Accelerating development of simulation-based medical skill training programs : a comparative evaluation research study

A shift in Military utilization of Live Tissue Training (LTT) to Simulation-based Training (SBT) for combat casualty care training programs is currently underway. While each has been reported to be effective, there is little high quality research comparing traditional LTT with SBT learning outcomes. The shift in training methods is partly in response to increased regulatory requirements, higher costs and public sentiments. The benefits of training with a live anesthetized animal are an immediate physiologic feedback to treatment interventions and practice in 'real-world', high-stakes continual patient assessment and decision making. Simulation-based training offers opportunities for deliberate practice and skill mastery without the sense of urgency or 'real-world' life and death outcomes the trainee will face in combat casualty care. The paucity of experimental evidence demonstrating that the two types of training are comparable has contributed to slow adoption of SBT technology for resuscitation procedures, particularly in combat casualty training. This study entails the direct comparison of LTT and SBT in a randomized, pre-test post-test experiment. Changes in trainee knowledge, psychomotor skill, and self-efficacy are assessed using established measures. Stress and emotion are known to play a role in performance and learning. This study also investigated the use of sweat measurement as a possible indicator of a stressful response to the training situation. This was accomplished by measuring changes in skin impedance during didactic and hands-on training. Following completion of the training session, training participants completed a survey regarding perceived value of the training. An independent evaluation of the study was conducted by the University of Central Florida's Institute for Simulation and Training. Statistical analyses showed no significant difference between the training groups in any of the learning measures. The change in electrodermal activity was non-significant between the two training groups. Participant evaluations revealed strong belief among trainees that LTT was of greater value to the training participants, however, participants suggested that LTT should be continued for combat casualty care training while SBT could be useful to other groups of learners. A more limited use of LTT would address the concerns regarding the use of live tissue. The comparison of learning outcomes in this controlled study provides new evidence to support further integration of SBT in combat casualty training. The study results will inform trauma education planning so that the most effective training methods available for military personnel preparing for combat casualty care can be utilized.Includes bibliographical references (pages 139-147)

Addressing the Burden of Antimicrobial Resistance in Vietnamese Hospitals

Hospital acquired infections (HAIs), especially ventilator associated respiratory infection (VARI) cause significant morbidity and mortality, and disproportionally so in low- and middle-income countries (LMICs), including Vietnam, where infection control in hospitals is often neglected. The management of HAIs in these settings is challenging because of the high proportions of antimicrobial drug resistance and limitations of laboratory diagnostics, financial and human resources in terms of knowledge and skills for antimicrobial stewardship and infection prevention and control. Because resistance is driven by use of antimicrobials, my thesis started with a question on use and cost of antimicrobials in public hospitals in the country followed by a detailed assessment of use and cost of antimicrobials in the management of ventilator associated respiratory infections (VARI). I obtained detailed bids from hospitals and provincial departments of health representing 28.7% (1.68 / 5.85 billion US$) of the total hospital medication budget in Vietnam. Antimicrobials represented 28.6$ 40 million per year. Our studies showed the need for an affordable and scalable intervention in critical care units to reduce the burden of VARI and provide cost savings for national health expenditure. My studies also showed that antimicrobial costs are a major component of the excess cost of VARI management in Vietnam (51.1%) and that a one day reduction in the duration of antimicrobial therapy can save US$ 1.72 million. Therefore, my thesis has focused on interventions to prevent VARI and to shorten antimicrobial therapy. In recognition of human resources constraints in Vietnam, including for microbiology diagnostics and critical care nursing, I have studied automatic technology and equipment, including matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) for rapid identification of pathogens and continuous automatic cuff pressure control device to prevent VARI. To examine effectiveness of these intervention, I conducted 2 randomised controlled trials to evaluate the clinical effectiveness of matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) in optimizing antimicrobial therapy and to evaluate the effectiveness of continuous cuff pressure control in preventing VARI. For the latter, pending unblinding and final results I describe the implementation of the trial and report the incidence of hospital acquired bloodstream infection during this trial. A diagnostic randomised controlled trial (RCT) was conducted to evaluate the impact of MALDITOF-MS versus conventional diagnostics in improving antimicrobial use in patients with confirmed infection. Although MALDITOF-MS provided more rapid identification of invasive bacterial and fungal pathogens than conventional microbiology, the proportion of patients on optimal therapy at 24 or 48 hours after growth of specimen did not increase. These findings showed that without human resources and an effective antimicrobial stewardship programme, technology alone cannot provide a solution for antimicrobial overuse in hospitals in LMICs. A randomized controlled clinical trial was conducted to evaluate the effectiveness of continuous cuff pressure control versus daily manual cuff measurement (VARI-prevent). In this study I recruited and followed-up 597 adult patients who were admitted to ICUs and were intubated within 48 hours of admission. The patients were randomised to receive either continuous or manual cuff pressure measurement and control and were followed for occurrence of VARI during ICU stay and up to 90 days after randomisation. The study has completed recruitment and follow-up and final analysis is ongoing. The overall rate of VARI and VAP in eligible patients was 23.7% (140/591) and 17.3% (102/591) respectively. The data from this trial (VARI-prevent) was analysed to estimate the incidence density rate of hospital acquired bloodstream infection (HABSI) in 3 ICUs in Vietnam for the first time. The most common pathogens causing HABSI were Klebsiella pneumoniae followed by Pseudomonas aeruginosa, Acinetobacter baumannii and Coagulase-Negative staphylococci. Polymicrobial culture results were reported in 6.8% (3/44) patients with culture confirmed HABSI. The rate of HABSI and central line associated BSI (CLABSI) were 7.4% (44/591) and 9.3% (31/333), respectively. The incidence density rate of HABSI and CLABSI were 3.76 per 1000 patients-days and 8.43 per 1000 catheter-days, respectively. This suggests that the implementation of infection prevention and control bundle including catheter care is important to reduce the high incidence of HABSI in Vietnam. The findings in my thesis are relevant to healthcare professionals and policy stakeholders. It demonstrates the magnitude of HAI burden and creates awareness of potential beneficial interventions. Results of my trials will be helpful to inform decisions to establish the antimicrobial stewardship programmes and infection prevention and control bundles to improve patients’ outcomes

Simulation in Nursing: Historical Analysis and Theoretical Modeling in Support of a Targeted Clinical Training Intervention

The use of simulation is widespread in healthcare education, and the potential impact of its use large. This is especially true for nursing education as we look to address problems with obtaining clinical experiences, develop critical thinking skills and create methods to measure the impact of simulation interventions. There is substantial empirical evidence in support of predictive relationships between simulation training interventions and knowledge acquisition. This has been extensively demonstrated with the use of a variety of simulation training modalities from standardized patients to human patient simulators. However, data to support changes in clinical practice and improved patient outcomes are quite limited, including attempts to measure the impact of simulation education on retention and transference of knowledge and skill for more complex healthcare process. Additionally, literature searches reveal that only a handful of authors have engaged in the types of foundational work that any emerging science needs. For example, while pieces of the simulation process have been examined in detail, few have attempted to describe what the process of simulation entails at a macro level. Within the past few years some researchers have begun to ask whether there is a causal or predictive relationship present, but few have explored what these associations may look like structurally and what the evidence for them is. The overall objectives of this current research were to: 1) perform an historical review of simulation in healthcare; 2) use this review to outline a new theoretical model of healthcare simulation; and, 3) conduct a small-scale study aimed at pilot-testing and describing part of that model. Hierarchical Task Analysis (HTA) was used to derive an optimum task set for the standard induction of general anesthesia (OTS-SIGA). New Student Registered Nurse Anesthetists (SRNAs) were trained to this task set, and their adherence to the process steps in the clinical setting was then assessed. We also attempted to measure whether repeating the HTA-derived OTS-SIGA simulation training would have an impact on knowledge and transference of simulation-developed skills to the clinical environment. These measures necessitated the development of associated data collection tools and processes for rater training

Identifying and understanding Risk factors for instability and adverse Events Associated with CHest physiotherapy in ventilated children

Background: Chest physiotherapy is a treatment option for ventilated children. Evidence supporting treatment effectiveness is limited and the safety profile is unknown. This study aimed to identify and understand risk factors for physiological instability and adverse events associated with chest physiotherapy in ventilated children. / Methods: This was a convergent mixed methods study. Work package 1: Explanatory sequential study to describe current physiotherapy practice and explore decision making, utilising an anonymous questionnaire, semi-structured interviews, focus groups, and document analysis. Work package 2: Retrospective single-centre study, using high-resolution data and electronic patient records. Mechanically ventilated children, aged 0-4 years, receiving chest physiotherapy were included. The primary outcome was oxygen saturation index (OSI). Incidence of adverse events (change ≥0.3) in the 60 minutes post-physiotherapy was investigated. / Results: The questionnaire was sent to 26/27 (96%) UK paediatric intensive care units, with a response rate of 61% (72/118). Sixteen physiotherapist interviews and two focus groups (n=7) were completed. Twenty-nine organisational documents were analysed. The most frequently used techniques were position changes, saline instillation, manual hyperinflations and chest wall vibrations. Variation in practice included the personnel involved in treatments. Clinical decision making was described as complex, iterative, and collaborative, with experience and expertise important factors. OSI data were available for 247 patients. OSI adverse event rates were between 7.4%-9.3%. The highest rate was recorded in the 5 minutes immediately post-physiotherapy. A higher proportion of patients with an adverse event were emergency admissions (p<0.001). There was no association between occurrence of an OSI adverse event post-physiotherapy and length of ventilation or mortality. / Conclusion: This is the first study to explore the safety of chest physiotherapy in ventilated children and the wider contextual factors. It has provided novel data regarding a popular treatment used in a vulnerable patient group. Further research is required to understand the risks and benefits of chest physiotherapy

Rescue activity of a civilian helicopter emergency medical service in the western cape, South Africa: a five-year retrospective review

Introduction - Helicopter search and rescue in Africa is conducted primarily by military organizations. Since 2002 the Western Cape of South Africa has had a dedicated contracted civilian helicopter emergency medical service (HEMS) conducting air ambulance, terrestrial and aquatic rescue. This is the first description of the operations of an African helicopter rescue service. Objective - To describe the terrestrial and aquatic helicopter rescue activity of a civilian operated HEMS in the Western Cape, South Africa from 1 January 2012 – 31 December 2016. Methods - A five-year retrospective review was conducted using data from the organization's operational database, aviation documents, rescue reports and patient care records. Patient demographics and activity at time of rescue, temporal and geographical distribution, crewing compositions, patient injury, triage, clinical interventions and rescue techniques were analysed. Results – A total of 581 search and rescue missions were conducted, of which 451 were terrestrial and 130 aquatic rescues. The highest volume of rescues was conducted within the urban Cape Peninsula. Hoisting using a rescue harness was the most common rescue technique used. 644 patients were rescued. Uninjured or minorly injured persons represented 79% of the sample. Trauma (33%, 196/644) was the most common medical reason for rescue, with lower limb trauma predominant (15%, 90/644). The most common clinical interventions performed were intravenous access (108, 24%), spinal immobilization (92, 21%), splinting (76, 17%) and analgesia administration (58, 13%). Conclusions - The patient demographics and rescue activity described are similar to those described in high-income settings

Accidental awareness during general anaesthesia in obstetric surgery

Accidental awareness during general anaesthesia (AAGA) occurs when a patient becomes unintentionally conscious during general anaesthesia, which may involve unpleasant memories of experiences during surgery. Contributory factors that may increase risk of AAGA coincide in pregnant women undergoing general anaesthesia for childbirth related surgery. Whilst obstetric general anaesthesia has largely been substituted by spinal and epidural (termed neuraxial) anaesthetic techniques, in which a mother can be awake and pain free during childbirth, general anaesthesia is still necessary to facilitate surgery rapidly in emergency situations or for mothers with certain medical conditions. In this thesis I investigate the distinct characteristics of general anaesthesia for pregnant women undergoing surgery for childbirth, whether these characteristics increase risk of AAGA, and changes to obstetric anaesthetic technique occurring in the context of wider anaesthetic developments over time. I provide evidence on the incidence, experiences, risk factors and psychological consequences of AAGA in peripartum women. Challenges to large scale clinical study of AAGA are explored and addressed in the design of a multi-centre, prospective, cross-sectional cohort study of women receiving general anaesthesia for obstetric surgery in 72 hospitals in England. A four-stage process for screening patients using direct questioning, verifying with corroborative detail, adjudicating and classifying descriptions of experiences is described. The interactional nature of research interviews, statistical modelling, psychological factors and the neurophysiology of memory are considered during development of study methodology. Psychological morbidity was assessed for 12 months after surgery. As part of an embedded study, descriptive epidemiology of obstetric patients and general anaesthesia techniques were identified, alongside risk factors for airway complications. A total of 3,115 patients were recruited, 12 of whom had certain/probable or possible AAGA: a prevalence of 0.39% or 1 in 256 (95%CI 149–500) for all obstetric surgery. Distressing experiences were reported by seven (0.22%) patients, paralysis by five (0.16%) and paralysis with pain by two (0.06%). Associations were identified between AAGA and patient risk factors (abnormal body mass index), organisational factors (out-of-hours surgery) and pharmacological factors (use of thiopental during induction of anaesthesia). Contextual factors relating anaesthesia for obstetric patients with AAGA and other anaesthesia complications, including difficult airway management, were evaluated. My study methodology and it’s context, in English public sector hospitals, identified a higher risk of AAGA in obstetric patients than previously detected using other methods and locations. These results have implications for healthcare policy of obstetric anaesthesia, informed consent of patients receiving general anaesthesia and post-natal screening care. I conclude on recommendations to minimise awareness risk for future patients and address the challenge of implementing systemic improvements in obstetric general anaesthesia care and patient safety