Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli Board of Anesthesiologists.

BACKGROUND: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODS A simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTS During the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONS Senior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study.

Simulation-based objective assessment discerns clinical proficiency in central line placement: a construct validation.

BACKGROUND: Central venous catheterization (CVC) is associated with patient risks known to be inversely related to clinician experience. We developed and evaluated a performance assessment tool for use in a simulation-based central line workshop. We hypothesized that instrument scores would discriminate between less experienced and more experienced clinicians. METHODS: Participants included trainees enrolled in an institutionally mandated CVC workshop and a convenience sample of faculty attending physicians. The workshop integrated several experiential learning techniques, including practice on cadavers and part-task trainers. A group of clinical and education experts developed a 15-point CVC Proficiency Scale using national and institutional guidelines. After the workshop, participants completed a certification exercise in which they independently performed a CVC in a part-task trainer. Two authors reviewed videotapes of the certification exercise to rate performance using the CVC Proficiency Scale. Participants were grouped by self-reported CVC experience. RESULTS: One hundred and five participants (92 trainees and 13 attending physicians) participated. Interrater reliability on a subset of 40 videos was 0.71, and Cronbach a was 0.81. The CVC Proficiency Scale Composite score varied significantly by experience: mean of 85%, median of 87% (range 47%-100%) for low experience (0-1 CVCs in the last 2 years, n = 27); mean of 88%, median of 87% (range 60%-100%) for moderate experience (2-49 CVCs, n = 62); and mean of 94%, median of 93% (range 73%-100%) for high experience (> 49 CVCs, n = 16) (P = .02, comparing low and high experience). CONCLUSIONS: Evidence from multiple sources, including appropriate content, high interrater and internal consistency reliability, and confirmation of hypothesized relations to other variables, supports the validity of using scores from this 15-item scale for assessing trainee proficiency following a central line workshop.

MOR: a simulation-based assessment centre for evaluating the personal and interpersonal qualities of medical school candidates.

CONTEXT: Medical school admissions traditionally rely heavily on cognitive variables, with non-cognitive measures assessed through interviews only. In recognition of the unsatisfactory reliability and validity of traditional interviews, medical schools are increasingly exploring alternative approaches that can provide improved measures of candidates' personal and interpersonal qualities. METHODS: An innovative assessment centre (MOR [Hebrew acronym for 'selection for medicine']) was designed to measure candidates' personal and interpersonal attributes. Three assessment tools were developed: behavioural stations, including encounters with simulated patients and group tasks; an autobiographical questionnaire, and a judgement and decision-making questionnaire. Candidates were evaluated by trained raters on four qualities: interpersonal communication; ability to handle stress; initiative and responsibility, and self-awareness. RESULTS: In the years 2004-05, the 588 medical school candidates with the highest cognitive scores were tested; this resulted in a change of approximately 20% in the cohort of accepted students compared with previous admission criteria. Internal consistency ranged from 0.80 to 0.88; inter-rater reliability ranged from 0.62 to 0.77 for the behavioural stations and from 0.72 to 0.95 for the questionnaires; test-retest score correlation was 0.7. The correlation between candidates' MOR scores and cognitive scores approached zero, reflecting the value of MOR in the screening process. Feedback from participants indicated that MOR was perceived as fair and appropriate for medical school screening. DISCUSSION: MOR is a reliable tool for measuring non-cognitive attributes in medical school candidates. It has high content and face validity. Furthermore, its implementation conveys the importance of maintaining humanist characteristics in the medical profession to students and faculty staff.

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

BACKGROUND: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. METHODS: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training. RESULTS: The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator. CONCLUSIONS: Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.

Domestic violence: a national simulation-based educational program to improve physicians' knowledge, skills and detection rates.

BACKGROUND: Although physicians are in a unique position to identify and report domestic violence (DV), detection rates are poor. AIM: To develop a national DV experiential training program, based on standardized patients (SPs), to improve knowledge, skills and detection rates among physicians. METHODS: The program was initiated by the Israeli Ministry of Health and took place at the Israel Center of Medical Simulation (MSR). Three one-day workshops for physicians were developed, each focusing on intimate partner violence, elder abuse or child abuse. Outcome measures were perceived capabilities, reported case management, and perceived intervention barriers, as obtained by self-assessment questionnaires at baseline and within a follow-up period of six months. RESULTS: A total of 150 participants took part in 15 workshops. Perception of knowledge and skills, routine screening frequency and reported case management all demonstrated significant improvement. A clear trend to elevation in detection, evaluation and referral rates was found. Ranking of intervention barriers was compared with baseline values and lack of knowledge, lack of skills and psychological difficulties diminished significantly. CONCLUSIONS: An SP-based experiential DV training program for physicians improved perceived capabilities and overall management of DV cases and reduced intervention barriers in a follow-up period of six months.

Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists.

OBJECTIVE: To evaluate the impact of simulation-based education on patient safety during pediatric procedural sedation. DESIGN: A prospective, observational, single-blind, controlled study of pediatric procedural sedation outside the operating room. SETTING: Two university teaching hospitals in Israel. PARTICIPANTS: Nonanesthesiologists, with or without training in simulation-based education on patient safety, who routinely perform procedural sedation outside the operating room. These comprise full-time pediatricians practicing emergency medicine and a cohort of pediatric gastroenterologists. INTERVENTION: The study investigators used the internally developed, 9-criteria Sedation Safety Tool to observe and evaluate nonanesthesiologists who were trained in sedation safety and compared their performance with that of colleagues who did not receive similar training. OUTCOME MEASURE: For each of the 9 criteria on the evaluation form, odds ratios and 95% confidence intervals were calculated to compare the actions of the individuals in the 2 study groups. RESULTS: Thirty-two clinicians were evaluated. Half of the physicians were graduates of the simulation-based sedation safety course. Significant differences in performance pertaining to patient safety were found between those physicians who did and those who did not complete simulation-based training. CONCLUSIONS: Pediatric procedural sedations conducted by simulator-trained nonanesthesiologists were safer. The simulation-based sedation safety course enhanced physician performance during pediatric procedural sedation.

Credentialing and certifying with simulation.

Assessment and evaluation are integral parts of any educational and training process, and students at all levels of training respond by studying more seriously for the parts of the course or training that are assessed. To promote and enhance effective learning successfully, simulation and other teaching methods should be both formative and summative, because the ultimate goal is to ensure professional competence. This article describes a model of medical competence, and focuses on the use of medical simulation in assessment and evaluation of different levels of clinical competence using examples from experience.

The Israel Center for Medical Simulation: a paradigm for cultural change in medical education.

Simulation-based medical education (SBME) is a rapidly growing field, as is illustrated by the increased development of simulation centers worldwide. SBME is becoming a powerful force in addressing the need to increase patient safety through quality-care training. Recognizing the benefits of SBME, increasing numbers of bodies involved in medical and health care education and training are establishing simulation centers worldwide. The general model of most facilities focuses on a single simulation modality or a specific branch of medicine or health care, limiting their overall impact on patient safety and quality of care across the health care systems. MSR, the Israel Center for Medical Simulation, is a comprehensive, national, multimodality, multidisciplinary medical simulation center dedicated to enhancing hands-on medical education, performance assessment, patient safety, and quality of care by improving clinical and communication skills. The center uses an "error-driven" educational approach, which recognizes that errors provide an opportunity to create a unique beneficial learning experience. The authors present the Israeli experience as an alternative model, and describe the impact of the MSR model on the Israeli medical community during four years of activity. They also describe the opportunities this model has opened towards changing the culture of medical education and patient safety within Israel Although this model may require modification when implemented in other medical systems, it highlights important lessons regarding the power of SBME in triggering and bringing about cultural changes in traditional medical education.

Exogenous influences on task set activation in task switching.

To explore the effect of exogenous processes on cognitive control, we used a cueing task-switching paradigm with two spatial judgement tasks and added an irrelevant colour attribute to the task-relevant spatial attribute of the target. The colour was not related to any specific Stimulus-Response relation in the tasks. A correlation was created between stimulus colour and task identity. This correlation was strong but imperfect in Experiment 1 and perfect in Experiment 2. As a result of the colour-task correlation, stimuli contained redundant information about task identity. By changing the correlation pattern every few blocks we caused this information to be sometimes invalid. In both experiments, performance was worse when the information carried by the target was invalid than when it was valid. However, this effect was exclusive to conditions with short task preparation time. By comparing performance with a control group, which had no colour-task correlation (in Experiment 2) we established that the colour manipulation did not cause a qualitative change in preparation strategy, and that the exogenous effect was stronger in switch trials than in repetition trials. We conclude that exogenous processes that are related to task set affect performance primarily if they are presented before endogenous processes of task set preparation have been launched.

Advance preparation and stimulus-induced interference in cued task switching: further insights from BOLD fMRI.

To switch from one cognitive task to another is thought to rely on additional control effort being indicated by performance costs relative to repeating the same task. This switch cost can be reduced by advance task preparation. In the present experiment the nature of advance preparation was investigated by comparing a situation where an explicit task cue was presented 2000 ms in advance of the target stimulus (CTI-2000) with a situation where cue and target were presented in close succession (CTI-100). We mapped the blood-oxygenation-level-dependent (BOLD) activation correlates of switch-related control effort and advance task preparation to test alternative explanations why advance preparation is reducing switch costs. A previously reported control-related cortical network of frontal and parietal brain areas emerged that was more strongly activated for switching between tasks. However, this was true exclusively for CTI-100 where no advance task preparation was possible. At CTI-2000 these same brain areas were equally engaged in both switch and repeat trials. For some of these areas, this common activation was time-locked to the presentation of both the cue as well as the target. Other areas were exclusively associated with target processing. The overall pattern of results suggests that advance task preparation is a common process of pre-activating (cue-locked activation) the currently relevant task set which does not face interference from a persisting N - 1 task set. During target processing the same brain areas are re-engaged (subsequent target-locked activation) to apply the pre-activated task set. Though being common to repeat and switch trials, advance preparation has a differential benefit for switch trials. This is because the instructed task set has time to settle into a stable state, thus becoming resistant against disruption from the previous task set, which is retrieved by the current target stimulus.

Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care.

In this prospective study, we used two full-scale prehospital trauma scenarios (severe chest injury and severe head injury) and checklists of specific actions, reflecting essential actions for a safe treatment and successful outcome, were used to assess performance of postinternship physician graduates of the Advanced Trauma Life Support (ATLS) course. In the first 36 participants, simulated training followed basic training in airway and breathing management, whereas in the next 36 participants, 45 min of simulative training in airway management using the Air-Man simulator (Laerdal, Norway) were added before performing the study scenarios. The content of training was based on common mistakes performed by participants of the first group. After the change in training, the number of participants not performing cricoid pressure or not using medication during intubation decreased from 55% (20 of 36) to 8% (3 of 36) and from 42% (15 of 36) to 11% (4 of 36), respectively (P < 0.05). The number of participants not holding the tube properly before fixation decreased from 28% (10 of 36) to 0% (0 of 36) (P < 0.05). In the severe head trauma scenario, performed by 15 of 36 participants in each group, the incidence of mistakes in the management of secondary airway or breathing problems after initial intubation decreased from 60% (9 of 15) to 0% (0 of 15) (P < 0.05). The present study highlights problems in prehospital trauma management, as provided by the ATLS course. It seems that graduates may benefit from simulation-based airway and breathing training. However, clinical benefits from simulation-based training need to be evaluated.

On the origins of the task mixing cost in the cuing task-switching paradigm.

Poorer performance in conditions involving task repetition within blocks of mixed tasks relative to task repetition within blocks of single task is called mixing cost (MC). In 2 experiments exploring 2 hypotheses regarding the origins of MC, participants either switched between cued shape and color tasks, or they performed them as single tasks. Experiment 1 supported the hypothesis that mixed-tasks trials require the resolution of task ambiguity by showing that MC existed only with ambiguous stimuli that afforded both tasks and not with unambiguous stimuli affording only 1 task. Experiment 2 failed to support the hypothesis that holding multiple task sets in working memory (WM) generates MC by showing that systematic manipulation of the number of stimulus-response rules in WM did not affect MC. The results emphasize the role of competition management between task sets during task control.

Equivalence of cognitive processes in brain imaging and behavioral studies: evidence from task switching.

A growing number of studies on the higher-order cognitive functions of the human brain use brain-imaging techniques, such as functional magnetic resonance imaging (fMRI). For the validity and generality of fMRI results, it is important that the relevant cognitive processes are equivalent to those functioning in typical settings used in behavioral research. This equivalence could be, for example, endangered by different spatial frames of reference when lying in the scanner. In the present study, we tested whether the cognitive processes, as reflected in behavioral data in brain-imaging settings, are indeed functionally equivalent to those reflected in "purely" behavioral settings. To this end, we used a task-switching paradigm with a spatial component, increasing the likelihood to find effects of experimental setting. We compared the data of three different groups that only differed in testing environments (real, operating fMRI vs simulated fMRI vs standard behavioral with upright position of participants) but used otherwise strictly equivalent experimental conditions. Of importance for our validation purposes, unlike previous studies, we included a group with a behavioral setting, and we tested whether we would replicate a nontrivial, complex three-way interaction across all three groups. We replicated the predicted complex data pattern in all groups, suggesting functional equivalence of the underlying cognitive processes. We also found strongly increased reaction time (RT) levels in the two fMRI groups. We attribute this increase to unspecific distracting factors affecting late motor processes and discuss potential methodological implications of this increased baseline RT in the scanner.

When the same response has different meanings: recoding the response meaning in the lateral prefrontal cortex.

The ability to adapt our behavioral repertoire to different situations and tasks is crucial for our behavioral control. Since the same motor behavior can have different meanings in different task situations, we often have to change the meaning of our responses when we get into a different task context. In a functional MRI experiment we manipulated this response recoding process. Subjects were required to execute two simple spatial tasks in a task switching paradigm. In one condition both tasks required the same set of responses, hence each response had two different meanings depending on the relevant task (bivalent condition). In the other condition subjects used a separate set of responses for each task (univalent condition). While subjects were required to recode the meaning when switching from one task to the next in the bivalent condition, response recoding was not required in the univalent condition. We demonstrate that the lateral prefrontal cortex is involved in recoding of response meaning. These results extend previous assumptions on the role of the prefrontal cortex in behavioral control.