Simulation-based medical education: an ethical imperative

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Training and simulation for patient safety

BACKGROUND

Simulation-based medical education enables knowledge, skills and attitudes to be acquired for all healthcare professionals in a safe, educationally orientated and efficient manner. Procedure-based skills, communication, leadership and team working can be learnt, be measured and have the potential to be used as a mode of certification to become an independent practitioner.

RESULTS

Simulation-based training initially began with life-like manikins and now encompasses an entire range of systems, from synthetic models through to high fidelity simulation suites. These models can also be used for training in new technologies, for the application of existing technologies to new environments and in prototype testing. The level of simulation must be appropriate to the learners' needs and can range from focused tuition to mass trauma scenarios. The development of simulation centres is a global phenomenon which should be encouraged, although the facilities should be used within appropriate curricula that are methodologically sound and cost-effective.

DISCUSSION

A review of current techniques reveals that simulation can successfully promote the competencies of medical expert, communicator and collaborator. Further work is required to develop the exact role of simulation as a training mechanism for scholarly skills, professionalism, management and health advocacy.

An introduction to the Barell body region by nature of injury diagnosis matrix

INTRODUCTION

The Barell body region by nature of injury diagnosis matrix standardizes data selection and reports, using a two dimensional array (matrix) that includes all International Classification of Diseases (ICD)-9-CM codes describing trauma.

AIM

To provide a standard format for reports from trauma registries, hospital discharge data systems, emergency department data systems, or other sources of non-fatal injury data. This tool could also be used to characterize the patterns of injury using a manageable number of clinically meaningful diagnostic categories and to serve as a standard for casemix comparison across time and place.

CONCEPT

The matrix displays 12 nature of injury columns and 36 body region rows placing each ICD-9-CM code in the range from 800 to 995 in a unique cell location in the matrix. Each cell includes the codes associated with a given injury. The matrix rows and columns can easily be collapsed to get broader groupings or expanded if more specific sites are required. The current matrix offers three standard levels of detail through predefined collapsing of body regions from 36 rows to nine rows to five rows. MATRIX DEVELOPMENT: This paper presents stages in the development and the major concepts and properties of the matrix, using data from the Israeli national trauma registry, and from the US National Hospital Discharge Survey. The matrix introduces new ideas such as the separation of traumatic brain injury (TBI), into three types. Injuries to the eye have been separated from other facial injuries. Other head injuries such as open wounds and burns were categorized separately. Injuries to the spinal cord and spinal column were also separated as are the abdomen and pelvis. Extremities have been divided into upper and lower with a further subdivision into more specific regions. Hip fractures were separated from other lower extremity fractures. FORTHCOMING DEVELOPMENTS: The matrix will be used for the development of standard methods for the analysis of multiple injuries and the creation of patient injury profiles. To meet the growing use of ICD-10 and to be applicable to a wider range of countries, the matrix will be translated to ICD-10 and eventually to ICD-10-CM.

CONCLUSION

The Barell injury diagnosis matrix has the potential to serve as a basic tool in epidemiological and clinical analyses of injury data.

Utilization of physician offices by adolescents in the United States

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years.

OBJECTIVE

To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents.

DESIGN

Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups.

SETTING

Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices.

SUBJECTS

A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994.

MAIN OUTCOME MEASURES

Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided.

RESULTS

Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%).

CONCLUSIONS

Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Emergency department utilization by adolescents in the United States

BACKGROUND

Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no published reports of adolescent utilization of emergency services on a national scale. Furthermore, emergency services data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care.

OBJECTIVE

To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescent subgroups.

DESIGN

Secondary analysis of the emergency department component of the 1994 National Hospital Ambulatory Medical Care Survey.

SETTING

Nationally representative sample of 418 emergency departments in the United States.

PATIENTS

Approximately 26,547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits.

OUTCOME MEASURES

Number of visits, health insurance, reasons for visits, urgency of visits, resulting diagnoses, and hospitalization rates.

RESULTS

Adolescents accounted for 15.4% of the population and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emergency department visits relative to their population proportion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of visits were urgent. These rates did not differ from those of children but were lower than those of adults.

CONCLUSIONS

Utilization of emergency departments increases and health insurance decreases during adolescence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency departments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.

Simulation based medical education: an opportunity to learn from errors

Medical professionals and educators recognize that Simulation Based Medical Education (SBME) can contribute considerably to improving medical care by boosting medical professionals' performance and enhancing patient safety. A central characteristic of SBME is its unique approach to making (and learning from) mistakes, which is regarded as a powerful educational experience and as an opportunity for professional improvement. The basic assumption underlying SBME is that increased practice in learning from mistakes and in error management in a simulated environment will reduce occurrences of errors in real life and will provide professionals with the correct attitude and skills to cope competently with those mistakes that could not be prevented. The main message of the present paper is that this assumption, which serves as the driving force of SBME, should also serve as a starting point for critical thinking and questioning regarding the multiple aspects and components of SBME. These questions, in turn, should lead to empirical research that will provide feedback concerning changes that may be necessary in order to attain the goal of improving medical professionals' performance. Based on such research, SBME will be held accountable for its outcomes, i.e. whether its educational techniques indeed result in decreased occurrence of errors or not, and whether the ability to cope with the errors that do occur is significantly improved. The first of three issues that were addressed concerns individuals' experience of performing mistakes. It is suggested that in order to benefit fully from the experience of performing mistakes in a simulated context, medical educators should create a balance between the emotional load associated with the experience and the professional lessons that can be learned. Furthermore, research should focus on the long-term effects of the experience in changing professionals' attitudes and behaviour. The second question concerned the contribution of the different components of the educational experience to creating the desired changes in professionals' performance. Analysis of the teaching and learning involved in each stage of the educational event should serve as the basis for research that aims at identifying the unique contribution and efficiency of each element, and defining the essential core activities of a simulated experience. Finally, the need to define a newly emerging profession-SBME educator-was addressed. The professional qualifications are, clearly, multidisciplinary and should be based on the growing experience of medical educators in training students and professionals. Defining the profession is essential in order to create academic environments in which professionals will be trained to develop and implement new programmes, accompanied by research and assessment.

Reliability and Validity of a Simulation-based Acute Care Skills Assessment for Medical Students and Residents

Background

Medical students and residents are expected to be able to manage a variety of critical events after training, but many of these individuals have limited clinical experiences in the diagnosis and treatment of these conditions. Life-sized mannequins that model critical events can be used to evaluate the skills required to manage and treat acute medical conditions. The purpose of this study was to develop and test simulation exercises and associated scoring methods that could be used to evaluate the acute care skills of final-year medical students and first-year residents.

Methods

The authors developed and tested 10 simulated acute care situations that clinical faculty at a major medical school expects graduating physicians to be able to recognize and treat at the conclusion of training. Forty medical students and residents participated in the evaluation of the exercises. Four faculty members scored the students/residents.

Results

The reliability of the simulation scores was moderate and was most strongly influenced by the choice and number of simulated encounters. The validity of the simulation scores was supported through comparisons of students'/residents' performances in relation to their clinical backgrounds and experience.

Conclusion

Acute care skills can be validly and reliably measured using a simulation technology. However, multiple simulated encounters, covering a broad domain, are needed to effectively and accurately estimate student/resident abilities in acute care settings.

Recurrent Obstetric Management Mistakes Identified by Simulation

OBJECTIVE

To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes.

METHODS

A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions.

RESULTS

Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions).

CONCLUSION

A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.

Simulation-based medical education: an ethical imperative

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these 2 needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic

BACKGROUND

Physicians play a crucial frontline role in the COVID-19 pandemic, which may involve high levels of anxiety. We aimed to investigate the association between pandemic-related stress factors (PRSF) and anxiety and to evaluate the potential effect of resilience on anxiety among physicians.

METHODS

A self-report digital survey was completed by 1106 Israeli physicians (564 males and 542 females) during the COVID-19 outbreak. Anxiety was measured by the 8-item version of the Patient-Reported Outcomes Measurement Information System. Resilience was evaluated by the 10-item Connor-Davidson Resilience Scale. Stress was assessed using a PRSF inventory.

RESULTS

Physicians reported high levels of anxiety with a mean score of 59.20 ± 7.95. We found an inverse association between resilience and anxiety. Four salient PRSF (mental exhaustion, anxiety about being infected, anxiety infecting family members, and sleep difficulties) positively associated with anxiety scores.

CONCLUSIONS

Our study identified specific PRSF including workload burden and fear of infection that are associated with increased anxiety and resilience that is associated with reduced anxiety among physicians.

Incorporating Simulation-Based Objective Structured Clinical Examination into the Israeli National Board Examination in Anesthesiology

We describe the unique process whereby simulation-based, objective structured clinical evaluation (OSCE) has been incorporated into the Israeli board examination in anesthesiology. Development of the examination included three steps: a) definition of clinical conditions that residents are required to handle competently, b) definition of tasks pertaining to each of the conditions, and c) incorporation of the tasks into hands-on simulation-based examination stations in the OSCE format, including 1) trauma management, 2) resuscitation, 3) crisis management in the operating room, 4) regional anesthesia, and 5) mechanical ventilation. Members of the Israeli Board of Anesthesiology Examination Committee assisted by experts from the Israel Center for Medical Simulation and from Israel's National Institute for Testing and Evaluation were involved in this process and in the development of the assessment tools, orientation of examinees, and preparation of examiners. The examination has been administered 4 times in the past 2 yr to 104 examinees and has gradually progressed from being a minor part of the oral board examination to a prerequisite component of this test. The pass rate ranged from 70% in resuscitation to 91% in regional anesthesia. The mean inter-rater correlations for all the checklist items, for the score based on the critical checklist items only, and for the general rating were 0.89, 0.86, and 0.76, respectively. The overall Kappa coefficients (the inter-rater agreement coefficient) for the total score and the critical checklist items were 0.71 and 0.76, respectively. The correlation between the total score and the general score was 0.76. According to a subjective feedback questionnaire, most (70%-90%) participants found the difficulty level of the examination stations reasonable to very easy and prefer this method of examination to a conventional oral examination. The incorporation of OSCE-driven modalities in the certification of anesthesiologists in Israel is a continuing process of evaluation and assessment.

Primary care physicians' use of an electronic medical record system: a cognitive task analysis

OBJECTIVE

To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular.

DESIGN

Cognitive task analysis using semi-structured interviews and field observations.

PARTICIPANTS

Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel.

RESULTS

The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped.

CONCLUSIONS

There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.

Rudeness and Medical Team Performance

OBJECTIVES

Rudeness is routinely experienced by medical teams. We sought to explore the impact of rudeness on medical teams' performance and test interventions that might mitigate its negative consequences.

METHODS

Thirty-nine NICU teams participated in a training workshop including simulations of acute care of term and preterm newborns. In each workshop, 2 teams were randomly assigned to either an exposure to rudeness (in which the comments of the patient's mother included rude statements completely unrelated to the teams' performance) or control (neutral comments) condition, and 2 additional teams were assigned to rudeness with either a preventative (cognitive bias modification [CBM]) or therapeutic (narrative) intervention. Simulation sessions were evaluated by 2 independent judges, blind to team exposure, who used structured questionnaires to assess team performance.

RESULTS

Rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (such as information and workload sharing, helping and communication) central to patient care (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05). CBM mitigated most of these adverse effects of rudeness, but the postexposure narrative intervention had no significant effect.

CONCLUSIONS

Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviors that, unfortunately, cannot be prevented.

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.

Enhancing Patient Safety During Pediatric Sedation

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.

Awareness Level of Obstructive Sleep Apnea Syndrome During Routine Unstructured Interviews of a Standardized Patient by Primary Care Physicians

OBJECTIVE

To assess the awareness level of primary care physicians of obstructive sleep apnea syndrome during patient-physician encounters.

DESIGN

A prospective study using a standardized patient approach, conducted between December 2001 and March 2002. Ten sleep experts reviewed and approved the checklist questionnaire.

SETTING

Primary care clinics of Clalit Health Care Services, in the central region of Israel.

PARTICIPANTS

Thirty physicians (100% compliance) randomly selected (matched by age, sex, board certification) from the 261 primary care givers in the region.

INTERVENTION

A standardized patient incorporated into the physicians' daily practices.

RESULTS

From the original checklist questionnaire, we identified 2 related question areas that at least 90% of sleep experts would pursue in light of the presenting scenario, "Do the patients snore, choke, or stop breathing in sleep?" and "Does the patient have sleepiness, unrefreshed sleep/fall asleep at undesirable times?" During the unstructured interview, only 10% of the physicians asked 3 or more questions. More than 85% of primary care physicians identified the need for polysomnography evaluation (27 physicians) or continuous positive airway pressure (26 physicians) treatment for obstructive sleep apnea syndrome. However, only 16% and 50% discussed possible complications of obstructive sleep apnea syndrome such as motor vehicle and work accidents and cardiovascular events, respectively.

CONCLUSIONS

Primary care physicians cannot identify a common disorder associated with cardiovascular and neurobehavioral disease and could not identify the sleepiness as a source of dangerous driving. While understanding the algorithms for the diagnosis of sleep apnea, physicians cannot identify the patients for whom the diagnostics are needed. Education programs need to be developed to increase the level of suspicion of obstructive sleep apnea syndrome among practicing primary care physicians. Activities can be monitored and evaluated over time in the daily practice by standardized patients.

EDUCATIONAL OBJECTIVE

Increased awareness level of obstructive sleep apnea syndrome among primary care physicians, through publications and educational programs, monitored by standardized patients.

Adult-onset diabetes among Arabs and Jews in Israel: a population-based study

AIMS

To study the age at presentation and factors associated with adult-onset diabetes (≥ 20 years) among Arabs and Jews in Israel.

METHODS

Participants (n = 1100) were randomly selected from the urban population of the Hadera District in Israel. The study sample was stratified into equal groups according to sex, ethnicity (Arabs and Jews) and age. Information on age at diabetes presentation, family history of diabetes, history of gestational diabetes, socio-demographic and lifestyle characteristics was obtained through personal interviews. Self reports of diabetes were compared with medical records and were found reliable (κ = 0.87). The risk for diabetes was calculated using Kaplan-Meier survival analysis. Factors associated with diabetes in both ethnic groups were studied using Cox proportional hazard model.

RESULTS

The prevalence of adult-onset diabetes was 21% among Arabs and 12% among Jews. Arab participants were younger than Jews at diabetes presentation. By the age of 57 years, 25% of Arabs had diagnosed diabetes; the corresponding age among Jews was 68 years, a difference of 11 years (P < 0.001). The greater risk for diabetes among Arabs was independent of lifestyle factors, family history of diabetes and, among women, history of gestational diabetes; adjusted hazard ratio 1.70; 95% confidence interval 1.19-2.43.

CONCLUSIONS

Arabs in Israel are at greater risk for adult-onset diabetes than Jews and are younger at diabetes presentation. Culturally sensitive interventions aimed at maintaining normal body weight and active lifestyle should be targeted at this population. Possible genetic factors and gene-environmental interactions underlying the high risk for diabetes among Arabs should be investigated.

Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors

This study aimed to assess the prevalence and incidence of postpartum depression (PPD) and to identify risk factors in a community cohort of Israeli-born, as well as new and veteran immigrant women. A random sample of 288 registrants at a community clinic was assessed for depressive symptoms at 26 weeks' pregnancy using the Beck Depression Inventory (BDI) and at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Information regarding risk factors was gathered through interviews and medical record abstracting. The prevalence of PPD was 22.6%. Two-thirds of the women had scored 'depressed' during pregnancy, and one-third (6.9%) were new incident cases. Immigrant status was the only significant demographic predictor of PPD identified by either univariate or multivariate analysis, with Russian new immigrants having over twice the risk for PPD as Israeli-born subjects. The rate of PPD in this Israeli cohort was comparable to that found in other countries. The finding that immigrant status was the most potent demographic predictor may support the role of stressful life events in the etiology of PPD. The use of the EPDS for PPD screening was found acceptable and feasible in the primary health setting.

Trajectories of post-traumatic stress symptoms, anxiety, and depression in hospitalized COVID-19 patients: A one-month follow-up

OBJECTIVES

Little is known about the mental health outcomes of hospitalized COVID-19 patients. The aims of the study were: (1) to examine the trajectories of anxiety, depression, and pandemic-related stress factors (PRSF) of COVID-19 hospitalized patients one-month following hospitalization; (2) to assess the presence of post-traumatic stress symptoms (PTSS) a month after hospitalization; (3) to identify baseline risk and protective factors that would predict PTSS one month after hospitalization.

METHODS

We contacted hospitalized COVID-19 patients (n = 64) by phone, at three time-points: during the first days after admission to the hospital (T1); after ~two weeks from the beginning of hospitalization (T2), and one month after hospitalization (T3). At all time-points we assessed the levels of anxiety and depression symptoms, as well as PRSF. At T3, PTSS were assessed.

RESULTS

The levels of depressive and anxiety symptoms decreased one-month following hospitalization. Moreover, higher levels of anxiety (standardized β = 1.15, 95% CI = 0.81-1.49, p < 0.001) and depression (β = 0.97, 95% CI = 0.63-1.31 p < 0.001) symptoms during the first week of hospitalization, feeling socially disconnected (β = 0.59, 95% CI = 0.37-0.81 p < 0.001) and experiencing a longer hospitalization period (β = 0.25, 95% CI = 0.03-0.47 p = 0.026) predicted higher PTSS scores a month post-hospitalization.

CONCLUSIONS

We identified early hospitalization risk factors for the development of PTSS one month after hospitalization that should be targeted to reduce the risk for PTSS.

Postpartum depression in an Israeli cohort: demographic, psychosocial and medical risk factors

Demographic, psychosocial and medical risk factors for postpartum depression (PPD) were studied prospectively in a community cohort of 288 Israeli women. An Edinburgh Postnatal Depression Scale score of > or = 10 at 6 weeks postpartum was the criterion for PPD. Psychosocial risk factors were found to be the most potent. Lack of social support, marital disharmony, depressive symptoms during pregnancy, history of emotional problems and prolonged infant health problems were most predictive of PPD. The major role of psychosocial factors in PPD was similar to that found in other countries. The results were somewhat different for new Russian immigrants. These findings indicate that early identification of women at risk for PPD is feasible, and that consideration should be taken of subgroups that may be at heightened risk, or for whom risk factors play different roles.

Improved accuracy of postpartum blood loss estimation as assessed by simulation

OBJECTIVE

Caregivers underestimate the amount of blood loss, but this almost five decades-old assumption has not been validated. We aimed at assessing the accuracy of estimated blood loss by obstetrical teams during a simulated Postpartum hemorrhage (PPH) scenario.

STUDY DESIGN

a prospective study conducted as part of the simulation-based training course, using sophisticated mannequin simulators adapted for obstetrical training by specially designed devices.

SETTING

Part of the simulation-based training course.

POPULATION

Obstetrical teams consisted of physicians and obstetrical nurses.

METHODS

Each of the participating obstetrical teams assessed blood loss during PPH scenarios. Their estimates were compared to the actual predefined 3.5-liter blood loss. An intervention group underwent a similar course in which they recorded their estimations after 1, 2 and 3.5 liters were lost.

OUTCOME MEASURES

Blood loss estimates after completion of the scenario in both groups.

RESULTS

Fifty obstetrical teams took part in the study. Eight comprised the interventional group. The average estimated blood loss was 1,780 ml (49% underestimation) for non-interventional teams. The interventional groups estimated blood loss to be 2,400 ml (32% underestimation). The main method of estimating blood loss was 'gut feeling', followed by verbalized guesses of team members and assessments of the 'patient's' hemodynamic status.

CONCLUSIONS

Accuracy of blood loss estimations by a simulation-based PPH scenario was 50-60%. Measurements at predetermined intervals significantly improved accuracy of these estimations. Our study suggests that implementation of periodic estimations of blood loss in the management of PPH might improve clinical judgment.

Status of simulation in health care education: an international survey

Simulation is rapidly penetrating the terrain of health care education and has gained growing acceptance as an educational method and patient safety tool. Despite this, the state of simulation in health care education has not yet been evaluated on a global scale. In this project, we studied the global status of simulation in health care education by determining the degree of financial support, infrastructure, manpower, information technology capabilities, engagement of groups of learners, and research and scholarly activities, as well as the barriers, strengths, opportunities for growth, and other aspects of simulation in health care education. We utilized a two-stage process, including an online survey and a site visit that included interviews and debriefings. Forty-two simulation centers worldwide participated in this study, the results of which show that despite enormous interest and enthusiasm in the health care community, use of simulation in health care education is limited to specific areas and is not a budgeted item in many institutions. Absence of a sustainable business model, as well as sufficient financial support in terms of budget, infrastructure, manpower, research, and scholarly activities, slows down the movement of simulation. Specific recommendations are made based on current findings to support simulation in the next developmental stages.