Publications by authors named "Ellen S Deutsch"

52 Publications

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation.

Otolaryngol Head Neck Surg 2021 May 18:1945998211013314. Epub 2021 May 18.

Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.
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http://dx.doi.org/10.1177/01945998211013314DOI Listing
May 2021

A Road Map for Simulation Based Medical Students Training in Pediatrics: Preparing the Next Generation of Doctors.

Indian Pediatr 2020 10;57(10):950-956

Pediatric Simulation Training and Research Society (PediSTARS), India; and Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, USA.

Current Medical training in India is generally didactic and pedagogical, and often does not systematically prepare newly graduated doctors to be competent, confident and compassionate. After much deliberation, the Medical Council of India (MCI) has recently introduced a new outcome-driven curriculum for undergraduate medical student training with specific milestones and an emphasis on simulation-based learning and guided reflection. Simulation-based education and debriefing (guided reflection) has transformed medical training in many countries by accelerating learning curves, improving team skills and behavior, and enhancing provider confidence and competence. In this article, we provide a broad framework and roadmap suggesting how simulation-based education might be incorporated and contextualized by undergraduate medical institutions, especially for pediatric training, using local resources to achieve the goals of the new MCI competency-based and simulation-enhanced undergraduate curriculum.
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October 2020

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

Laryngoscope 2021 05 9;131(5):1168-1174. Epub 2020 Oct 9.

Department of Otolaryngology, Head and Neck Surgery, Stanford University, Lucile Salter Packard Children's Hospital, Palo Alto, California, U.S.A.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal.

Study Design: Blinded modified Delphi consensus process.

Setting: Tertiary care center.

Methods: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items.

Results: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus.

Conclusions: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated.

Level Of Evidence: 5. Laryngoscope, 131:1168-1174, 2021.
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http://dx.doi.org/10.1002/lary.29126DOI Listing
May 2021

Regionalization of ORL Boot Camps: Report of the Society of University Otolaryngologists Task Force.

Laryngoscope 2021 04 28;131(4):737-743. Epub 2020 Aug 28.

Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, U.S.A.

Objectives: Simulation-based boot camps have emerged as timely vehicles to help novice residents develop the skills needed to manage medical emergencies. Geographically regional boot camps provide opportunities for interaction between residents and faculty from multiple otolaryngology programs. The Society of University Otolaryngologists (SUO) Boot Camp Task Force investigated the concept of regional access to otolaryngology boot camps with the goal of making more regional boot camps available for otolaryngology residents across the United States.

Study Design: Interviews.

Methods: The SUO Boot Camp Task Force assessed regional access to otolaryngology boot camps with a focus on geographic distribution, curricular content, and finances. Boot camp directors were contacted by email and telephone and interviewed to elicit information on all these areas.

Results: Data were available from 10 known regional simulation-based boot camps designed for novice residents. Individual boot camps included from 12 to 30 residents and 10 to 50 faculty members. Curricula included both technical (ie, procedural) and non-technical (eg, communication, leadership) skills for individuals and teams. Content was heavily weighted toward a variety of airway problems and management techniques, although various conditions involving hemorrhage, and airway fires were also addressed. Funding and expense structures had the greatest variability.

Conclusions: Considerable variability was identified among the known regional boot camps in terms of numbers of participants and finances, but fewer differences in curriculum. Geographic opportunity for 9 to 10 new boot camps was identified. The SUO Task Force recommends that a consensus be developed for several individual skill and teamwork scenario objectives to be included in each boot camp. Laryngoscope, 131:737-743, 2021.
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http://dx.doi.org/10.1002/lary.29052DOI Listing
April 2021

Systems-focused simulation to prepare for COVID-19 intraoperative emergencies.

Paediatr Anaesth 2020 08 6;30(8):947-950. Epub 2020 Aug 6.

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1111/pan.13971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404905PMC
August 2020

"Changing the focus" for simulation-based education assessment… not simply "changing the view" with videolaryngoscopy.

J Pediatr (Rio J) 2021 Jan-Feb;97(1):4-6. Epub 2020 Jun 30.

University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Philadelphia, United States.

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http://dx.doi.org/10.1016/j.jped.2020.06.003DOI Listing
February 2021

SimTube: A National Simulation Training and Research Project.

Otolaryngol Head Neck Surg 2020 09 26;163(3):522-530. Epub 2020 May 26.

Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine Bronx, New York, USA.

Objective: To test the feasibility and impact of a simulation training program for myringotomy and tube (M&T) placement.

Study Design: Prospective randomized controlled.

Setting: Multi-institutional.

Subjects And Methods: An M&T simulator was used to assess the impact of simulation training vs no simulation training on the rate of achieving competency. Novice trainees were assessed using posttest simulator Objective Structured Assessment of Technical Skills (OSATS) scores, OSATS score for initial intraoperative tube insertion, and number of procedures to obtain competency. The effect of simulation training was analyzed using χ tests, Wilcoxon-Mann-Whitney tests, and Cox proportional hazards regression.

Results: A total of 101 residents and 105 raters from 65 institutions were enrolled; however, just 63 residents had sufficient data to be analyzed due to substantial breaches in protocol. There was no difference in simulator pretest scores between intervention and control groups; however, the intervention group had better OSATS global scores on the simulator (17.4 vs 13.7, = .0003) and OSATS task scores on the simulator (4.5 vs 3.6, = .02). No difference in OSATS scores was observed during initial live surgery rating ( = .73 and = .41). OSATS scores were predictive of the rate at which residents achieved competence in performing myringotomy; however, the intervention was not associated with subsequent OSATS scores during live surgeries ( = .44 and = .91) or the rate of achieving competence ( = .16).

Conclusions: A multi-institutional simulation study is feasible. Novices trained using the M&T simulator achieved higher scores on simulator but not initial intraoperative OSATS, and they did not reach sooner than those not trained on the simulator.
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http://dx.doi.org/10.1177/0194599820920833DOI Listing
September 2020

Do Fellows and Faculty Share the Same Perception of Simulation Fidelity? A Pilot Study.

Simul Healthc 2020 Aug;15(4):266-270

From the Department of Anesthesiology and Critical Care Medicine (D.S., T.K., H.G., E.S.D.), Children's Hospital of Philadelphia; Department of Anesthesiology and Critical Care Medicine (D.S., H.G., E.S.D.), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and Department of Anesthesiology (T.K.), Aichi Children's Health and Medical Center Obu, Aichi, Japan.

Introduction: Simulation is increasingly integrated into graduate medical education, and simulation faculty generally attempt to optimize the fidelity of simulators and simulations on behalf of trainees, so as to approach the realism of actual patient care experiences. As residents and fellows participate as learners in simulations, which faculty design, this investigation sought to address whether fellows and faculty have similar perceptions of fidelity by comparing ratings of 2 types of simulation experiences.

Methods: Prospective single-center observational study comparing surveys completed by fellows and faculty participating in multiple simulation sessions during a one-day simulation-based boot camp.

Results: Overall, both the fellows and the faculty provided moderate to high ratings of fidelity for both a technical skill and a teamwork simulation session. Fellows' ratings of an airway skills session were significantly higher than faculty ratings in 4 of 6 questions but similar to faculty ratings of a teamwork scenario session.

Conclusions: Pediatric anesthesia fellows' ratings of simulation fidelity were at least as high as faculty ratings during an annual boot camp, suggesting that faculty in this setting developed simulations that the fellows found to be realistic. Faculty were relatively more critical of the fidelity of a skill session, compared with a teamwork scenario session. If this finding is generalizable, this may reassure faculty designing simulations for fellows. Continued inspection of the entwined nature of fidelity and simulation will help inform more effective learning for this growing educational modality.
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http://dx.doi.org/10.1097/SIH.0000000000000454DOI Listing
August 2020

Competency-Based Assessment Tool for Pediatric Tracheotomy: International Modified Delphi Consensus.

Laryngoscope 2020 11 10;130(11):2700-2707. Epub 2019 Dec 10.

Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Pediatric Otolaryngology, Doernbecher Children's Hospital, Portland, Oregon, U.S.A.

Objectives/hypothesis: Create a competency-based assessment tool for pediatric tracheotomy.

Study Design: Blinded, modified, Delphi consensus process.

Methods: Using the REDCap database, a list of 31 potential items was circulated to 65 expert surgeons who perform pediatric tracheotomy. In the first round, items were rated as "keep" or "remove," and comments were incorporated. In the second round, experts were asked to rate the importance of each item on a seven-point Likert scale. Consensus criteria were determined a priori with a goal of 7 to 25 final items.

Results: The first round achieved a response rate of 39/65 (60.0%), and returned questionnaires were 99.5% complete. All items were rated as "keep," and 137 comments were incorporated. In the second round, 30 task-specific and seven previously validated global rating items were distributed, and the response rate was 44/65 (67.7%), with returned questionnaires being 99.3% complete. Of the Task-Specific Items, 13 reached consensus, 10 were near consensus, and 7 did not achieve consensus. For the 7 previously validated global rating items, 5 reached consensus and two were near consensus.

Conclusions: It is feasible to reach consensus on the important steps involved in pediatric tracheotomy using a modified Delphi consensus process. These items can now be considered to create a competency-based assessment tool for pediatric tracheotomy. Such a tool will hopefully allow trainees to focus on the important aspects of this procedure and help teaching programs standardize how they evaluate trainees during this procedure.

Level Of Evidence: 5 Laryngoscope, 130:2700-2707, 2020.
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http://dx.doi.org/10.1002/lary.28461DOI Listing
November 2020

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study.

J Allergy Clin Immunol Pract 2020 04 23;8(4):1239-1246.e3. Epub 2019 Nov 23.

Departments of Pediatrics and Emergency Medicine, Yale University, New Haven, Conn.

Background: Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported.

Objective: To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors.

Methods: A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.

Results: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid.

Conclusions: A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
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http://dx.doi.org/10.1016/j.jaip.2019.11.013DOI Listing
April 2020

Patient Safety in Anesthesia.

Otolaryngol Clin North Am 2019 Dec 17;52(6):1005-1017. Epub 2019 Sep 17.

Department of Anesthesiology, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, 110 East 210th Street, 4th Floor Silver Zone, Bronx, NY 10467, USA.

Anesthesiologists and otolaryngologists share the airway in an elegant ballet that requires communication, collaboration, and mutual respect. This article addresses principles to prevent or manage challenging conditions such as airway fires, anatomically difficult airways, and post-tonsillectomy hemorrhage. Discussion includes rationales for the use of simulation and resilience engineering principles to achieve the safest patient care.
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http://dx.doi.org/10.1016/j.otc.2019.08.003DOI Listing
December 2019

An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams.

Am J Med Qual 2019 Nov/Dec;34(6):569-576. Epub 2019 Feb 9.

The Hospital for Sick Children, Toronto, ON, Canada.

Errors in thinking contribute to harm, delays in diagnosis, incorrect treatments, or failures to recognize clinical changes. Models of cognition are useful in understanding error occurrence and avoidance. Intra-team conflict can represent failures in joint cognitive processing. The authors developed training focused on recognizing and managing cognitive bias and resolving conflicts. The program provides context and introduces models of cognition, concepts of bias, team cognition, conflict resolution, and 2 tools. "IDEA" incorporates 4 de-biasing strategies: Identify assumptions; Don't assume correctness; Explore expectations; Assess alternatives. "TLA" presents strategies for resolving conflicts: Tell your thoughts; Listen actively, and Ask questions. A total of 4941 care providers participated in training using didactic presentations, group discussion, and simulation. Learners rated training effectiveness at 4.68 on a scale of 1 to 5 (5 as optimum) and perceived improvement in recognizing or managing errors. Nonphysician caregivers reported greatest improvement. Training to improve critical thinking is feasible, well received, and effective.
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http://dx.doi.org/10.1177/1062860618820687DOI Listing
July 2020

Simulation Saves the Day (and Patient).

Otolaryngol Clin North Am 2019 Feb 22;52(1):115-121. Epub 2018 Sep 22.

Department of Emergency Medicine, Center for Experiential Learning and Simulation, University of Florida, 1104 Newell Drive, Suite 445, Gainesville, FL 32610, USA.

Surgeons can use simulation to improve the safety of the systems they work within, around, because of, and despite. Health care is a complex adaptive system that can never be completely knowable; simulation can expose aspects of patient care delivery that are not necessarily evident prospectively, during planning, or retrospectively, during investigations or audits. The constraints of patient care processes and adaptive capacity of health care providers may become most evident during simulations conducted "in situ" using real teams and real equipment, in actual patient care locations.
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http://dx.doi.org/10.1016/j.otc.2018.08.005DOI Listing
February 2019

Staying Well in a Sea of Harm.

Authors:
Ellen S Deutsch

Otolaryngol Head Neck Surg 2018 06 13;158(6):983-984. Epub 2018 Mar 13.

1 Pennsylvania Patient Safety Authority, Harrisburg, Pennsylvania, USA.

Physician psychological wellness is an emergent outcome resulting from dynamic interactions among complex conditions. We may enhance opportunities for physician wellness by applying principles developed to improve another emergent outcome: patient safety. The Safety I approach to patient safety focuses on "what went wrong" and considers humans a liability. Safety II is a powerful complementary approach that focuses on "what went right" and values human creativity. These contrasting perspectives are described in the context of patient safety, but the underlying principles have relevance for physician psychological wellness. We can create conditions that interfere with wellness and conditions that support wellness. We can learn from exploring and reinforcing successes and improving routine processes; together, these approaches may have a greater cumulative positive impact than just addressing problems. In addition to learning from failures, there is much we can learn from success.
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http://dx.doi.org/10.1177/0194599818764409DOI Listing
June 2018

Wrong-site nerve blocks: A systematic literature review to guide principles for prevention.

J Clin Anesth 2018 05 2;46:101-111. Epub 2018 Mar 2.

Pennsylvania Patient Safety Authority, 333 Market Street, Lobby Level, Harrisburg, PA 17120, USA. Electronic address:

Study Objective: Wrong-site nerve blocks (WSBs) are a significant, though rare, source of perioperative morbidity. WSBs constitute the most common type of perioperative wrong-site procedure reported to the Pennsylvania Patient Safety Authority. This systematic literature review aggregates information about the incidence, patient consequences, and conditions that contribute to WSBs, as well as evidence-based methods to prevent them.

Design: A systematic search of English-language publications was performed, using the PRISMA process.

Main Results: Seventy English-language publications were identified. Analysis of four publications reporting on at least 10,000 blocks provides a rate of 0.52 to 5.07 WSB per 10,000 blocks, unilateral blocks, or "at risk" procedures. The most commonly mentioned potential consequence was local anesthetic toxicity. The most commonly mentioned contributory factors were time pressure, personnel factors, and lack of site-mark visibility (including no site mark placed). Components of the block process that were addressed include preoperative nerve-block verification, nerve-block site marking, time-outs, and the healthcare facility's structure and culture of safety.

Discussion: A lack of uniform reporting criteria and divergence in the data and theories presented may reflect the variety of circumstances affecting when and how nerve blocks are performed, as well as the infrequency of a WSB. However, multiple authors suggest three procedural steps that may help to prevent WSBs: (1) verify the nerve-block procedure using multiple sources of information, including the patient; (2) identify the nerve-block site with a visible mark; and (3) perform time-outs immediately prior to injection or instillation of the anesthetic. Hospitals, ambulatory surgical centers, and anesthesiology practices should consider creating site-verification processes with clinician input and support to develop sustainable WSB-prevention practices.
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http://dx.doi.org/10.1016/j.jclinane.2017.12.008DOI Listing
May 2018

Using Simulation to Improve Systems.

Otolaryngol Clin North Am 2017 Oct 8;50(5):1015-1028. Epub 2017 Jul 8.

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Pennsylvania Patient Safety Authority, Harrisburg, PA, USA; ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462, USA. Electronic address:

Attempts to understand and improve health care delivery often focus on the characteristics of the patient and the characteristics of the health care providers, but larger systems surround and integrate with patients and providers. Components of health care delivery systems can support or interfere with efforts to provide optimal health care. Simulation in situ, involving real teams participating in simulations in real care settings, can be used to identify latent safety threats and improve the work environment while simultaneously supporting participant learning. Thoughtful planning and skilled debriefing are essential.
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http://dx.doi.org/10.1016/j.otc.2017.05.011DOI Listing
October 2017

Are All Manikins Created Equal? A Pilot Study of Simulator Upper Airway Anatomic Fidelity.

Otolaryngol Head Neck Surg 2017 06 25;156(6):1154-1157. Epub 2016 Oct 25.

4 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

This study evaluates the anatomic fidelity of several commercially available pediatric and adult manikins, including airway task trainers, which could be used in aerodigestive procedure training. Twenty-three experienced otolaryngologists assessed the aerodigestive anatomy of 5 adult and 5 pediatric manikins in a passive state, using rigid and flexible endoscopy. Anatomic fidelity was rated on a 5-point scale for the following: nasal cavity, nasopharynx, oral cavity, oropharynx, larynx, trachea, esophagus, and neck. Mean scores and standard deviations were tabulated for each manikin at each anatomic site. Ratings by survey participants demonstrated variation in the anatomic fidelity of the aerodigestive tract in a range of manikins. Radar chart display of the results allows comparison of manikin fidelity by anatomic site. Differences in scores may allow instructors to select manikins with the best anatomic fidelity for specific educational purposes, and they may contribute to recommendations to improve future manikin design.
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http://dx.doi.org/10.1177/0194599816674658DOI Listing
June 2017

Using High-Technology Simulators to Prepare Anesthesia Providers Before Implementation of a New Electronic Health Record Module: A Technical Report.

Anesth Analg 2017 06;124(6):1815-1819

From the Departments of *Anesthesiology and Critical Care Medicine; ‡Center for Simulation, Advanced Education and Innovation; §Biomedical Engineering, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and †ECRI Institute, Plymouth Meeting, Pennsylvania.

Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.
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http://dx.doi.org/10.1213/ANE.0000000000001775DOI Listing
June 2017

Leveraging Health Care Simulation Technology for Human Factors Research: Closing the Gap Between Lab and Bedside.

Hum Factors 2016 11 6;58(7):1082-1095. Epub 2016 Jun 6.

Children's Hospital of Philadelphia, PennsylvaniaMayo Clinic, Rochester, MinnesotaStanford University, Palo Alto, CaliforniaJohns Hopkins University, Baltimore, MarylandDuke University, Durham, North CarolinaSociety for Simulation in Healthcare, Norfolk, Virginia.

Objective: We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery.

Background: The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care.

Method: Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium.

Results: Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning.

Conclusion: The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency.

Application: Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery.
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http://dx.doi.org/10.1177/0018720816650781DOI Listing
November 2016

Pediatric anesthesiology fellow education: is a simulation-based boot camp feasible and valuable?

Paediatr Anaesth 2016 May 7;26(5):481-7. Epub 2016 Mar 7.

Pennsylvania Patient Safety Authority and ECRI Institute, Harrisburg, PA, USA.

Background: Pediatric anesthesiologists must manage crises in neonates and children with timely responses and limited margin for error. Teaching the range of relevant skills during a 12-month fellowship is challenging. An experiential simulation-based curriculum can augment acquisition of knowledge and skills.

Objectives: To develop a simulation-based boot camp (BC) for novice pediatric anesthesiology fellows and assess learner perceptions of BC activities. We hypothesize that BC is feasible, not too basic, and well received by fellows.

Methods: Skills stations, team-based in situ simulations, and group discussions of complex cases were designed. Stations were evaluated by anonymous survey; fellows rated usefulness in improving knowledge, self-confidence, technical skill, and clinical performance using a Likert scale (1 strongly disagree to 5 strongly agree). They were also asked if stations were too basic or too short. Median and interquartile range (IQR) data were calculated and noted as median (IQR).

Results: Fellows reported the difficult airway station and simulated scenarios improved knowledge, self-confidence, technical skill, and clinical performance. They disagreed that stations were too basic or too short with exception of the difficult airway session, which was too short [4 (4-3)]. Fellows believed the central line station improved knowledge [4 (4-3)], technical skills [4 (4-4)], self-confidence [4 (4-3)], and clinical performance [4 (4-3)]; scores trended toward neutral likely because the station was perceived as too basic [3.5 (4-3)]. An interactive session on epinephrine and intraosseous lines was valued. Complicated case discussion was of educational value [4 (5-4)], the varied opinions of faculty were helpful [4 (5-4)], and the session was neither too basic [2 (2-2)] nor too short [2 (2-2)].

Conclusion: A simulation-based BC for pediatric anesthesiology fellows was feasible, perceived to improve confidence, knowledge, technical skills, and clinical performance, and was not too basic.
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http://dx.doi.org/10.1111/pan.12865DOI Listing
May 2016

Safety-I, Safety-II and Resilience Engineering.

Curr Probl Pediatr Adolesc Health Care 2015 Dec 6;45(12):382-9. Epub 2015 Nov 6.

Pennsylvania Patient Safety Authority and ECRI Institute, Philadelphia, PA; The Children's Hospital of Philadelphia, Philadelphia, PA.

In the quest to continually improve the health care delivered to patients, it is important to understand "what went wrong," also known as Safety-I, when there are undesired outcomes, but it is also important to understand, and optimize "what went right," also known as Safety-II. The difference between Safety-I and Safety-II are philosophical as well as pragmatic. Improving health care delivery involves understanding that health care delivery is a complex adaptive system; components of that system impact, and are impacted by, the actions of other components of the system. Challenges to optimal care include regular, irregular and unexampled threats. This article addresses the dangers of brittleness and miscalibration, as well as the value of adaptive capacity and margin. These qualities can, respectively, detract from or contribute to the emergence of organizational resilience. Resilience is characterized by the ability to monitor, react, anticipate, and learn. Finally, this article celebrates the importance of humans, who make use of system capabilities and proactively mitigate the effects of system limitations to contribute to successful outcomes.
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http://dx.doi.org/10.1016/j.cppeds.2015.10.001DOI Listing
December 2015

Best practices across surgical specialties relating to simulation-based training.

Surgery 2015 Nov 11;158(5):1395-402. Epub 2015 Jul 11.

American College of Surgeons, Chicago, IL.

Introduction: Simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best be leveraged for training. There is much to be learned from one another as we all strive to meet new requirements within the context of Undergraduate Medical Education, Graduate Medical Education, and Continuing Medical Education.

Method: To address this need, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes consisting of key leaders in the field of simulation from 4 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology.

Conclusion: An overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners is presented.
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http://dx.doi.org/10.1016/j.surg.2015.03.041DOI Listing
November 2015

Simulation Activity in Otolaryngology Residencies.

Otolaryngol Head Neck Surg 2015 Aug 27;153(2):193-201. Epub 2015 May 27.

Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

Objectives: Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training or assessment as well as for board certification or maintenance of certification. This study investigates current simulation resources and activities in US otolaryngology residency programs and examines interest in advancing simulation training and assessment within the specialty.

Study Design: Web-based survey.

Setting: US otolaryngology residency training programs.

Subjects And Methods: An electronic web-based survey was disseminated to all US otolaryngology program directors to determine their respective institutional and departmental simulation resources, existing simulation activities, and interest in further simulation initiatives. Descriptive results are reported.

Results: Responses were received from 43 of 104 (43%) residency programs. Simulation capabilities and resources are available in most respondents' institutions (78.6% report onsite resources; 73.8% report availability of models, manikins, and devices). Most respondents (61%) report limited simulation activity within otolaryngology. Areas of simulation are broad, addressing technical and nontechnical skills related to clinical training (94%). Simulation is infrequently used for research, credentialing, or systems improvement. The majority of respondents (83.8%) expressed interest in participating in multicenter trials of simulation initiatives.

Conclusion: Most respondents from otolaryngology residency programs have incorporated some simulation into their curriculum. Interest among program directors to participate in future multicenter trials appears high. Future research efforts in this area should aim to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs.
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http://dx.doi.org/10.1177/0194599815584598DOI Listing
August 2015

Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school.

Acad Med 2015 Aug;90(8):1116-24

R.M. Minter is associate chair of education and associate program director, Department of Surgery, associate professor and chief, Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, and associate professor, Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan. K.D. Amos was, at the time of this research, associate professor, Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina. M.L. Bentz is professor and chairman, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin. P. Gabler Blair is associate director, Division of Education, American College of Surgeons, Chicago, Illinois. C. Brandt is the chair and Richard B. Fratianne MD Professor of Surgery, Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio. J. D'Cunha was, at the time of this research, associate program director, Division of Thoracic and Foregut Surgery, and assistant professor, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, and is now associate professor and associate director of lung transplantation, associate program director of thoracic surgery, and vice chairman, Academic Affairs, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. E. Davis is education research associate, Division of Education, American College of Surgeons, Chicago, Illinois. K.A. Delman is associate professor, Department of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia. E.S. Deutsch is physician, Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, Delaware. C. Divino is professor and chief, Division of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York. D. Kingsley is assistant professor, Department of Surgery, University of New Mexico School

Purpose: To evaluate interns' perceived preparedness for defined surgical residency responsibilities and to determine whether fourth-year medical school (M4) preparatory courses ("bootcamps") facilitate transition to internship.

Method: The authors conducted a multi-institutional, mixed-methods study (June 2009) evaluating interns from 11 U.S. and Canadian surgery residency programs. Interns completed structured surveys and answered open-ended reflective questions about their preparedness for their surgery internship. Analyses include t tests comparing ratings of interns who had and had not participated in formal internship preparation programs. The authors calculated Cohen d for effect size and used grounded theory to identify themes in the interns' reflections.

Results: Of 221 eligible interns, 158 (71.5%) participated. Interns self-reported only moderate preparation for most defined care responsibilities in the medical knowledge and patient care domains but, overall, felt well prepared in the professionalism, interpersonal communication, practice-based learning, and systems-based practice domains. Interns who participated in M4 preparatory curricula had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation, at statistically significant levels (P < .05) with medium effect sizes. Themes identified in interns' characterizations of their greatest internship challenges included anxiety or lack of preparation related to performance of technical skills or procedures, managing simultaneous demands, being first responders for critically ill patients, clinical management of predictable postoperative conditions, and difficult communications.

Conclusions: Entering surgical residency, interns report not feeling prepared to fulfill common clinical and professional responsibilities. As M4 curricula may enhance preparation, programs facilitating transition to residency should be developed and evaluated.
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http://dx.doi.org/10.1097/ACM.0000000000000680DOI Listing
August 2015

American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum needs assessment.

Am J Surg 2014 Feb 29;207(2):165-9. Epub 2013 Oct 29.

Clerkship Directors Committee, Association for Surgical Education, Springfield, IL, USA.

Background: Simulation can enhance learning effectiveness, efficiency, and patient safety and is engaging for learners.

Methods: A survey was conducted of surgical clerkship directors nationally and medical students at 5 medical schools to rank and stratify simulation-based educational topics. Students applying to surgery were compared with others using Wilcoxon's rank-sum tests.

Results: Seventy-three of 163 clerkship directors (45%) and 231 of 872 students (26.5%) completed the survey. Of students, 28.6% were applying for surgical residency training. Clerkship directors and students generally agreed on the importance and timing of specific educational topics. Clerkship directors tended to rank basic skills, such as examination skills, higher than medical students. Students ranked procedural skills, such as lumbar puncture, more highly than clerkship directors.

Conclusions: Surgery clerkship directors and 4th-year medical students agree substantially about the content of a simulation-based curriculum, although 4th-year medical students recommended that some topics be taught earlier than the clerkship directors recommended. Students planning to apply to surgical residencies did not differ significantly in their scoring from students pursuing nonsurgical specialties.
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http://dx.doi.org/10.1016/j.amjsurg.2013.07.032DOI Listing
February 2014

Simulation-based otorhinolaryngology emergencies boot camp: Part 1: Curriculum design and airway skills.

Laryngoscope 2014 Jul 29;124(7):1562-5. Epub 2014 Apr 29.

Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan.

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http://dx.doi.org/10.1002/lary.24572DOI Listing
July 2014

Simulation-based otorhinolaryngology emergencies boot camp: Part 2: Special skills using task trainers.

Laryngoscope 2014 Jul 29;124(7):1566-9. Epub 2014 Apr 29.

Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, DC.

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http://dx.doi.org/10.1002/lary.24571DOI Listing
July 2014

Simulation-based otorhinolaryngology emergencies boot camp: Part 3: Complex teamwork scenarios and conclusions.

Laryngoscope 2014 Jul 29;124(7):1570-2. Epub 2014 Apr 29.

Department of Anesthesia and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1002/lary.24570DOI Listing
July 2014

A qualitative analysis of faculty motivation to participate in otolaryngology simulation boot camps.

Laryngoscope 2013 Apr 16;123(4):890-7. Epub 2013 Feb 16.

Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Objectives/hypothesis: To characterize factors that motivate faculty to participate in Simulation-Based Boot Camps (SBBC); to assess whether prior exposure to Simulation-Based Medical Education (SBME) or duration (years) of faculty practice affects this motivation.

Study Design: Qualitative content analysis of semi-structured interviews of faculty.

Methods: Interviews of 35 (56%) of 62 eligible faculty including demographic questions, and scripted, open-ended questions addressing motivation. Interviews were recorded, transcribed, de-identified, coded and analyzed using qualitative analysis software. Demographic characteristics were described. Emerging response categories were organized into themes contributing to both satisfaction and dissatisfaction.

Results: Three major themes of faculty motivation emerged: enjoyment of teaching and camaraderie; benefits to residents, patients and themselves; and opportunities to learn or improve their own patient care and teaching techniques. Expense, and time away from work and family, were identified as challenges. Faculty with many versus few years in practice revealed a greater interest in diversity of teaching experiences and techniques. Comparison of faculty with extensive versus limited simulation experience yielded similar motivations.

Conclusion: Enjoyment of teaching; benefits to all participants; and opportunities for self-improvement emerged as themes of faculty motivation to participate in SBBC. SBBC have unique characteristics which provide an opportunity to facilitate teaching experiences that motivate faculty.
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http://dx.doi.org/10.1002/lary.23965DOI Listing
April 2013

The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives.

Pediatr Clin North Am 2012 Dec;59(6):1329-40

Department of Emergency Medicine, Simulation Center, Drexel University College of Medicine, Philadelphia, PA 19102, USA.

Simulation-based educational processes are emerging as key tools for assessing and improving patient safety. Multidisciplinary or interprofessional simulation training can be used to optimize crew resource management and safe communication principles. There is good evidence that simulation training improves self-confidence, knowledge, and individual and team performance on manikins. Emerging evidence supports that procedural simulation, deliberate practice, and debriefing can also improve operational performance in clinical settings and can result in safer patient and population/system outcomes in selected settings. This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.
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http://dx.doi.org/10.1016/j.pcl.2012.09.004DOI Listing
December 2012
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