Faculty Bibliography

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Deep exploration of a complex health care issue in pediatrics might be hindered by the sensitive or infrequent nature of a particular topic in pediatrics. Health care simulation builds on constructivist theories to guide individuals through an experiential cycle of action, self-reflection, and open discussion, but has traditionally been applied to the educational domain in health sciences. Leveraging the emotional activation of a simulated experience, investigators can prime participants to engage in open dialogue for the purposes of qualitative research. The framework of simulation-primed qualitative inquiry consists of 3 main iterative steps. First, researchers determine applicability by consideration of the need for an exploratory approach and potential to enrich data through simulation priming of participants. Next, careful attention is needed to design the simulation, with consideration of medium, technology, theoretical frameworks, and quality to create simulated reality relevant to the research question. Finally, data collection planning consists of a qualitative approach and method selection, with particular attention paid to psychological safety of subjects participating in the simulation. A literature review revealed 37 articles that used this newly described method across a variety of clinical and educational research topics and used a spectrum of simulation modalities and qualitative methods. Although some potential limitations and pitfalls might exist with regard to resources, fidelity, and psychological safety under the auspices of educational research, simulation-primed qualitative inquiry can be a powerful technique to explore difficult topics when subjects might experience vulnerability or hesitation.

Introduction/UNASSIGNED:High-fidelity mannequin-based simulation is frequently used to compliment medical student education during clinical clerkships. However, psychiatric educators have not broadly adopted this modality, focusing rather on standardized patient actors. We developed and delivered a simulation case involving a patient with alcohol withdrawal and lithium toxicity followed by a debriefing session to medical students at the end of their psychiatric clerkship. Methods/UNASSIGNED:The case involves a 40-year-old male truck driver with a history of bipolar disorder who presents to the emergency room after a truck accident. The patient is in alcohol withdrawal, which responds to benzodiazepines. A workup reveals that the patient also has lithium toxicity related to the co-ingestion of lithium and naproxen for pain. Participants learn to evaluate and treat alcohol withdrawal, consider medical comorbidities and legal consequences, and complete a brief intervention for substance use. This case requires a simulation mannequin. Results/UNASSIGNED:) on a question about enjoyment, and 3.93 on a question about confidence with evaluation and treatment of patients in alcohol withdrawal. Discussion/UNASSIGNED:Psychiatric education currently underutilizes mannequin-based simulation compared to other medical disciplines. Mannequin simulation is feasible and effective in psychiatric education, especially in cases involving medical complexity, as shown in this novel case involving a patient with alcohol withdrawal and lithium toxicity.

In situ simulation (ISS), a point of care training strategy that occurs within the patient care environment involving actual healthcare team members, provides additional benefits to centre-based simulation. ISS can serve several roles within emergency medicine (EM): improves provider/team performance, identifies and mitigates threats to patient safety and improves systems and infrastructure. The effective use of ISS fosters inter-professional team training and a culture of safety essential for high performance EM teams and resilient systems. Using a case example, this article addresses the uses of ISS in EM, strategies for implementation and mitigation strategies for ED-specific challenges.

INTRODUCTION: While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design. METHODS: Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs. RESULTS: One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training. CONCLUSION: A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

Background: While treating potentially violent patients in the ED, both patients and staff may be subject to unintentional injury. Preliminary studies have shown that a team-based approach with targeted staff training have significant positive outcomes in mitigating violence in health care settings. Objectives: The goal for our study was to show that a simulationbased interdisciplinary curriculum would improve attitudes and staff safety toward management of patient aggression in the ED. Methods: Formal roles and responsibilities for each member of the care team including positioning during restraint placement were predefined in conjunction with ED leadership. EM residents, nurses and hospital police officers were assigned to interdisciplinary teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement. Next, we conducted two simulation scenarios using standardized participants and structured debriefing. The study consisted of a survey-based design comparing pre- and postintervention responses to assess changes in staff attitudes. We utilized the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs and performed analysis with the Student paired t-test. Results: 162 ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/ interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively, Figure 479). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented including the creation of an ED-based interprofessional crisis management alert and response protocol. Conclusion: A structured interdisciplinary simulation-based intervention was successful in improving ED staff attitudes toward caring for agitated patients. Attitudes towards managing them remained conflicted. Ongoing work includes a follow-up qualitative study utilizing staff focus groups and tracking patient outcomes. (Figure Presented)

Background: Airway management skills are an essential part of EM resident training. They are recognized as a key ACGME competency milestone. All EM trainees must achieve mastery in performing basic support of oxygenation and ventilation until a definitive airway can be secured. Junior residents frequently overlook these important fundamental skills. In our residency, no formalized program was in place to assess first year residents' airway skill retention or identify potential skill improvement and remediation. Objectives: The goal of our study is to demonstrate improvements in PGY1 residents' comfort with basic airway management skills using an immersive simulation-based curriculum. Methods: Residents participated in three high fidelity simulations. The scenarios required identification of risk factors for a difficult airway, demonstration of effective BVM skills, patient repositioning, and use of nasal trumpets, oral airways and PEEP valve if necessary. The cases included a patient with methadone overdose where naloxone was not yet available, a patient with pulmonary edema requiring ventilatory support, and a MVC patient requiring maintenance of C-spine immobilization during airway management. We utilized a survey-based design with pre- and post-session distribution assessing trainees' comfort with basic airway skills. The survey consisted of 5-point Likertscale questions, and we employed the paired Student t-test for data analysis. Results: A total of 13 PGY1 residents completed the one-on-one didactic session. All residents universally chose "strongly agree" when asked if the simulations were helpful. Instructors responded that the residents' airway techniques improved at the completion of the scenarios. The trainees reported significantly higher confidence in basic airway skills after training (mean score +1.13, p<0.005). During subsequent feedback, residents identified how cognitive stress impaired information retrieval, decision-making, and in some, fine motor skills. Adherence to an airway checklist mitigated these potential safety threats. Conclusion: An immersive simulation-based curriculum significantly improved PGY1 residents in their comfort level toward basic airway skills. As a secondary objective, program leadership was also able to assess and complete the level 1 ACGME milestones for airway skills for all PGY1 session attendees

Background: Team training initiatives have been implemented in hospitals nationwide in response to patient safety reports citing teamwork and communication failures as the most frequent contributors of errors. TeamSTEPPSTM is an evidence-based teamwork training system designed to improve patient outcomes by enhancing communication and skills of health care professionals. We developed a novel ED team training course based on TeamSTEPPSTM principles as a pilot curriculum for the Bellevue Hospital ED. Objectives: This study's purpose was to address the gap in current health care education at the Bellevue ED, by creating an interprofessional curriculum for nursing and residents focused on teamwork and communication utilizing simulation based education. We hypothesized that there would be a significant improvement in the staff's attitudes toward teamwork after the intervention. Methods: The team T\training course was conducted via a simulation center based training session over three hours consisting of an introductory didactic session, two simulation scenarios, video and self-observed evaluation utilizing the TeamSTEPPSTM Team Performance Observation Tool. Subjects consisted of EM nurses and residents organized into teams of six participants. We used the previously validated TeamSTEPPSTM Teamwork Attitudes Questionnaire with a five-point Likert scale model, designed to measure individual attitudes related to core components of teamwork, and distributed them in person pre- and post-session. Data analysis was performed using the Student's t-test to compare scores. Results: Over seven sessions from July to September 2012, a total of 76 nurses and residents participated in the course with 100% survey response. Seven of the pre-session and ten of the post-session surveys were disqualified as dictated in the protocol. Four of the five teamwork construct question groups had significant improvements in scores: 6.4%, 2.8%, 4.0%, and 4.0% for Team Structure, Leadership, Situation Monitoring, and Mutual Suppo!

BACKGROUND: The purpose of this study was to systematically examine the impact of insurance status on access to and utilization of elective specialty hand surgical care. We hypothesized that patients with Medicaid insurance or those without insurance would have greater difficulty accessing care both in obtaining local surgical care and in reaching a tertiary center for appointments. METHODS: This retrospective cohort study included all new patients with orthopaedic hand problems (n = 3988) at a tertiary center in a twelve-month period. Patient insurance status was categorized and clinical complexity was quantified on an ordinal scale. The relationships of insurance status, clinical complexity, and distance traveled to appointments were quantified by means of statistical analysis. An assessment of barriers to accessing care stratified with regard to insurance status was completed through a survey of primary care physicians and an analysis of both patient arrival rates and operative rates at our tertiary center. RESULTS: Increasing clinical complexity significantly correlated (p < 0.001) with increasing driving distance to the appointment. Patients with Medicaid insurance were significantly less likely (p < 0.001) to present with problems of simple clinical complexity than patients with Medicare and those with private insurance. Primary care physicians reported that 62% of local surgeons accepted patients with Medicaid insurance and 100% of local surgeons accepted patients with private insurance. Forty-four percent of these primary care physicians reported that, if patients who were underinsured (i.e., patients with Medicaid insurance or no insurance) had been refused by community surgeons, they were unable to drive to our tertiary center because of limited personal resources. Patients with Medicaid insurance (26%) were significantly more likely (p < 0.001) to fail to arrive for appointments than patients with private insurance (11%), with no-show rates increasing with the greater distance required to reach the tertiary center. CONCLUSIONS: Economically disadvantaged patients face barriers to accessing specialty surgical care. Among patients with Medicaid coverage or no insurance, local surgical care is less likely to be offered and yet personal resources may limit a patient's ability to reach distant centers for non-emergency care.