Simulation to develop tomorrow's medical registrar

A multidisciplinary simulation programme to improve advance care planning skills and engagement across primary and secondary care

BACKGROUND

In the context of an ageing population, many healthcare professionals have limited experience and confidence in having necessary advance care planning (ACP) conversations.

METHODS

We conducted nine half-day simulation sessions, using professional actors. One-hundred and thirty-two participants attended from multidisciplinary backgrounds across primary and secondary care.

RESULTS

Following the course, 90.2% felt confident or very confident initiating conversations, compared with 14.4% beforehand. Understanding of when ACP is appropriate also increased from 70% to 100%. Post-course, 98% of participants stated that they would be more likely to initiate an ACP. Three months later, 86% had a sustained change in practice. All participants said they would recommend this simulation course and multidisciplinary approach.

CONCLUSION

Multidisciplinary simulation training is an effective way to teach ACP to doctors, nurses and allied healthcare professionals. The simulation was shown to improve participant understanding, confidence and reduce barriers to discussions, both immediately and 3 months later.

Evaluation of a Prehospital Rotation by Senior Residents: A Web-Based Survey

The added value of prehospital emergency medicine is usually assessed by measuring patient-centered outcomes. Prehospital rotations might however also help senior residents acquire specific skills and knowledge. To assess the perceived added value of the prehospital rotation in comparison with other rotations, we analyzed web-based questionnaires sent between September 2011 and August 2020 to senior residents who had just completed a prehospital rotation. The primary outcome was the perceived benefit of the prehospital rotation in comparison with other rotations regarding technical and non-technical skills. Secondary outcomes included resident satisfaction regarding the prehospital rotation and regarding supervision. A pre-specified subgroup analysis was performed to search for differences according to the participants’ service of origin (anesthesiology, emergency medicine, or internal medicine). The completion rate was of 71.5% (113/158), and 91 surveys were analyzed. Most senior residents found the prehospital rotation either more beneficial or much more beneficial than other rotations regarding the acquisition of technical and non-technical skills. Anesthesiology residents reported less benefits than other residents regarding pharmacological knowledge acquisition and confidence as to their ability to manage emergency situations. Simulation studies should now be carried out to confirm these findings.

Medical emergency team training: needs assessment, feedback and learning objectives

BACKGROUND

There are no published studies assessing learning needs and attitudes prior to attending a medical emergency team (MET) education programme.

AIMS

To conduct a learning needs assessment of MET education programme participants to assess what technical and non-technical skills should be incorporated.

METHODS

All participants in a MET education programme over a 12-month period were invited to complete a self-administered electronic survey. Participants were ICU team members (intensive care registrars and nurses) and medical registrars. Responses were captured through a 5-point Likert scale.

RESULTS

There were 62 responses out of 112 participants (55% response rate). Most participants either agreed or strongly agreed that MET training was valuable (59 respondents) and should be multidisciplinary (61 respondents). ICU team members were more likely to select 'Management of End-of-Life Care' (72% compared with only 16% of medical registrars, P < 0.05) as an important learning objective. Non-technical skills such as 'Task Management' (67% compared with 37%, P < 0.05) and 'Team Communication' (79% compared with 32%, P < 0.05) were also more likely to be selected by ICU team members. Nursing team members were more likely to select 'Approach to Common MET Calls' (100% compared with 50% of medical team members, P < 0.05).

CONCLUSIONS

MET education programme participants overwhelmingly feel that training should be multidisciplinary. However, there are disparities between the perceived learning needs of medical and nursing personnel, and between intensive care team members and medical registrars, which may impact on the design and implementation of a multidisciplinary education programme.

[Assessment of lumbar puncture skills in students, interns and residents attending hospital internship]

Bien que la ponction lombaire soit reconnue comme étant d'un grand apport dans le diagnostic de certaines maladies neurologiques, les modalités d'apprentissage de ce geste technique restent encore mal définies dans la formation de nos étudiants lors de leurs stages cliniques. L'appréhension liée au manque d'expérience et la peur de l'échec font que ces derniers délaissent la pratique de ce geste. Notre objectif était d'évaluer les compétences des étudiants de la Faculté de Médecine de Nouakchott sur la pratique de la ponction lombaire et d'apprécier leur ressenti subjectif vis-à-vis de ce geste. Nous avons mené au mois de mai 2017 une enquête auprès des internes, des résidents, et des étudiants inscrits en TCEM (Troisième cycle des études médicales) et en DCEM 4 (Deuxième cycle d'études de médecine en 4 ans.) Pour cela, un questionnaire anonyme sur l'enseignement et la pratique de la ponction lombaire a été élaboré et rempli par 92 participants. L'analyse des données de cette étude a été effectuée sur un logiciel SPSS, version 20. Sur un total de 105 fiches de questionnaire, nous n'avons pu en exploiter que 92, soit un taux de participation de 87,6%. Il y avait 67 garçons pour 25 filles. Douze participants n'ont jamais pratiqué la moindre ponction lombaire, le plus souvent par manque de confiance en eux-mêmes. Près de 10% des étudiants n'ont jamais appris à faire ce geste et 22% l'ont appris sans être supervisés par un médecin senior. Le taux d'échec lors de la première ponction était de 45% chez nos stagiaires. Peu d'entre eux reconnaissent (7,5%) qu'ils prescrivent une sédation ou une anesthésie locale au patient avant la réalisation de la ponction lombaire (PL). La position assise était de loin plus utilisée que le décubitus latéral, mais 30% des étudiants déclarent qu'ils ont utilisé les 2 positions. Le but de la PL (ponction lombaire) était diagnostique à 69%, mais dans 25% des cas elle a été réalisée dans un but à la fois diagnostique et thérapeutique. Les indications diagnostiques étaient dominées par les méningites et les méningo-encéphalites tandis que l'hydrocéphalie à pression normale constituait le premier motif des PL thérapeutiques. Au décours d'une PL, les complications rencontrées par nos stagiaires étaient surtout une PL traumatique suivie par les céphalées. Le Service de Pédiatrie était celui où les étudiants ont pratiqué le plus de PL (35%), suivi par la Neurologie (29%), les Urgences (19%) et la Médecine interne (9%). Les résultats de notre enquête montrent que la ponction lombaire reste encore pour nombre d'étudiants comme un geste difficile et risqué, et qu'ils ne sont pas suffisamment préparés pour l'affronter. Les modalités d'enseignement et d'apprentissage de ce geste technique devraient être revues par les encadreurs qui pourraient intégrer de nouvelles techniques telles que la simulation sur mannequins comme c'est le cas actuellement dans la plupart des pays développés.

Crew resource management training in healthcare: a systematic review of intervention design, training conditions and evaluation

OBJECTIVES

Crew resource management (CRM) training formats have become a popular method to increase patient safety by consideration of the role that human factors play in healthcare delivery. The purposes of this review were to identify what is subsumed under the label of CRM in a healthcare context and to determine how such training is delivered and evaluated.

DESIGN

Systematic review of published literature.

DATA SOURCES

PubMed, PsycINFO and ERIC were searched through 8 October 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Individually constructed interventions for healthcare staff that were labelled as CRM training, or described as based on CRM principles or on aviation-derived human factors training. Only studies reporting both an intervention and results were included.

DATA EXTRACTION AND SYNTHESIS

The studies were examined and coded for relevant passages. Characteristics regarding intervention design, training conditions and evaluation methods were analysed and summarised both qualitatively and quantitatively.

RESULTS

Sixty-one interventions were included. 48% did not explain any keyword of their CRM intervention to a reproducible detail. Operating room teams and surgery, emergency medicine, intensive care unit staff and anaesthesiology came in contact most with a majority of the CRM interventions delivered in a 1-day or half-day format. Trainer qualification is reported seldomly. Evaluation methods and levels display strong variation.

CONCLUSIONS

Critical topics were identified for the CRM training community and include the following: the need to agree on common terms and definitions for CRM in healthcare, standards of good practice for reporting CRM interventions and their effects, as well as the need for more research to establish non-educational criteria for success in the implementation of CRM in healthcare organisations.

Being the 'med reg': an exploration of junior doctors' perceptions of the medical registrar role

The role of the medical registrar is challenging and acknowledged as being a disincentive to a career in medicine for some junior doctors. We set out to build a broader understanding of the role through exploration of Foundation Doctors' and Core Medical Trainees' perceptions of the role. Data, gathered from focus groups, were analysed using a framework approach. Six key themes were identified, which were grouped under the headings 'perceptions of the medical registrar role' and 'transition into the role'. Our work builds on existing literature to inform a deeper understanding of how junior doctors perceive the medical registrar role. In light of our findings we offer suggestions on possible training initiatives to tackle the issues identified. We also highlight positive perceptions of the role and emphasise the key ambassadorial role that current medical registrars have in relation to attracting tomorrow's medical registrars to the specialty.

Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety

BACKGROUND

Preventable harm is one of the top six health problems in the developed world. Developing patient safety skills and knowledge among advanced trainee doctors is critical. Clinical supervision is the main form of training for advanced trainees. The use of supervision to develop patient safety competence has not been established.

OBJECTIVE

To establish the use of clinical supervision and other workplace training to develop non-technical patient safety competency in advanced trainee doctors.

DATA SOURCES

Keywords, synonyms and subject headings were used to search eight electronic databases in addition to hand-searching of relevant journals up to 1 March 2014.

METHOD

Titles and abstracts of retrieved publications were screened by two reviewers and checked by a third. Full-text articles were screened against the eligibility criteria. Data on design, methods and key findings were extracted. Clinical supervision documents were assessed against components common to established patient safety frameworks. Findings from the reviewed articles and document analysis were collated in a narrative synthesis.

RESULTS

Clinical supervision is not identified as an avenue for embedding patient safety skills in the workplace and is consequently not evaluated as a method to teach trainees these skills. Workplace training in non-technical patient safety skills is limited, but one-off training courses are sometimes used.

CONCLUSIONS

Clinical supervision is the primary avenue for learning in postgraduate medical education but the most overlooked in the context of patient safety learning. The widespread implementation of short courses is not matched by evidence of rigorous evaluation. Supporting supervisors to identify teaching moments during supervision and to give weight to non-technical skills and technical skills equally is critical.

Simulation of cardiac emergencies with real patients

BACKGROUND

Simulation training with manikin simulators for medical emergencies is increasingly used in medical training. The assessment of a manikin, in particular history and examination, is very different to that of a real patient. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients.

STUDY DESIGN

In-patients who had recently experienced a cardiac emergency were asked to recall their symptoms as if they were still present. Medical students assessed these patients in the role of foundation year-1 (FY1) doctors, supervised by core medical trainee (CMT) doctors, and were encouraged to formulate a differential diagnosis and initial management plan. The students filled in a questionnaire prior to, immediately after and 1 week after each simulation session. This included a self-assessment of confidence in managing cardiac emergencies, as well as knowledge-based questions on aspects of assessment and management of cardiac emergencies. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients

RESULTS

Confidence in managing cardiac emergencies was initially low, but significantly increased after one simulation training session (p < 0.001). This increase was sustained on re-assessment 1 week after the training session (p < 0.001). In addition to the increase in confidence, a significant and sustained increase in knowledge score was also observed (p < 0.001).

CONCLUSION

Simulation training with real patients led to an immediate and sustained increase in self-assessed confidence. There was also an increase in medical knowledge of the assessment and management of cardiac emergencies. This simulation technique is inexpensive, easily reproducible and can be used to complement learning from traditional simulation training with manikins.

Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base

Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.

Identifying incidents of suboptimal care during paediatric emergencies-an observational study utilising in situ and simulation centre scenarios

AIM

Life threatening paediatric emergencies are relatively uncommon events. When they do occur staff caring for these children must have the ability to recognise the deterioration, evaluate and simultaneously treat these patients. The aim of this study was to identify suboptimal care during standardised simulated scenarios and to identify the potential causation factors.

METHODS

Participants were emergency department and operating theatre staff in Sydney, Australia. Incidents of suboptimal care were identified during scenarios and were analysed by thematic qualitative assessment methods. Potential causation factors were elicited both during and immediately after the scenarios and during facilitated debriefings. Causation factors were attributed to any of seven pre-defined categories.

RESULTS

Seventy-three simulations occurred over 9 month period in 2011. 270 doctors, 235 nurses and 11 students participated. 194 incidents of suboptimal care were observed and attributed to 325 causation factors. There were 76 knowledge deficits, 39 clinical skill deficits, 36 leadership problems, 84 communication failures, 20 poor resource utilisations, 23 preparation and planning failures and 47 incidents of a loss of situational awareness. Clinically important themes were: paediatric life support, drug choice and doses, advanced airway and ventilation, intravenous fluids and recognition of the deteriorating patient. Recurring incidents included the failure to recognise a cardiac arrest, inadequate fluid resuscitation and incorrect medication dose administration.

CONCLUSIONS

During standardised paediatric simulations multiple incidents of suboptimal care have been identified and multiple causation factors attributed to these. Educators should use this information to adapt current training programs to encompass these factors.