: In the first project, groups of 4 to 6 fourth-year medical students were exposed to common crisis scenarios. Each student took turns to individually handle the situation (in the hot seat), while the rest of the group watched "live" via video-link. A group debrief was done after the completion of all scenarios and learning points were emphasized. A test was conducted shortly after, and the student who managed the same scenario in the hot seat earlier was compared to the rest of the group with respect to crisis recognition, management and diagnosis. In the second project, 36 fourth-year medical students were assigned to learn endotracheal intubation through a directed or experiential method. Students were recalled after 3 months and tested on 4 major categories: preparation, technique, success and ventilation. RESULTS: Students in the hot seat tended to perform better (72% vs. 64%), and were more likely to be the highest scoring student within their group; although this did not reach statistical significance. For the intubation study, students in the experiential group had a higher success rate at 3 months (78% vs. 41%). CONCLUSIONS: Experiential teaching methods with simulation result in better learning of crisis management and endotracheal intubation.

Prediction of excessive bleeding after coronary artery bypass graft surgery: the influence of timing and heparinase on thromboelastography.

OBJECTIVE: To compare the ability of thromboelastography, when done at either 10 or 60 minutes after protamine reversal of heparin, to predict excessive bleeding after coronary artery bypass graft (CABG) surgery and to investigate, with the use of heparinase, whether heparin contamination was responsible for the difference, if any. DESIGN: Prospective study. SETTING: University hospital, single institution. PARTICIPANTS: Patients undergoing elective CABG surgery (n = 40). INTERVENTIONS: Blood samples for thromboelastography and routine coagulation tests were collected before induction of anesthesia and at 10 and 60 minutes after protamine reversal of heparin. Blood loss and blood product use were recorded postoperatively. MEASUREMENTS AND MAIN RESULTS: Of 40 patients undergoing elective CABG surgery, 10 fulfilled the criteria for excessive postoperative bleeding. The sensitivity of thromboelastography to identify patients who bled was better at 60 minutes than at 10 minutes after protamine reversal of heparin (100% v 70%). There was greater specificity (83% v 40% at 10 minutes; 73% v 20% at 60 minutes) and positive predictive value (58% v 28% at 10 minutes; 55% v 29% at 60 minutes) when heparinase was added. At both times, thromboelastography showed only moderate correlation with total blood loss and the use of fresh frozen plasma or platelets or both. Conventional coagulation tests did not predict excessive postoperative bleeding. CONCLUSION: This study suggests that timing and the use of heparinase influence the predictive ability of thromboelastography, but its usefulness as a sole predictor of post-CABG surgery bleeding is limited.