Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study.

RESEARCH PURPOSE: We evaluated the impact of a backboard on chest compression depth during cardiac arrest practice sessions conducted using a high-fidelity mannequin on a standard emergency department stretcher. METHODS: Forty-three health care trainees completed cardiac resuscitation simulations requiring 2 minutes of uninterrupted chest compressions. Twenty-one were randomly allocated to the intervention group in which a backboard was concealed by placement between the stretcher mattress and a top sheet and, 22 were allocated to the control group in which no backboard was placed. The mannequin software automatically recorded mean chest compression depth in 10-second intervals for the 2 minutes of compressions. RESULTS: The backboard group achieved a mean compression depth of 41.2 mm (95% confidence interval, 37.8-44.6). The no-backboard group's mean compression depth was 41.4 mm (95% confidence interval, 38.7-44.2). Most subjects in both groups did not achieve the 50-mm compression depth threshold recommended by the American Heart Association. CONCLUSIONS: Use of a backboard as an adjunct during cardiopulmonary resuscitation of a simulated patient lying on a standard emergency department stretcher did not improve the mean chest compression depth achieved by advanced life support rescuers. Most rescuers did not achieve the minimum compression depth of 50 mm recommended by the American Heart Association.

Gearing up for milestones in surgery: Will simulation play a role?

BACKGROUND: The Consortium of American College of Surgeons-Accredited Education Institutes was created to promote patient safety through the use of simulation, develop new education and technologies, identify best practices, and encourage research and collaboration. METHODS: During the 7th Annual Meeting of the Consortium, leaders from a variety of specialties discussed how simulation is playing a role in the assessment of resident performance within the context of the Milestones of the Accreditation Council for Graduate Medical Education as part of the Next Accreditation System. CONCLUSION: This report presents experiences from several viewpoints and supports the utility of simulation for this purpose.

A Simulation-based Randomized Controlled Study of Factors Influencing Chest Compression Depth.

INTRODUCTION: Current resuscitation guidelines emphasize a systems approach with a strong emphasis on quality cardiopulmonary resuscitation (CPR). Despite the American Heart Association (AHA) emphasis on quality CPR for over 10 years, resuscitation teams do not consistently meet recommended CPR standards. The objective is to assess the impact on chest compression depth of factors including bed height, step stool utilization, position of the rescuer's arms and shoulders relative to the point of chest compression, and rescuer characteristics including height, weight, and gender. METHODS: Fifty-six eligible subjects, including physician assistant students and first-year emergency medicine residents, were enrolled and randomized to intervention (bed lowered and step stool readily available) and control (bed raised and step stool accessible, but concealed) groups. We instructed all subjects to complete all interventions on a high-fidelity mannequin per AHA guidelines. Secondary end points included subject arm angle, height, weight group, and gender. RESULTS: Using an intention to treat analysis, the mean compression depths for the intervention and control groups were not significantly different. Subjects positioning their arms at a 90-degree angle relative to the sagittal plane of the mannequin's chest achieved a mean compression depth significantly greater than those compressing at an angle less than 90 degrees. There was a significant correlation between using a step stool and achieving the correct shoulder position. Subject height, weight group, and gender were all independently associated with compression depth. CONCLUSION: Rescuer arm position relative to the patient's chest and step stool utilization during CPR are modifiable factors facilitating improved chest compression depth.

Simulation in emergency medicine training.

Simulation provides a range of educational tools that have increasingly been incorporated into emergency medicine (EM) curricula. Standardized patients and some partial task trainers, such as intubation heads, have been used for decades. More recently, a growing number of computer-screen simulations, high-fidelity mannequins, and virtual-reality simulators have expanded the number of procedures and conditions, which can be effectively simulated.The Accreditation Council for Graduate Medical Education transitioned to a competency-based assessment of residency programs in 2001 and included simulation as a method for incorporating the 6 core competencies into graduate medical education curricula. Over the past decade, numerous peer-reviewed publications have promoted simulation as an effective educational tool for each of the core competencies.The advanced technology used to operate many current simulators can erroneously become the focus of efforts to create a simulation-based curriculum. Simulation can most effectively be incorporated into EM curricula through the use of time-proven concepts, which start with defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective. In many, but not all, instances, simulation can be the best tool for achieving EM learning objectives.

Improved fourth-year medical student clinical decision-making performance as a resuscitation team leader after a simulation-based curriculum.

OBJECTIVE: To determine the impact of simulation-based instruction on student performance in the role of emergency department resuscitation team leader. METHODS: A randomized, single-blinded, controlled study using an intention to treat analysis. Eighty-three fourth-year medical students enrolled in an emergency medicine clerkship were randomly allocated to two groups differing only by instructional format. Each student individually completed an initial simulation case, followed by a standardized curriculum of eight cases in either group simulation or case-based group discussion format before a second individual simulation case. A remote coinvestigator measured eight objective performance end points using digital recordings of all individual simulation cases. McNemar chi2, Pearson correlation, repeated measures multivariate analysis of variance, and follow-up analysis of variance were used for statistical evaluation. RESULTS: Sixty-eight students (82%) completed both initial and follow-up individual simulations. Eight students were lost from the simulation group and seven from the discussion group. The mean postintervention case performance was significantly better for the students allocated to simulation instruction compared with the group discussion students for four outcomes including a decrease in mean time to (1) order an intravenous line; (2) initiate cardiac monitoring; (3) order initial laboratory tests; and (4) initiate blood pressure monitoring. Paired comparisons of each student's initial and follow-up simulations demonstrated significant improvement in the same four areas, in mean time to order an abdominal radiograph and in obtaining an allergy history. CONCLUSIONS: A single simulation-based teaching session significantly improved student performance as a team leader. Additional simulation sessions provided further improvement compared with instruction provided in case-based group discussion format.

Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial.

STUDY OBJECTIVE: We determine the effect of a simulation-based curriculum on fourth-year medical student test performance and satisfaction during an emergency medicine clerkship. METHODS: This was a randomized controlled study using a crossover design for curriculum format and an anonymous end-of-rotation satisfaction survey. Students were randomized into 2 groups. One group started the rotation with simulation and the other with group discussion. Midrotation, they each crossed over to the opposite format. All students subsequently completed the same multiple choice examination. We assessed paired samples of the number of questions missed for material taught in each format. Students rated satisfaction with a 5-point Likert scale framed as attitude toward simulation compared with group discussion. Scores ranged from 5, signifying strong agreement with a statement, to 1, signifying strong disagreement. RESULTS: Ninety students (99%) completed the multiple choice test. Significantly fewer questions were missed for material presented in simulation format compared with group discussion, with a mean difference per student of 0.7 (95% confidence interval [CI] 0.3 to 1.0; P=.006). This corresponds to mean scores of 89.8% for simulation and 86.4% for group discussion. Eighty-eight (97%) students completed the satisfaction survey. Students rated simulation as more stressful (mean 4.1; 95% CI 3.9 to 4.3), but also more enjoyable (mean 4.5; 95% CI 4.3 to 4.6), more stimulating (mean 4.7; 95% CI 4.5 to 4.8), and closer to the actual clinical setting (mean 4.6; 95% CI 4.4 to 4.7) compared with group discussion. CONCLUSION: A simulation-based curriculum yielded measurable benefits. Students demonstrated a small improvement in learning and were more satisfied with the simulation-based curriculum compared with group discussion.

Medical malpractice: utilization of layered simulation for resident education.

OBJECTIVES: The authors present a novel approach to the use of simulation in medical education with a two-event layered simulation. A patient care simulation with an adverse outcome was followed by a simulated deposition. METHODS: Senior residents in an academic emergency medicine (EM) program were solicited as simulation research volunteers. Other than stating that the research involved adverse outcomes, no identifying information was given. Seven volunteers participated in a simulation involving a forced error (nurse confederate gave an incorrect medication dose). Six weeks later based on the initial simulation, one physician completed a simulated deposition in a teaching conference conducted by a licensed attorney with malpractice experience. The audience, consisting of residents, attendings, and students, watched a recording of the patient care, witnessed the deposition, and evaluated the experience using a 17-question survey with 5-point Likert scales. RESULTS: Participants felt that overall the training program was a useful educational tool (mean +/- standard deviation [SD] Likert score = 4.63 +/- 0.49) that would change aspects of their practice (3.31 +/- 0.85). Participants stated that they would be more careful in their documentation (3.88 +/- 0.60), review high-risk situations with staff (4.00 +/- 0.71), and monitor more carefully for errors (3.95 +/- 0.74). There was increased fear of the litigation process (3.95 +/- 1.18), but participants felt the experience would help improve the risk profile of their practices (3.71 +/- 0.68). CONCLUSIONS: A novel approach to medical education was successful in changing attitudes and provided an expanded educational experience for participants. Layered simulation can be successfully incorporated into educational programs for numerous issues including medical malpractice.

Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements.

INTRODUCTION: Hospital surge capacity is a crucial part of community disaster preparedness planning, which focuses on the requirements for additional beds, equipment, personnel, and special capabilities. The scope and urgency of these requirements must be balanced with a practical approach addressing cost and space concerns. Renewed concerns for infectious disease threats, particularly from a potential avian flu pandemic perspective, have emphasized the need to be prepared for a prolonged surge that could last six to eight weeks. NULL HYPOTHESIS: The surge capacity that realistically would be generated by the cumulative Greater Dayton Area Hospital Association (GDAHA) plan is sufficient to meet the demands of an avian influenza pandemic as predicted by the [US] Centers for Disease Control and Prevention (CDC) models. METHODS: Using a standardized data form, surge response plans for each hospital in the GDAHA were assessed. The cumulative results were compared to the demand projected for an avian influenza pandemic using the CDC's FluAid and FluSurge models. RESULTS: The cumulative GDAHA capacity is sufficient to meet the projected demand for bed space, intensive care unit beds, ventilators, morgue space, and initial personal protective equipment (PPE) use. There is a shortage of negative pressure rooms, some basic equipment, and neuraminidase inhibitors. Many facilities lack a complete set of written surge policies, including screening plans to segregate contaminated patients and staff prior to entering the hospital. Few hospitals have agreements with nursing homes or home healthcare agencies to provide care for patients discharged in order to clear surge beds. If some of the assumptions in the CDC's models are changed to match the morbidity and mortality rates reported from the 1918 pandemic, the surge capacity of GDAHA facilities would not meet the projected demand. CONCLUSIONS: The GDAHA hospitals should test their regional distributors' ability to resupply PPE for multiple facilities simultaneously. Facilities should retrofit current air exchange systems to increase the number of potential negative pressure rooms and include such designs in all future construction. Neuraminidase inhibitor supplies should be increased to provide treatment for healthcare workers exposed in the course of their duties. Each hospital should have a complete set of policies to address the special considerations for a prolonged surge. Additional capacity is required to meet the predicted demands of a threat similar to the 1918 pandemic.

Morbidity of hurricane Frederic

On September 12, 1979, Hurricane Frederic struck the Gulf Coasts of Mississippi and Alabama. A retrospective review of emergency department logs for a three-week period surrounding the storm was conducted to determine the amount and type of back up needed for an emergency department to cope with the results of such a disaster. There was a significant increase in the number of patients presenting to the emergency depatment for professionals skilled in outpatient trauma management. The nature of hurricanes is discussed, as are specific items to be considered in disaster planning for areas subjected to these storms(AU)