Simulation in New Zealand: what have you done for me lately? New Zealand Association for Simulation in Healthcare (NZASH) white paper

Medical simulation has become an integral aspect of modern healthcare education and practice. It has evolved to become an essential aspect of teaching core concepts and skills, common and rare presentations, algorithms and protocols, communication, interpersonal and teamworking skills and testing new equipment and systems. Simulation-based learning (SBL) is useful for the novice to the senior clinician. Healthcare is a complex adaptive system built from very large numbers of mutually interacting subunits (e.g., different professions, departments, equipment). These subunits generate multiple repeated interactions that have the potential to result in rich, collective behaviour that feeds back into the organisation. There is a unique opportunity in New Zealand with the formation of Te Whatu Ora - Health New Zealand and Te Aka Whai Ora - Māori Health Authority and the reorganisation of the healthcare system. This viewpoint is a white paper for the integration of SBL into our healthcare system. We describe our concerns in the current system and list our current capabilities. The way SBL could be implemented in pre- and post-registration phases of practice are explored as well as the integration of communication and culture. Interprofessional education has been shown to improve outcomes and is best done with an interprofessional simulation curriculum. We describe ways that simulation is currently used in our system and describe other uses such as quality improvement, safety and systems engineering and integration. The aim of this viewpoint is to alert Te Whatu Ora and Te Aka Whai Ora of the existing infrastructure of the simulation community in New Zealand and encourage them to invest in its future.

Goals of care in the Wellington Emergency Department: a clinical audit

AIMS

To determine how often goals of care (GOC) are being discussed with older patients in the emergency department (ED).

METHODS

This clinical audit included 300 presentations of patients aged 80 years and over in the Wellington ED. The timeframe was from 1 July to 17 July 2021. Electronic records were interrogated for GOC discussions.

RESULTS

Most older patients (62%) did not have a GOC discussion in the ED. Of patients over the age of 80 who had a GOC discussion in the emergency department, only 14% of those discussions were initiated by ED clinicians.

CONCLUSIONS

There are no current standards for GOC within the ED and this should be established for further research. Protocols and education regarding facilitating GOC discussions in the ED could be established to improve the frequency of GOC discussions.

Evolving swabbing practices for COVID-19 in a New Zealand emergency department during the early stages of an emerging pandemic

OBJECTIVE

To review if tests for suspected COVID-19 were performed according to the Ministry of Health (MoH) case definitions, identify patterns associated with testing outside of the case definition, and discuss the potential impacts on hospital services.

METHODS

This was a retrospective audit of patients presenting to the Wellington Hospital ED between 24 March 2020 and 27 April 2020 who were swabbed for COVID-19 in ED. Swabs were audited against the March 15th and April 8th MoH COVID-19 case definitions.

RESULTS

Five hundred and thirty-six COVID-19 swabs for 518 patients were taken during the study period. There was poor alignment of testing with the March 15th case definition, with only 11.6% of the 164 swabs taken during this period meeting the case definition. Of the 145 swabs that did not meet the case definition, the majority (n = 119, 82.1%) met symptom criteria only. Alignment of testing with the wider April 8th case definition was much higher with 88.2% meeting criteria. Factors associated with being swabbed despite not meeting the case definitions included fever >38°, a diagnosis of cancer, subsequent hospital admission, and for the March case definition only 'contact with a traveller'.

CONCLUSION

There were associations found between testing outside of criteria and specific variables potentially perceived as high-risk. Poor alignment of testing with case definitions can impact hospital services through the (mis)use of limited laboratory testing capacity and implications for resource management. Improved communication and feedback between clinicians and policymakers may improve case definition implementation in a clinical setting.

Diagnostic performance of S100B as a rule-out test for intracranial pathology in head-injured patients presenting to the emergency department who meet NICE Head Injury Guideline criteria for CT-head scan

BACKGROUND

Traumatic brain injury is a common ED presentation. CT-head utilisation is escalating, exacerbating resource pressure in the ED. The biomarker S100B could assist clinicians with CT-head decisions by excluding intracranial pathology. Diagnostic performance of S100B was assessed in patients meeting National Institute of Health and Clinical Excellence Head Injury Guideline (NICE HIG) criteria for CT-head within 6 and 24 hours of injury.

METHODS

This multicentre prospective observational study included adult patients presenting to the ED with head injuries between May 2020 and June 2021. Informed consent was obtained from patients meeting NICE HIG CT-head criteria. A venous blood sample was collected and serum was tested for S100B using a Cobas Elecsys-S100 module; >0.1 µg/mL was the threshold used to indicate a positive test. Intracranial pathology reported on CT-head scan by the duty radiologist was used as the reference standard to review diagnostic performance.

RESULTS

This study included 265 patients of whom 35 (13.2%) had positive CT-head findings. Within 6 hours of injury, sensitivity of S100B was 93.8% (95% CI 69.8% to 99.8%) and specificity was 30.8% (22.6% to 40.0%). Negative predictive value (NPV) was 97.3% (95% CI 84.2% to 99.6%) and area under the curve (AUC) was 0.73 (95% CI 0.61 to 0.85; p=0.003). Within 24 hours of injury, sensitivity was 82.9% (95% CI 66.4% to 93.44%) and specificity was 43.0% (95% CI 36.6% to 49.7%). NPV was 94.29% (95% CI 88.7% to 97.2%) and AUC was 0.65 (95% CI 0.56 to 0.74; p=0.046). Theoretically, use of S100B as a rule-out test would have reduced CT-head scans by 27.1% (95% CI 18.9% to 36.8%) within 6 hours and 37.4% (95% CI 32.0% to 47.2%) within 24 hours. The risk of missing a significant injury with this approach would have been 0.75% (95% CI 0.0% to 2.2%) within 6 hours and 2.3% (95% CI 0.5% to 4.1%) within 24 hours.

CONCLUSION

Within 6 hours of injury, S100B performed well as a diagnostic test to exclude significant intracranial pathology in low-risk patients presenting with head injury. In theory, if used in addition to NICE HIGs, CT-head rates could reduce by one-quarter with a potential miss rate of <1%.

Exploring the feasibility of smartglass facilitated remote supervision in the emergency department: A simulation study

OBJECTIVE

Smartglasses are a wearable computer technology that has potential to facilitate remote supervision to junior doctors working in different clinical settings. The present study aimed to explore the feasibility of smartglass technology to enable remote supervision of junior clinicians by senior clinicians during emergency simulation scenarios.

METHODS

This was a feasibility simulation study using high-fidelity mannequins and standardised patients. Trainee interns (TIs) and supervising clinicians (SCs) were invited to participate in two scenarios: a trauma case and a stroke case. There was a pre-sim questionnaire. The TI wore the smartglasses in a simulated ED bay and performed patient assessment and management. Remote supervision was provided by the SC via a livestream on a remote computer. Upon completion, participants completed a survey regarding their experience comprising of Likert scale and free-text questions.

RESULTS

Fifteen TIs and 19 SCs participated. In general feedback from TIs and SCs was positive. TIs were able to identify and treat the key diagnostic problems set during the scenarios. Free-text survey responses provided specific feedback about what did and did not work when using the glasses.

CONCLUSION

The present study demonstrates that smartglasses facilitated remote assistance has promise as an emergent technology and warrants further investigation in simulated and non-simulated environments.

Novel use of technology

Nil.

Cruise ship patient presentation, admission, and intervention rates to the emergency department

AIMS

Patients presenting to emergency departments (EDs) from cruise ships are a unique cohort of patients with several management challenges. Little evidence details the effect this has on EDs in terms of resource use. Therefore, we aimed to review the frequency, characteristics, admission, and intervention rates of cruise ship patient presentations to ED.

METHODS

This retrospective study reviewed patient presentations to Wellington ED from cruise ships between 2016 and 2019. Data regarding presenting features, intervention and disposition were extracted via chart review.

RESULTS

There were 214 patient presentations included with a median age of 68 (IQR 43.0-76.0); 97/214(45.3%) were female. Regarding referral, cruise ship doctors referred 79/214 (36.9%) patients; 16/79 (24.1%) to in-patient specialties and 63/79 (79.7%) to emergency medicine (EM); and 135/214 (63%) self-referred to ED. Common presenting complaints were chest pain, abdominal pain and trauma. Advanced imaging was requested for 21.5% of patients and 9.9% required urgent intervention. Regarding disposition, 38% were admitted (22% to in-patient wards, 16% to ED observation unit [OU]) and 61% were discharged (30% by ED and 31% after specialty consultation).

CONCLUSION

Overall, the number of cruise ship patients presenting to the ED was low and unlikely to be a significant resource burden. Referrals by cruise ship doctors were appropriate. Education for cruise ship patients and port services regarding non-emergent care options would be valuable to reduce self-referral rates.

The Art of Sim-Making: What to Learn from Film-Making

The components of each stage have similarities as well as differences, which make each unique in its own right. As the film-making and the movie industry may have much we can learn from, some of these will be covered under the different sections of the paper, for example, "Writing Powerful Narratives," depiction of emotional elements, specific industry-driven developments as well as the "cultural considerations" in both. For medical simulation and simulation-based education, the corresponding stages are as follows: DevelopmentPreproductionProductionPostproduction andDistribution. The art of sim-making has many similarities to that of film-making. In fact, there is potentially much to be learnt from the film-making process in cinematography and storytelling. Both film-making and sim-making can be seen from the artistic perspective as starting with a large piece of blank, white sheet of paper, which will need to be colored by the "artists" and personnel involved; in the former, to come up with the film and for the latter, to engage learners and ensure learning takes place, which is then translated into action for patients in the actual clinical care areas. Both entities have to go through a series of systematic stages. For film-making, the stages are as follows: Identification of problems and needs analysisSetting objectives, based on educational strategiesImplementation of the simulation activityDebriefing and evaluation, as well asFine-tuning for future use and archiving of scenarios/cases.

Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study

OBJECTIVE

Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis.

METHODS

This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi-structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio-recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software.

RESULTS

Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail.

CONCLUSION

ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies.

Simulation Centers and Simulation-Based Education during the Time of COVID 19: A Multi-Center Best Practice Position Paper by the World Academic Council of Emergency Medicine

COVID 19 struck us all like a bolt of lightning and for the past 10 months, it has tested our resilience, agility, creativity, and adaptability in all aspects of our lives and work. Simulation centers and simulation-based educational programs have not been spared. Rather than wait for the pandemic to be over before commencing operations and training, we have been actively looking at programs, reviewing alternative methods such as e-learning, use of virtual learning platforms, decentralization of training using in situ simulation (ISS) modeling, partnerships with relevant clinical departments, cross-training of staff to attain useful secondary skills, and many other alternatives and substitutes. It has been an eye-opening journey as we maximize our staff's talent and potential in new adoptions and stretching our goals beyond what we deemed was possible. This paper shares perspectives from simulation centers; The SingHealth Duke NUS Institute of Medical Simulation which is integrated with an Academic Medical Center in Singapore, The Robert and Dorothy Rector Clinical Skills and Simulation Center, which is integrated with Thomas Jefferson University, Oakhill Emergency Department, Florida State University Emergency Medicine Program, Florida, USA and The Wellington Regional Simulation and skills center. It describes the experiences from the time when COVID 19 first struck countries around the world to the current state whereby the simulation centers have stWWarting functioning in their "new norm." These centers were representative examples of those in countries which had extremely heavy (USA), moderate (Singapore) as well as light (New Zealand) load of COVID 19 cases in the nation. Whichever categories these centers were in, they all faced disruption and had to make the necessary adjustments, aligning with national policies and advisories. As there is no existing tried and tested model for the running of a simulation center during an infectious disease pandemic, this can serve as a landmark reference paper, as we continue to fine-tune and prepare for the next new, emerging infectious disease or crisis.

Effect of simulation training on nurse leadership in a shared leadership model for cardiopulmonary resuscitation in the emergency department

OBJECTIVE

Empowering a senior nurse in a shared leadership role has been proposed as a more efficient set up for the cardiac arrest team in ED. In this model, a senior nurse leads the cardiac arrest algorithm which allows cognitive off-loading of the lead emergency physician. The emergency physician is then more available to perform tasks such as echocardiography and exclude reversible causes. Simulation provides an opportunity for training and practice of this shared leadership model. We hypothesised that a structured simulation training programme that focused on implementing a nurse and doctor shared leadership model for cardiopulmonary resuscitation (CPR), would improve leadership and teamwork quality in the setting of cardiac arrest as measured by a Trauma Non-technical Skills (T-NOTECHS) teamwork scale.

METHODS

Fifteen senior ED nurses participated in this pre-interventional post-observational study. Training consisted of a didactic course on team leadership and crisis resource management (CRM) followed by 4 × 10-min resuscitation scenarios with a structured debrief focusing on team leadership skills and CRM. The primary outcome was measured on scenarios 1 and 4 using a modified T-NOTECHS teamwork scale.

RESULTS

A statistically significant increase in the T-NOTECHS scale was detected for the measures of leadership (P = 0.0028), CRM (P = 0.0001), adherence to New Zealand Resuscitation Council ALS algorithm (P = 0.0088) and situational awareness (P = 0.0002).

CONCLUSION

The present study shows that a short simulation training programme improved nurse leadership and teamwork performance in the setting of a shared leadership model for CPR in the ED which could easily be replicated in other departments.

Ciguatera fish poisoning

Ciguatera fish poisoning (CFP) is the most common cause of seafood-toxin poisoning in the world and is most prevalent in tropical and subtropical areas. It causes gastroenteritis but also myriad neurological and cardiovascular symptoms. We present a cluster of CFP that occurred in Wellington Hospital, New Zealand. It resulted in three patients with life threatening cardiotoxicity and a fourth case with severe gastro-intestinal symptoms. The epidemiology, clinical manifestations, diagnosis, treatment and public health issues are discussed.

Parenteral poppy seed tea packs a powerful punch

Poppy seed tea (PST) has a long history of use for its medicinal (analgesic, anti-diarrhoeal, anxiolytic) effects. It is also commonly used as a recreational drug in its oral form throughout the world, but reports of intravenous use are very rare. We present two cases of intravenously injected PST with dramatic effects in order to create awareness among health professionals of this method of drug use and its potential complications, as well as to help clinicians dealing with opiate-dependent patients to warn them of the risk.

Simulation in a high stakes clinical performance exam

Background:

Hi-fidelity simulation is becoming accepted as a teaching tool for medical providers. Advanced simulations allow educators to test difficult clinical scenarios. The goal of this study was to test the diagnostic and treatment skills of a third-year medical student faced with a simulated patient having evidence of a stable pneumothorax. Students are then expected to evaluate the teaching simulation in comparison to traditional methods.

Methods:

The case was one of a 12 cases in the “high stakes” Clinical Performance Exam. The patient with evidence of a stable pneumothorax was chosen to evaluate both diagnostic abilities and decision making in therapeutic options. Students were assessed using a university-wide standardized checklist: diagnosis, management, and interaction with the simulator. Immediately following the simulation, the students evaluated the experience.

Results:

The exam was given to 117 students. The correct diagnosis was made by 115/117 (98%). Treatment was considered acceptable in a majority of students, Send patient to the Emergency Department 77%, Oxygen 26% and Analgesia 39%. The follow-up survey completed by 78% of the students revealed the students felt comfortable with the simulators, but had concerns about the exam. Students liked the simulator as an educational tool 88% of the time.

Conclusions:

Simulation was used in a year-end exam and majority of students chose the correct diagnosis and treatment plan. It was also found that a significant percentage of students performed an unnecessary and potentially harmful procedure. The survey revealed that students were concerned about distractions and realism, but overall expressed desire for more education using simulation.

Evaluating emergency ultrasound training in India

Background:

In countries with fully developed emergency medicine systems, emergency ultrasound (EUS) plays an important role in the assessment and treatment of critically ill patients.

Methods:

The authors sought to introduce EUS to a group of doctors working in the emergency departments (EDs) in India through an intensive 4-day adult and pediatric ultrasound course held at the Apex Trauma Center and EM division of the All India Institute of Medical Sciences in New Delhi. The workshop was evaluated with a survey questionnaire and a hands-on practical test. The questionnaire was designed to assess the current state of EUS in India's EDs, and to identify potential barriers to the incorporation of EUS into current EM practice. The EUS course consisted of a general introductory didactic session followed by pediatric, abdominal and trauma, cardiothoracic, obstetrical and gynecologic, and vascular modules. Each module had a didactic session followed by handson applications with live models and/or simulators. A post-course survey questionnaire was given to the participants, and there was a practical test on the final day of the course. The ultrasound images taken by the participants were digitally recorded, and were subsequently graded for their accuracy by independent observers, residency, and/or fellowship trained in EUS.

Results:

There were a total of 42 participants who completed the workshop and took the practical examination; 32 participants filled in the course evaluation survey. Twenty-four (75%) participants had no prior experience with EUS, 5 (16%) had some experience, and 3 (9%) had significant experience. During the practical examination, 38 of 42 participants (90%) were able to identify Morison's pouch on the focused abdominal sonography for trauma (FAST) examination, and 32 (76%) were able to obtain a parasternal long axis cardiac view and identify the left ventricle. The inferior vena cava was identified as it crosses the diaphragm into the right atrium by 20 (48%) participants. All participants felt they would be able to incorporate what they had learned into their practice, and indicated that they were advocates for further training of non-radiologist clinicians in the use of ED ultrasound.

Conclusion:

After this introductory workshop in EUS, the participants were comfortable in their ability to use the ultrasound machine. Participants deemed it particularly useful for certain ED applications, particularly the FAST examination, the lung examination, and vascular access.

Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol

Breaking bad news (BBN) in the emergency department (ED) is a common occurrence. This is especially true for an emergency physician (EP) as there is little time to prepare for the event and likely little or no knowledge of the patients or family background information. At our institution, there is no formal training for EP residents in delivering bad news. We felt teaching emergency medicine residents these communication skills should be an important part of their educational curriculum. We describe our experience with a defined educational program designed to educate and improve physician’s confidence and competence in bad news and death notification. A regularly scheduled 5-h grand rounds conference time frame was dedicated to the education of EM residents about BBN. A multidisciplinary approach was taken to broaden the prospective of the participants. The course included lectures from different specialties, role playing for three short scenarios in different capacities, and hi-fidelity simulation cases with volatile psychosocial issues and stressors. Participants were asked to fill out a self-efficacy form and evaluation sheets. Fourteen emergency residents participated and all thought that this education is necessary. The mean score of usefulness is 4.73 on a Likert Scale from 1 to 5. The simulation part was thought to be the most useful (43%), with role play 14%, and lecture 7%. We believe that teaching physicians to BBN in a controlled environment is a good use of educational time and an important procedure that EP must learn.

Introduction of hi-fidelity simulation techniques as an ideal teaching tool for upcoming emergency medicine and trauma residency programs in India

Emergency medicine (EM) residency programs are a new concept to India. As these programs develop in India the need for effective teaching tools for skills education will rise. A high fidelity simulation workshop was conducted with a intent to expose current residents posted in emergency departments (EDs) to the concept of simulation technology. The participants were subjected to scenarios which tested their core competencies, medical knowledge, and procedural skills using simulation technology. 50 residents were tested over 5 days and an overall satisfaction score and personal comments were assessed to rate the performance of this study. A pre- and post simulation survey was done. Results showed that participants felt that their understanding of communication of expectations increased from 38% fair or good to 76% very good or best. The frequency in which they thought they would ask for help increased from 36% fair or good to 88% very good or best. It was found that students had increased their confidence to challenge a questionable order from a superior from 48% occasionally or half of the time to 76% who would do it the majority of the time or always. In the post-survey, 80% would the majority of the time or always admit that they did not know something from 46% who stated they would only do it occasionally or half of the time. We concluded that simulation as a tool for teaching unknown and stressful conditions of ED naturally pair. Resident core competencies can be taught and evaluated more effectively in the simulation lab in a controlled, safe, and collegial manner.

Simulation in a disaster drill: comparison of high-fidelity simulators versus trained actors

OBJECTIVES

High-fidelity patient simulation provides lifelike medical scenarios with real-time stressors. Mass casualty drills must construct a realistic incident in which providers care for multiple injured patients while simultaneously coping with numerous stressors designed to tax an institution's resources. This study compared the value of high-fidelity simulated patients with live actor-patients.

METHODS

A prospective cohort study was conducted during two mass casualty drills in December 2006 and March 2007. The providers' completion of critical actions was tested in live actor-patients and simulators. A posttest survey compared the participants' perception of "reality" between the simulators and live actor victims.

RESULTS

The victims (n = 130) of the mass casualty drill all had burn-, blast-, or inhalation-related injuries. The participants consisted of physicians, residents, medical students, clerks, and paramedics. The authors compared the team's execution of the 136 critical actions (17 critical actions x 8 scenarios) between the simulators and the live actor-patients. Only one critical action was missed in the simulator group and one in the live actor group, resulting in a miss rate of 0.74% (95% confidence interval [CI] = 0.01% to 4.5%). All questionnaires were returned and analyzed. The vast majority of participants disagreed or strongly disagreed that the simulators were a distraction from the disaster drill. More than 96% agreed or strongly agreed that they would recommend the simulator as a training tool. The mean survey scores for all participants demonstrated agreement that the simulators closely mimicked real-life scenarios, accurately represented disease states, and heightened the realism of patient assessment and treatment options during the drill with the exception of nurse participants, who agreed slightly less strongly.

CONCLUSIONS

This study demonstrated that simulators compared to live actor-patients have equivalent results in prompting critical actions in mass casualty drills and increase the perceived reality of such exercises.

Tourniquet syndrome: a review of constricting band removal

A constricting band causing tourniquet syndrome is a common problem that can cause much frustration and pain for both the patient and practitioner. The following review classifies and describes the different aspects of the treatment of this condition. We also describe a policy and procedure for the motorized removal of large bands by using a high revolutions per minute cutting device.