Collaborative Use of Lung Mechanics Simulation for Testing and Iterative Design for Three Emergency Use Ventilation Device Projects.

SUMMARY STATEMENT: We describe our collaboration with engineering, clinical, and simulation colleagues to use a lung simulator (IngMar Medical ASL 5000) to aid in the development of 3 open-source ventilation devices for patients with COVID-19.Twenty-nine test conditions were created by programming software lung models of varying disease severity in the ASL 5000 to test basic functionality, safety features, and compliance with regulatory requirements for emergency use authorization for the 3 projects' prototypes. More than 200 simulations were performed, with the design team present to enable rapid troubleshooting and design iteration in real time.Working with 3 separate simultaneous ventilation device projects allowed us to rapidly learn from each, improving our ability to successfully collaborate with the different design/build teams.This project illustrates the role of simulation in facilitating collaborative innovation in health care, both in emergency and everyday settings that extend beyond the COVID-19 pandemic.

Operating Room In Situ Interprofessional Simulation for Improving Communication and Teamwork.

BACKGROUND: Effective teamwork and communication are correlated with improved patient care quality and outcomes. The belief that each team member contributes to excellent patient care in the operating room (OR) leads to a more productive work environment. However, poor teamwork and communication lead to poorer OR outcomes. We qualitatively and quantitatively explored perspectives of three OR professions (nursing, anesthesiology, and surgery) on teamwork and communication in the OR preinterprofessional and postinterprofessional in situ OR simulation. MATERIALS AND METHODS: One-on-one semi-structured interviews were conducted; 14 pre-in situ simulations during July-October 2017 (three surgery, four anesthesiology, and six nursing staff), and 10 post-in situ simulations during August-November 2017 (five surgery, four anesthesiology, and one nursing staff). Themes were identified inductively to create a codebook. The codebook was used to consensus code all interviews. This analysis informed the development of a quantitative survey distributed to all contactable interviewees (22). RESULTS: Presimulation and postsimulation interview participants concurred on teamwork and communication importance, believed communication to be key to effective teamwork, and identified barriers to communication: lack of cordiality, lack of engagement from other staff, distractions, role hierarchies, and lack of familiarity with other staff. The large majority of survey participants-all having participated in simulations-believed they could use effective communication in their workplace. CONCLUSIONS: Establishing methods for improving and maintaining the ability of OR professionals to communicate with each other is imperative for patient safety. Effective team communication leads to safe and successful outcomes, as well as a productive and supportive OR work environment.

Research regarding debriefing as part of the learning process.

INTRODUCTION: Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills. A review of existing research and a process for identifying future opportunities was undertaken. METHODS: A selective critical review of the literature on debriefing in simulation-based education was done. An iterative process of analysis, gathering input from audience participants, and consensus-based synthesis was conducted. RESULTS: Research is sparse and limited in presentation for all important topic areas where debriefing is a primary variable. The importance of a format for reporting data on debriefing in a research context was realized and a "who, when, where, what, why" approach was proposed. Also, a graphical representation of the characteristics of debriefing studies was developed (Sim-PICO) to help guide simulation researchers in appropriate experimental design and reporting. CONCLUSION: A few areas of debriefing practice where obvious gaps that deserve study were identified, such as comparing debriefing techniques, comparing trained versus untrained debriefers, and comparing the effect of different debriefing venues and times. A model for publication of research data was developed and presented which should help researchers clarify methodology in future work.

Leadership lessons from military education for postgraduate medical curricular improvement.

BACKGROUND: quality medical education includes both teaching and learning of data-driven knowledge, and appropriate technical skills and tacit behaviours, such as effective communication and professional leadership. But these implicit behaviours are not readily adaptable to traditional medical curriculum models. This manuscript explores a medical leadership curriculum informed by military education. CONTEXT: our paediatric anaesthesia residents expressed a strong desire for more leadership opportunity within the training programme. Upon exploration, current health care models for leadership training were limited to short didactic presentations or lengthy certificate programmes. We could not find an appropriate model for our 1-year fellowship. INNOVATION: in collaboration with the US Naval Academy, we modified the 'Leadership Education and Development Program' curriculum to introduce daily and graduated leadership opportunities: starting with low-risk decision-making tasks and progressing to independent professional decision making and leadership. Each resident who opted into the programme had a 3-month role as team leader and spent 9 months as a team member. At the end of the first year of this curriculum both quantitative assessment and qualitative reflection from residents and faculty members noted significantly improved clinical and administrative decision making. The second-year residents' performance showed further improvement. IMPLICATIONS: medical education has long emphasised subject-matter knowledge as a prime focus. However, in competency-based medical education, new curriculum models are needed. Many helpful models can be found in other professional fields. Collaborations between professional educators benefit the students, who are learning these new skills, the medical educators, who work jointly with other professionals, and the original curriculum designer, who has an opportunity to reflect on the strengths and weaknesses of his or her model.

Use of medical simulation to explore equipment failures and human-machine interactions in anesthesia machine pipeline supply crossover.

BACKGROUND: High-fidelity medical simulation can be used to explore failure modes of technology and equipment and human-machine interactions. We present the use of an equipment malfunction simulation scenario, oxygen (O(2))/nitrous oxide (N(2)O) pipeline crossover, to probe residents' knowledge and their use of anesthetic equipment in a rapidly escalating crisis. METHODS: In this descriptive study, 20 third-year anesthesia residents were paired into 10 two-member teams. The scenario involved an Ohmeda Modulus SE 7500 anesthetic machine with a Datex AS/3 monitor that provided vital signs and gas monitoring. Before the scenario started, we switched pipeline connections so that N(2)O entered through the O(2) pipeline and vice versa. Because of the switched pipeline, the auxiliary O(2) flowmeter delivered N(2)O instead of O(2). Two expert, independent raters reviewed videotaped scenarios and recorded the alarms explicitly noted by participants and methods of ventilation. RESULTS: Nine pairs became aware of the low fraction of inspired O(2) (Fio(2)) alarm. Only 3 pairs recognized the high fraction of inspired N(2)O (Fin(2)o) alarm. One group failed to recognize both the low Fio(2) and the high Fin(2)o alarms. Nine groups took 3 or more steps before instigating a definitive route of oxygenation. Seven groups used the auxiliary O(2) flowmeter at some point during the management steps. CONCLUSIONS: The fact that so many participants used the auxiliary O(2) flowmeter may expose machine factors and related human-machine interactions during an equipment crisis. Use of the auxiliary O(2) flowmeter as a presumed external source of O(2) contributed to delays in definitive treatment. Many participants also failed to notice the presence of high N(2)O. This may have been, in part, attributable to 2 facts that we uncovered during our video review: (a) the transitory nature of the "high N(2)O" alert, and (b) the dominance of the low Fio(2) alarm, which many chose to mute. We suggest that the use of high-fidelity simulations may be a promising avenue to further examine hypotheses related to failure modes of equipment and possible management response strategies of clinicians.

Patient simulation: a literary synthesis of assessment tools in anesthesiology.

High-fidelity patient simulation (HFPS) has been hypothesized as a modality for assessing competency of knowledge and skill in patient simulation, but uniform methods for HFPS performance assessment (PA) have not yet been completely achieved. Anesthesiology as a field founded the HFPS discipline and also leads in its PA. This project reviews the types, quality, and designated purpose of HFPS PA tools in anesthesiology. We used the systematic review method and systematically reviewed anesthesiology literature referenced in PubMed to assess the quality and reliability of available PA tools in HFPS. Of 412 articles identified, 50 met our inclusion criteria. Seventy seven percent of studies have been published since 2000; more recent studies demonstrated higher quality. Investigators reported a variety of test construction and validation methods. The most commonly reported test construction methods included "modified Delphi Techniques" for item selection, reliability measurement using inter-rater agreement, and intra-class correlations between test items or subtests. Modern test theory, in particular generalizability theory, was used in nine (18%) of studies. Test score validity has been addressed in multiple investigations and shown a significant improvement in reporting accuracy. However the assessment of predicative has been low across the majority of studies. Usability and practicality of testing occasions and tools was only anecdotally reported. To more completely comply with the gold standards for PA design, both shared experience of experts and recognition of test construction standards, including reliability and validity measurements, instrument piloting, rater training, and explicit identification of the purpose and proposed use of the assessment tool, are required.

Monitoring during sedation given by non-anaesthetic doctors.

Conscious sedation is routinely performed by non-anaesthetic doctors. Although guidelines exist to help promote patient safety, it is not clear how stringently these are adhered to. We circulated a questionnaire to non-anaesthetic doctors in training to assess sedation practices. A response rate of 79% (111/140) was achieved. Results showed that 70% of respondents used data recording sheets and/or had protocols for recovery and discharge. In all, 88% of procedures were performed in the presence of an assistant; 82% of respondents used pulse oximetry; 80% used non-invasive blood pressure monitoring; 53% used ECG monitoring; and none used capnography. Of respondents, 29% were Advanced Cardiac Life Support (ACLS) certified; and 22% reported an adverse event. Two respondents experienced adverse events that required the assistance of an anaesthetist. The practice of sedation is not without risk, and doctors involved in the practice should be aware of, and adhere to, appropriate guidelines.