Article

Simulation Trainer for Practicing Emergent Open Thoracotomy Procedures

Authors:
  • St. Francis Medical Center, Trenton, NJ
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Abstract

An emergent open thoracotomy (OT) is a high-risk, low-frequency procedure uniquely suited for simulation training. We developed a cost-effective Cardiothoracic (CT) Surgery trainer and assessed its potential for improving technical and interprofessional skills during an emergent simulated OT. We modified a commercially available mannequin torso with artificial tissue models to create a custom CT Surgery trainer. The trainer's feasibility for simulating emergent OT was tested using a multidisciplinary CT team in three consecutive in situ simulations. Five discretely observable milestones were identified as requisite steps in carrying out an emergent OT; namely (1) diagnosis and declaration of a code situation, (2) arrival of the code cart, (3) arrival of the thoracotomy tray, (4) initiation of the thoracotomy incision, and (5) defibrillation of a simulated heart. The time required for a team to achieve each discrete step was measured by an independent observer over the course of each OT simulation trial and compared. Over the course of the three OT simulation trials conducted in the coronary care unit, there was an average reduction of 29.5% (P< 0.05) in the times required to achieve the five critical milestones. The time required to complete the whole OT procedure improved by 7 min and 31 s from the initial to the final trial-an overall improvement of 40%. In our preliminary evaluation, the CT Surgery trainer appears to be useful for improving team performance during a simulated emergent bedside OT in the coronary care unit. Copyright © 2015 Elsevier Inc. All rights reserved.

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... 3,5,7 Highfidelity simulation models are increasingly being employed to allow for repetitive practice; however, no competency-based curriculum currently exists for EDT. [10][11][12][13] Mastery learning is a well-regarded, reliable, and highly effective competency-based education approach within health professions education. Its core tenants dictate that trainees must achieve an a priori-defined level of high proficiency in a given instructional unit with little to no variation prior to proceeding to the next unit. ...
Article
Introduction: Emergency department thoracotomy (EDT) is a lifesaving procedure within the scope of practice of emergency physicians. Because EDT is infrequently performed, emergency medicine (EM) residents lack opportunities to develop procedural competency. There is no current mastery learning curriculum for residents to learn EDT. The purpose of this study was to develop and implement a simulation-based mastery learning curriculum to teach and assess EM residents' performance of the EDT. Methods: We developed an EDT curriculum using a mastery learning framework. The minimum passing standard (MPS) for a previously developed 22-item checklist was determined using the Mastery Angoff approach. EM residents at a four-year academic EM residency program underwent baseline testing in performing an EDT on a simulation trainer. Performance was scored by two raters using the checklist. Learners then participated in a novel mastery learning EDT curriculum that included an educational video, hands-on instruction, and deliberate practice. After a three-month period, residents then completed initial post testing. Residents who did not meet the minimum passing standard after post testing participated in additional deliberate practice until mastery was obtained. Baseline and post-test scores, and time to completion of the procedure were compared with paired t-tests. Results: Of 56 eligible EM residents, 54 completed baseline testing. Fifty-two residents completed post-testing until mastery was reached. The minimum passing standard was 91.1%, (21/22 items correct on the checklist). No participants met the MPS at the baseline assessment. After completion of the curriculum, all residents subsequently reached the MPS, with deliberate practice sessions not exceeding 40 minutes. Scores from baseline testing to post-testing significantly improved across all postgraduate years from a mean score of 10.2/22 to 21.4/22 (p <0.001). Mean time to complete the procedure improved from baseline testing (6 minutes [min] and 21 seconds [sec], interquartile range [IQR] = 4 min 54 sec - 7 min 51 sec) to post-testing (5 min 19 seconds, interquartile range 4 min 17sec - 6 min 15 sec; p = 0.001). Conclusion: This simulation-based mastery learning curriculum resulted in all residents performing an EDT at a level that met or exceeded the MPS with an overall decrease in time needed to perform the procedure.
... We sought to construct a low-cost, low fidelity model that sought to bridge that gap in knowledge and experience with our residents. Commercially available models were available but found to be cost-prohibitive [2,3]. Previous low-cost thoracotomy trainers have been proposed in the past but typically revolve around modifying a costly existing simulation model or are very low fidelity and bear limited resemblance to actual landmarks and anatomy [4,5]. ...
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Emergent thoracotomy is a rare but high-stakes procedure for trauma patients. Emergency medicine residents are expected to perform this procedure after graduation, but few get the opportunity to perform it, leading to suboptimal performance and patient morbidity and mortality. Previous low-cost thoracotomy trainers revolve around modifying an existing costly thoracotomy task trainer or bear limited resemblance to actual landmarks and anatomy. This study attempts to bridge this gap by creating a low-cost model with supplies found at most home improvement/craft stores that is more anatomically accurate. We constructed a low fidelity model, which residents ultimately found to be helpful in mastering this rare procedure, and after the training session, they reported a greater level of comfort and familiarization with the procedure.
... In der Herz-Thorax-Chirurgie wurden Trainingseinheiten in Szenarien durch- geführt, um beispielsweise die Zusam- menarbeit von Intensivmedizinpersonal und Operateuren zu verbessern. Die Notfallthorakotomie während Reani- mation aufgrund eines Perikardergusses nach minimalinvasiver Koronar-Bypass- Operation wurde mit einem selbst er- stellten Köperteilsimulator und einem "high fidelity simulator" auf einer reellen Intensivstation durchgeführt [12]. The- menschwerpunkte waren das Design des Köperteilmodells für die Thorakotomie und die Kommunikation im Team. ...
Article
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Simulation ist ein etabliertes Instrument in der medizinischen Aus-, Fort- und Weiterbildung und deckt technische sowie nichttechnische Aspekte ab. Sie bietet eine Plattform für das Training psychomotorischer Kompetenzen und professionellen Verhaltens. Verschiedene Simulatoren wurden für die Herz-, Thorax- und Gefäßchirurgie entwickelt. „Skill trainer“ sind für die Herzklappenchirurgie und koronare Bypässe beschrieben. Neben den klassischen Tiermodellen gibt es kommerzielle Simulatoren, die das schlagende Herz realitätsnah imitieren. Die virtuelle Realität (VR) ermöglicht Training auch im Bereich der interventionellen und thorakoskopischen Chirurgie. Jeder Simulator muss in ein definiertes Curriculum einbettet sein, um den bestmöglichen Trainingseffekt zu erzielen. Durch Curricula in Form von Kursen können chirurgische Basisfertigkeiten bisweilen effektiver erlernt werden als in der realen Patientenversorgung im OP. Eine hierzu genutzte Methode ist das Szenariotraining in Echtzeit. Internationale Organisationen empfehlen dieses für die Notfallmedizin und die Evaluation von chirurgischen Fertigkeiten in diversen Fachbereichen. Aspekte wie Kommunikation, Teamführung und Entscheidungsfindung können effektiv trainiert werden. Es gibt nur wenige, aber wichtige Publikationen, die den positiven Effekt des Simulatortrainings auf die Patientenversorgung im herzchirurgischen OP und auf Intensivstationen nachweisen. Jedoch kann Simulation nie die Erfahrung am Patienten ersetzen. Insbesondere unerfahrene Ärzte neigen dazu, ihre eigenen medizinischen Kompetenzen in der Patientenversorgung nach einem Training am Simulator zu überschätzen. Simulation bietet daher einen wertvollen Zusatz, aber keinen Ersatz in der medizinischen Aus-, Fort- und Weiterbildung.
... These studies support the use of simulations to increase the confidence and the efficiency of interprofessional teams involved in ECMO programs. Similarly, a new Cardiothoracic Surgery Trainer proved useful for improving team performance during a simulated bedside open thoracotomy in the CCU[27]. Technical skills: ...
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Objective: Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED). Methods: Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants' assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours. Results: 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time. Conclusions: In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.
Article
Deliberate practice is an important skill-training strategy in emergency medicine (EM) education. Learning curves display the relationship between practice and proficiency. Forgetting curves show the opposite, and demonstrate how skill decays over time when it is not reinforced. Using examples of published studies of deliberate practice in EM we list the properties of learning and forgetting curves and suggest how they can be combined to create experience curves: a longitudinal representation of the relationship between practice, skill acquisition, and decay over time. This framework makes explicit the need to avoid a piecemeal, episodic approach to skill practice and assessment in favor of more emphasis on what can be done to improve durability of competence over time. The authors highlight the implications for both educators and education researchers.
Article
The utility of simulation in surgical training is now well-established, with proven validity and demonstrable transfer of skills to the clinical setting. Through a reduction in the technical learning curve, simulation can prepare surgeons for actual practice and in doing so it has the potential to improve both patient safety and service efficiency. More broadly, multi-disciplinary simulation of the theatre environment can aid development of non-technical skills and assist in preparing theatre teams for infrequently encountered scenarios such as surgical emergencies. The role of simulation in the formal training curriculum is less well-established, and availability of facilities for this is currently unknown. This paper reviews the contemporary evidence supporting simulation in surgical training and reports trainee access to such capabilities. Our national surgical trainee survey with 1130 complete responses indicated only 41.2% had access to skills simulator facilities. Of those with access, 16.3% had availability out-of-hours and only 54.0% had local access (i.e. current work place). These results highlight the paucity in current provision of surgical skills simulator facilities, and availability (or awareness of availability) varies widely between region, grade and specialty. Based on these findings and current best-evidence, the Association of Surgeons in Training propose 22 action-points for the introduction, availability and role of simulation in surgical training. Adoption of these should guide trainers, trainees and training bodies alike to ensure equitable provision of appropriate equipment, time and resources to allow the full integration of simulation into the surgical curriculum.
Article
A paradigm shift in surgical training has led to national efforts to incorporate simulation-based learning into cardiothoracic residency programs. Our goal was to determine the feasibility of developing a cardiac surgery simulation curriculum using the formal steps of curriculum development. Cardiothoracic surgery residents (n = 6) and faculty (n = 9) evaluated 54 common cardiac surgical procedures to determine their need for simulation. The highest scoring procedures were grouped into similarly themed monthly modules, each with specific learning objectives. Educational tools consisting of inanimate, animate, and cadaveric facilities and a newly created virtual operating room were used for curriculum implementation. Resident satisfaction was evaluated by way of a 5-point Likert scale. Perceived competency (scale of 1-10) and pre-/post-self-confidence (scale of 1-5) scores were collected and analyzed using cumulative mean values and a paired t-test. Of the 23 highest scoring procedures (mean score, ≥ 4.0) on the needs assessment, 21 were used for curriculum development. These procedures were categorized into 12 monthly modules. The simulation curriculum was implemented using the optimal simulation tool available. Resident satisfaction (n = 57) showed an overwhelmingly positive response (mean score, ≥ 4.7). The perceived competency scores highlighted the procedures residents were uncomfortable performing independently. The pre-/post-self-confidence scores increased throughout the modules, and the differences were statistically significant (P < .001). It is feasible to develop and implement a cardiac surgery simulation curriculum using a structured approach. High-fidelity, low-technology tools such as a fresh tissue cadaver laboratory and a virtual operating room could be important adjuncts.
Article
With increasing complexity of medical care and continuing limitations on medical education, the use of simulation is becoming ever more important. Several simulators have been developed to teach procedural-based surgical tasks. The care of the cardiac surgical patient requires an in-depth understanding of physiology, particularly as pertains to cardiopulmonary bypass. We describe the use of the Human Patient Simulator (HPS) to teach perioperative fundamentals to surgical residents. General surgery residents from the University of Kentucky participated in an interactive simulation pilot program. The METI (Medical Education Technology, Inc, Sarasota, Florida) HPS was used with custom programming to demonstrate simulated intraoperative and postoperative physiology related to cardiopulmonary bypass. Didactics, in addition to intraoperative echocardiographic images, were provided. Fund of knowledge was assessed by a computerized pre- and posttest that was administered to the trainees, and self-assessment data were collected using a Likert scale. Nineteen general surgery residents participated. An overall improvement in performance on the test was demonstrated from 63% correct to 85% correct. In general, residents found the simulation useful, appreciated the opportunity to treat crisis situations without risk of harm to a patient, and felt they could apply the knowledge gained from this program in their future practice. Simulation serves as a useful adjunct to medical education. We have demonstrated the use of the HPS to provide a real-time simulation of the physiology of cardiopulmonary bypass and postoperative care. We plan to use this system as part of our standard curriculum of training rotating residents and junior fellows and anticipate this system could be used as part of future cardiothoracic simulations.
Article
This study presents a cost-utility analysis that compared medium- vs. high-fidelity human patient simulation manikins in nursing education. The analysis sought to determine whether the extra costs associated with high-fidelity manikins can justify the differences, if any, in the outcomes of clinical reasoning, knowledge acquisition and student satisfaction. Investment in simulated learning environments has increased at an unprecedented pace. One of the driving forces is the potential for simulation experiences to improve students' learning and engagement. A cost-effectiveness analysis is needed to inform decisions related to investment in and use of simulation equipment. Costs associated with the use of medium- and high-fidelity manikins were calculated to determine the total cost for each. A cost-utility analysis using multiattribute utility function was then conducted to combine costs and three outcomes of clinical reasoning, knowledge acquisition and student satisfaction from a quasi-experimental study to arrive at an overall cost utility. The cost analysis indicated that to obtain equivalent clinical reasoning, knowledge acquisition and student satisfaction scores, it required $AU1·21 (US$ 1·14; €0·85) using medium-fidelity as compared with $AU6·28 (US$6·17; €4·40) for high-fidelity human patient simulation manikins per student. Based on the results of the cost-utility analysis, medium-fidelity manikins are more cost effective requiring one-fifth of the cost of high-fidelity manikins to obtain the same effect on clinical reasoning, knowledge acquisition and student satisfaction. It is important that decision-makers have an economic analysis that considers both the costs and outcomes of simulation to identify the approach that has the lowest cost for any particular outcome measure or the best outcomes for a particular cost.
Article
Extracorporeal membrane oxygenation (ECMO) is a high-risk, complex therapy. Opportunities to develop teamwork skills and expertise to mitigate risks are few. Our objective was to assess whether simulation would improve technical and nontechnical skills in dealing with ECMO circuit emergencies and allow transfer of skills from the simulated setting to clinical environment. Subjects were ECMO circuit providers who performed scenarios utilizing an infant simulator and functional ECMO circuit, followed immediately by video-assisted debriefings. Within the simulation laboratory, outcomes were timed responses, percentage of correct actions, teamwork, safety knowledge, and attitudes. Identification of latent safety threats (LSTs) was the focus of debriefings. Within the clinical setting, translation of learned skills was assessed by measuring circuit readiness and compliance with a cannulation initiation checklist. Nineteen subjects performed 96 simulations during enrollment. In the laboratory, there was no improvement in timed responses or percent correct actions. Teamwork (P = 0.001), knowledge (P = 0.033), and attitudes (P = 0.001) all improved compared with baseline. Debriefing identified 99 LSTs. Clinically, 26 cannulations occurred during enrollment. Median time from blood available to circuit readiness was 17 minutes (range, 5-95), with no improvement during the study. Compliance with the initiation checklist improved compared with prestudy baseline (P < 0.0001). Simulation-based training is an effective method to improve safety knowledge, attitudes, and teamwork surrounding ECMO emergencies. On-going training is feasible and allows identification of LSTs. Further work is needed to assess translation of learned skills and behaviors into the clinical environment.
Article
: Our institution recently opened a satellite hospital including a pediatric emergency department. The staffing model at this facility does not include residents or subspecialists, a substantial difference from our main hospital. Our previous work and published reports demonstrate that simulation can identify latent safety threats (LSTs) in both new and established settings. Using simulation, our objective was to define optimal staff roles, refine scope of practice, and identify LSTs before facility opening. : Laboratory simulations were used to define roles and scope of practice. After each simulation, teams were debriefed using video recordings. The National Aeronautics and Space Administration-Task Load Index was completed by each participant to measure perceived workload. Simulations were scored for team behaviors by video reviewers using the Mayo High Performance Team Scale. Subsequent in situ simulations focused on identifying LSTs and monitoring for unintended consequences from changes made. : Twenty-four simulations were performed over 3 months before the hospital opening. Laboratory debriefing identified the need to modify provider responsibilities. National Aeronautics and Space Administration-Task Load Index scores and debriefings demonstrated that the medication nurse had the greatest workload during resuscitations. Modifying medication delivery was deemed critical. Lower Mayo High Performance Team Scale scores, implying less teamwork, were noted during in situ simulations. In situ sessions identified 37 LSTs involving equipment, personnel, and resources. : Simulation can help determine provider workload, refine team responsibilities, and identify LSTs. This pilot project provides a template for evaluation of new teams and clinical settings before patient exposure.
Article
Since the publication of "To Err Is Human" in 1999, health care professionals have looked to high-reliability industries such as aviation for guidance on improving system safety. One of the most widely adopted aviation-derived approaches is simulation-based team training, also known as crew resource management training. In the health care domain, crew resource management training often takes place in custom-built simulation laboratories that are designed to replicate operating rooms or labor and delivery rooms. Unlike these traditional crew resource management training programs, "in situ simulation" occurs on actual patient care units, involves actual health care team members, and uses actual organization processes to train and assess team performance. During the past 24 months, our research team has conducted nearly 40 in situ simulations. In this article, we present the results from 1 such simulation: a patient who experienced a difficult labor that resulted in an emergency caesarian section and hysterectomy. During the simulation, a number of latent environmental threats to safety were identified. This article presents the latent threats and the steps that the hospital has taken to remedy them.
Article
The simulation-based team training used in commercial aviation can provide healthcare professionals with guidance on improving patient safety. To show how in situ simulation can identify latent environmental threats to patient safety. Case study. This in situ simulation took place at a large Midwestern hospital in January 2007. It involved a patient with chest pain and hypotension that required cardiac catheterization. The simulation had 2 phases: emergency department and catheterization laboratory. Materials included a patient manikin, a high-definition camcorder, and software for annotating the video in real time. Props (eg, simulated electrocardiogram results, chest x-rays) were used. A Master Scenario Event List was used to orchestrate the entire simulation event. Three latent environmental threats to patient safety were identified: procedures for transporting patients between the 2 units, for managing the handoff process, and for organizing the cardiac catheterization process. These were not training issues, but were due to poorly developed or nonexistent procedures that affected the performance of all healthcare teams on those units every working day. The threats were identified by the simulation participants (along with their supervisors) during the post-simulation debriefing as being sufficiently common and dangerous to warrant further review and remedy. By conducting our simulations in the actual environment of care, using intact teams of healthcare professionals who practiced their actual technologies and work processes during the simulation, we could identify latent environmental threats to patient safety that could never be explored in an artificial laboratory environment.
Article
Physical signs that can be seen, heard, and felt are one of the cardinal features that convey realism in patient simulations. In critically ill children, physical signs are relied on for clinical management despite their subjective nature. Current technology is limited in its ability to effectively simulate some of these subjective signs; at the same time, data supporting the educational benefit of simulated physical features as a distinct entity are lacking. We surveyed pediatric housestaff as to the realism of scenarios with and without simulated physical signs. Residents at three children's hospitals underwent a before-and-after assessment of performance in mock resuscitations requiring Pediatric Advanced Life Support (PALS), with a didactic review of PALS as the intervention between the assessments. Each subject was randomized to a simulator with physical features either activated (simulator group) or deactivated (mannequin group). Subjects were surveyed as to the realism of the scenarios. Univariate analysis of responses was done between groups. Subjects in the high-fidelity group were surveyed as to the relative importance of specific physical features in enhancing realism. Fifty-one subjects completed all surveys. Subjects in the high-fidelity group rated all scenarios more highly than low-fidelity subjects; the difference achieved statistical significance in scenarios featuring a patient in asystole or pulseless ventricular tachycardia (P < 0.04 for both comparisons). Chest wall motion and palpable pulses were rated most highly among physical features in contributing to realism. PALS scenarios were rated as highly realistic by pediatric residents. Slight differences existed between subjects exposed to simulated physical features and those not exposed to them; these differences were most pronounced in scenarios involving pulselessness. Specific physical features were rated as more important than others by subjects. Data from these surveys may be informative in designing future simulation technology.
Article
The purposes of this study were to a) estimate the incidence of intensive care units nurses' intention to leave due to working conditions; and b) identify factors predicting this phenomenon. Cross-sectional design. Hospitals and critical care units. Registered nurses (RNs) employed in adult intensive care units. Organizational climate, nurse demographics, intention to leave, and reason for intending to leave were collected using a self-report survey. Nurses were categorized into two groups: a) those intending to leave due to working conditions; and b) others (e.g., those not leaving or retirees). The measure of organizational climate had seven subscales: professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate. Setting characteristics came from American Hospital Association data and a survey of chief nursing officers. A total of 2,323 RNs from 66 hospitals and 110 critical care units were surveyed across the nation. On average, the RN was 39.5 yrs old (SD = 9.40), had 15.6 yrs (SD = 9.20) experience in health care, and had worked in his or her current position for 8.0 yrs (SD = 7.50). Seventeen percent (n = 391) of the respondents indicated intending to leave their position in the coming year. Of those, 52% (n = 202) reported that the reason was due to working conditions. Organizational climate factors that had an independent effect on intensive care unit nurse intention to leave due to working conditions were professional practice, nurse competence, and tenure (p < .05). Improving professional practice in the work environment and clinical competence of the nurses as well as supporting new hires may reduce turnover and help ensure a stable and qualified workforce.
Article
A survey was conducted on CTSNet, the cardiothoracic network website in order to ascertain an international viewpoint on a range of issues in resuscitation after cardiac surgery. From 40 questions, 19 were selected by the EACTS clinical guidelines committee. Respondents were anonymous but their location was determined by their Internet protocol (IP) address. The responses were checked for duplication and completion errors and then the results were presented either as percentages or median and range. From 387 responses, 349 were suitable for inclusion from 53 countries. The median size of unit of respondents performed 560 cases per year. The incidence of cardiac arrest reported was 1.8%, emergency resternotomy after arrest 0.5% and emergency reinstitution of bypass 0.2%. Only 32% of respondents follow current guidelines on resuscitation in their unit and an additional 25% of respondents have never read these guidelines. Respondents indicated that they would perform three attempts at defibrillation for ventricular fibrillation without intervening external cardiac massage and for all arrests perform emergency resternotomy within 5 min if within 24h of the operation. Fifty percent of respondents would give adrenaline immediately, 58% of respondents would be happy for a non-surgeon to perform an emergency resternotomy and 76% would allow a surgeon's assistant and 30% an anaesthesiologist to do this. Only 7% regularly practise for arrests, but 80% thought that specific training in this is important. This survey supports the EACTS guideline for resuscitation in cardiac arrest after cardiac surgery published in this issue of the journal.
Article
The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given. This guideline is subject to continuous informal review, and when new evidence becomes available.
Article
Emergency chest reopen of the post cardiac surgical patient in the intensive care unit is a high-stakes but infrequent procedure which requires a high-level team response and a unique skill set. We evaluated the impact on knowledge and confidence of team-based chest reopen training using a patient simulator compared with standard video-based training. We evaluated 49 medical and nursing participants before and after training using a multiple choice questions test and a questionnaire of self-reported confidence in performing or assisting with emergency reopen. Both video- and simulation-based training significantly improved results in objective and subjective domains. Although the post-test scores did not differ between the groups for either the objective (P=0.28) or the subjective measures (P=0.92), the simulation-based training produced a numerically larger improvement in both domains. In a multiple choice question out of 10, participants improved by a mean of 1.9 marks with manikin-based training compared to 0.9 with video training (P=0.03). On a questionnaire out of 20 assessing subjective levels of confidence, scores improved by 3.9 with manikin training compared to 1.2 with video training (P=0.002). Simulation-based training appeared to be at least as effective as video-based training in improving both knowledge and confidence in post cardiac surgical emergency resternotomy.
Article
Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis. Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed. Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training. In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.
Article
Surgical reexploration due to postoperative bleeding occurs in 2% to 6% of cardiac surgical patients and is accompanied by increased morbidity and mortality. In this study, we addressed the postoperative course of patients needing surgical reexploration, with specific respect to the timing of reexploration and the transfusional needs as determinants of morbidity and mortality. This was a retrospective study of 232 patients having undergone surgical reexploration owing to postoperative bleeding after cardiac operations, compared with a control, propensity-matched group. Patients in the surgical reexploration group had greater morbidity (low cardiac output, acute renal failure, sepsis) and longer mechanical ventilation time and intensive care unit stay than did control patients, and a significantly higher mortality rate (14.2% versus 3.4%, p = 0.001). The timing of surgical reexploration was not associated with morbidity or mortality. The amount of packed red cells transfused was significantly associated with increased morbidity (acute renal failure, low cardiac output syndrome, sepsis), with mechanical ventilation time and intensive care unit stay, and with the mortality rate (0.25% increase for each unit transfused). The main determinant of morbidity and mortality for patients requiring a surgical reexploration after cardiac operations is the amount of packed red cells transfused. Delaying the timing of reexploration may represent a risk factor only when the delay creates the need for an excessive use of allogeneic blood products, or in the presence of clinical signs of cardiac tamponade.
Article
Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993. Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time. The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors--increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.0.3)--were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p < 0.0001), and atrial arrhythmias (p = 0.006). These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations.
Article
The outcome of cardiopulmonary resuscitation (CPR) following cardiac surgery is not known to date. A retrospective analysis of all patients subjected to CPR during their hospital stay following heart surgery was conducted; 1.4% of patients required CPR 0.5-192 h following surgery. The mean duration of CPR was 42 +/- 29 min. Twenty-nine patients were subjected to emergency rethoractomy and 14 patients received coronary artery bypass grafting. The hospital mortality was 46%. There was a significant correlation of duration of CPR and death (r = 0.44, p = 0.004). The commonest cause of death was consecutive multiorgan failure in 12 patients. Twenty-one patients were long-term survivors without neurological sequelae. Twenty patients were in NYHA class I or II. Ventricular fibrillation and myocardial ischaemia are the commonest conditions leading to CPR in an average population of patients immediately after cardiac surgery. Aggressive treatment and emergency rethoracotomy in most cases results in long-term survival in 50%.
Article
To assess the incidence of acute mechanical causes precipitating sudden cardiac arrest in cardiac surgery patients during the immediate postoperative period. In addition, we report the success rate of cardiopulmonary resuscitation (CPR) in which open-chest CPR was employed at an early stage of the resuscitation effort. Data on all cardiac surgical patients who suffered a sudden cardiac arrest during the first 24 h after surgery were collected prospectively. CPR consisted of conventional closed-chest CPR initially and was followed within 3 to 5 min, if needed, by open-chest CPR. Of 3,982 patients undergoing cardiac surgery over a 30-month period, 29 patients (0.7%) had a sudden cardiac arrest. Of these, 13 patients (45%) were successfully resuscitated with closed-chest CPR, 14 (48%) with open-chest CPR, and 2 (7%) died despite closed- and open-chest CPR. Four CPR survivors died subsequently in the ICU, yielding an overall hospital discharge rate of 79%. Perioperative myocardial infarction was the underlying cause of sudden cardiac arrest in 14 patients (48%), and mechanical impediments to cardiac function (tamponade or graft malfunction) in another 8 (28%) patients; in the remaining 7 patients (24%), no underlying cause was found. The length of ICU stay was 6+/-1 (mean+/-SE) days. None of the patients developed wound infection and all were neurologically intact at hospital discharge. Mechanical factors account for a substantial portion (28%) of causes of sudden cardiac arrest occurring in hemodynamically stable patients during the immediate postoperative period. This high incidence, in conjunction with the high survival rate achieved by open CPR, supports an early approach to open-chest CPR in this group of patients.
Article
At our institution, cardiac reoperations are routinely performed in the cardiac intensive care unit, as opposed to taking these patients back to the operating room. Our hypothesis was that reoperation in a cardiac intensive care unit does not increase sternal infection rate. A retrospective analysis was performed on 6,908 adult patients undergoing cardiac operation over a 9-year period. Excluding those in cardiac arrest, 340 (4.9%) patients underwent reoperation in the cardiac intensive care unit, of which 289 survived (85%). Of the 289 patients who survived reoperation in the intensive care unit, 6 developed wound infections that required operative debridement (2.1%), which was not significantly different from those patients not requiring reoperation (1.9%, 121 of 6,497, p = 0.70). Hospital charges for a 2-hour reoperation in the intensive care unit and operating room are approximately $1,972/patient and $5,832/patient, respectively. Reoperation in the intensive care unit does not increase wound infection rate compared to those without reoperation. Decreased charges, avoiding transport of potentially unstable patients, quicker time to intervention, and convenience are advantages of reoperation in an intensive care unit.
Article
High fidelity simulation has become a popular technique for training teamwork skills in high risk industries such as aviation, health care, and nuclear power production. Simulation is a powerful training tool because it allows the trainer to systematically control the schedule of practice, presentation of feedback, and introduction (or suppression) of environmental distractions within a safe, controlled learning environment. Unfortunately, many within the training community have begun to use the terms simulation and high fidelity simulation almost synonymously. This is unfortunate because doing so overemphasises the instructional technology to the detriment of more substantive issues, such as the training's goals, content, and design. It also perpetuates several myths: simulation fidelity is unidimensional, or higher levels of simulation fidelity lead to increased training effectiveness. The authors propose a typology of simulation fidelity and provide examples of how the different classes of simulation have been successfully used to train teamwork skills in high risk industries. Guidelines are also provided to maximise the usefulness of simulation for training teamwork skills in health care.
Article
Issues concerning the training and certification of surgical specialists have taken on great significance in the last decade. A realistic computer-assisted, tissue-based simulator developed for use in the training of cardiac surgical residents in the conduct of a variety of cardiac surgical procedures in a low-volume cardiothoracic surgery unit of a typical developing country is described. The simulator can also be used to demonstrate the function of technology specific to cardiac surgical procedures in a way that previously has only been possible via the conduct of a procedure on a live animal or human being. A porcine heart in a novel simulated operating theatre environment with real-time simulated haemodynamic monitoring and coronary blood flow, in arrested and beating-heart modes, is used as a training tool for surgical residents. Standard and beating-heart coronary arterial bypass, aortic valve replacement, aortic homograft replacement and pulmonary autograft procedures can be simulated with high degrees of realism and with the superimposition of adverse clinical scenarios requiring valid decision making and clinical judgments to be made by the trainees. The cardiac surgical simulation preparation described here would appear to be able to contribute positively to the training of residents in low-volume centres, as well as having the potential for application in other settings as a training tool or clinical skills assessment or accreditation device. Collaboration with larger centres is recommended in order to accurately assess the utility of this preparation as an adjunctive cardiothoracic surgical training aid.
Article
The practice of sedating patients in the hospital for diagnostic and therapeutic procedures may be associated with life-threatening respiratory depression. We describe a method that uses a simulated event to identify latent system failures. A simulated scenario was developed that was reproducible with realistic physiology that degraded over time if no interventions occurred and improved when treated appropriately. Management of the scenario was observed in an ideal setting, a radiology department, and an emergency department. Event management was videotaped. The simulator's physiological data were saved automatically at 5-s intervals. Deviations from "best practice" were measured by using a set of video markers for event detection, diagnosis, and treatment. The simulator data files were used to calculate time out of range for critical variables. Hypoxia and hypotension lasted 4.5 and 5.5 min in the radiology and emergency departments, respectively, compared with 0 min in the gold standard setting. Many latent failures were identified by reviewing the video. This study supports the feasibility of using available human simulation as a crash-test dummy to more objectively quantify rescue system performance in actual sedation care settings. This method revealed vulnerabilities in personnel and in care systems even though sedation care regulatory requirements were met.
Article
According to the data from different cardiac surgery centers, the incidence of urgent repetitive resternotomy for bleeding after cardiac on-pump operations varies from 2 to 5%. The aim of the study was to determinate the risk factors influencing resternotomy after cardiac surgery, features of early postoperative period, and outcomes. Altogether, 37 consecutive patients undergoing urgent resternotomy due to bleeding early after cardiac surgery were analyzed retrospectively. Urgent resternotomies made up 4.3% of all cardiac on-pump surgeries performed on 856 patients at the Clinic of Cardiac Surgery of Kaunas University of Medicine Hospital during 2004. The mean age of patients was 64.9+/-12.9 years; 29.7% of patients were women and 70.3% were men. During analysis of preoperative clinical data factors that could influence coagulation status were determined. Twenty patients (54.1%) had moderate hypertension, three patients (8.1%) had severe insulin-dependent diabetes mellitus, and five patients (13.5%) had chronic renal insufficiency treated with dialysis. Assessing other risk factors it was observed that many patients were on peroral anticoagulation therapy before surgery. The most frequently administered drugs preoperatively were aspirin (16 cases, 43.2%) and direct-acting anticoagulants (17 cases, 45.9%). The use of antiaggregants and anticoagulants before surgery increases the incidence of resternotomies in the early postoperative period. Postoperative infections that require more expensive treatment with antibiotics are detected much more frequently in patients after resternotomies comparing to the remaining postoperative cardiac patients (15/37 and 69/819, respectively). However, longer hospitalization length (15.8 and 58.0 days, respectively) and higher mortality rate (4.5 and 10.8%, respectively) were observed in patients after resternotomy.
Article
Traditional medical education has emphasized autonomy, and until recently issues related to teamwork have not been explicitly included in medical curriculum. The Institute of Medicine highlighted that health care providers train as individuals, yet function as teams, creating a gap between training and reality and called for the use of medical simulation to improve teamwork. The aviation industry created a program called Cockpit and later Crew Resource Management that has served as a model for team training programs in medicine. This article reviews important concepts related to teamwork and discusses examples where simulation either could be or has been used to improve teamwork in medical disciplines to enhance patient safety.
Article
The healthcare system has an inconsistent record of ensuring patient safety. One of the main factors contributing to this poor record is inadequate interdisciplinary team behavior. This article describes in situ simulation and its 4 components--briefing, simulation, debriefing, and follow-up-as an effective interdisciplinary team training strategy to improve perinatal safety. The purpose of this manuscript is to describe the experiential nature of in situ simulation for the participants. Involved in a pilot study of 35 simulations in 6 hospitals with over 700 participants called, "In Situ Simulation for Obstetric and Neonatal Emergencies," conducted by Fairview Health Services in collaboration with the University of Minnesota's Academic Health Center.