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INTRODUCTION Simulation is becoming a popular educational modality for physician continuing professional development (CPD). This study sought to characterize how simulation-based CPD (SBCPD) is being used in Canada and what academic emergency physicians (AEPs) desire in an SBCPD program. METHODS Two national surveys were conducted from March to June 2018. First, the SBCPD Needs Assessment Survey was administered online to all full-time AEPs across 9 Canadian academic emergency medicine (EM) sites. Second, the SBCPD Status Survey was administered by telephone to the department representatives (DRs)-simulation directors or equivalent-at 20 Canadian academic EM sites. RESULTS Response rates for the SBCPD Needs Assessment and the SBCPD Status Survey were 40% (252/635) and 100% (20/20) respectively. Sixty percent of Canadian academic EM sites reported using SBCPD, although only 30% reported dedicated funding support. Academic emergency physician responses demonstrated a median annual SBCPD of 3 hours. Reported incentivization for SBCPD participation varied with AEPs reporting less incentivization than DRs. Academic emergency physicians identified time commitments outside of shift, lack of opportunities, and lack of departmental funding as their top barriers to participation, whereas DRs thought AEPs fear of peer judgment and inexperience with simulation were substantial barriers. Content areas of interest for SBCPD were as follows: rare procedures, pediatric resuscitation, and neonatal resuscitation. Lastly, interprofessional involvement in SBCPD was valued by both DRs and AEPs. CONCLUSIONS Simulation-based CPD programs are becoming common in Canadian academic EM sites. Our findings will guide program coordinators in addressing barriers to participation, selecting content, and determining the frequency of SBCPD events.

ObjectivesExtracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program.MethodsThis retrospective health records review included patients aged 18–75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both “liberal” and “restrictive” ECPR criteria were defined and applied to our cohort.ResultsA total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31–53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR.ConclusionAt our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Objectives Emergency department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend on effective interactions between the health care team, the patient, and the environment. Resuscitation teams work in dynamic environments and strive to ensure the timely delivery of necessary treatments, equipment, and skill sets when required. However, systemic failures in this environment cannot always be adequately anticipated, which exposes patients to opportunities for harm. Methods As part of a new interprofessional education and quality improvement initiative, this prospective, observational study sought to characterize latent safety threats (LSTs) identified during the delivery of in situ, simulated resuscitations in our ED. In situ simulation (ISS) sessions were delivered on a monthly basis in the EDs at each campus of a large tertiary care academic hospital system, during which a variety of scenarios were run with teams of ED health care professionals. LSTs were identified by simulation facilitators and participants during the case and debriefing and then grouped thematically for analysis. Results During the study period, 22 ISS sessions were delivered, involving 58 cases and reaching 383 ED health care professionals. 196 latent safety threats were identified through these sessions (mean = 3.4 LSTs per case) of which 110 were determined to be "actionable" at a system level. LSTs identified included system/environmental design flaws, equipment problems, failures in department processes, and knowledge/skill gaps. Corrective mechanisms were initiated in 85% of actionable cases. Conclusions Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care. ISS, beyond its role as a training tool for developing intrinsic and crisis resource management skills, can be effectively used to identify system issues in the ED that could expose critically ill patients to harm.

ObjectiveSimulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).MethodsSimulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.ResultsTwenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.ConclusionThis study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

Providing care in a twenty-first century urban emergency department (ED) and trauma center is a complex high-pressure practice environment. The pressure is intensified during patient surge scenarios commonly seen during mass casualty incidents, such that response must be practiced regularly. Beyond clinical mastery of individual patient trauma care, a coordinated system-level response is essential to optimize patient care during these relatively infrequent events. This paper highlights the need to perform exercises in hospitals while providing practical advice on how to utilize in situ simulation for mass casualty testing. Eleven lessons are presented to assist other emergency management professionals, hospital administrators, or clinical staff to achieve success with in situ simulation. Based upon our experience designing and executing an in situ mass casualty simulation within an ED, we offer lessons applicable to any type of disaster exercise. Simulation offers a powerful tool for the conduct of disaster preparedness exercises for staff across multiple hospital departments and professions.

Objectives Disaster-preparedness and response are a commonly overlooked aspect of hospital policy and can frequently be outdated and undertested. Simulation-based education has become a core education modality within Canadian medical training programs. We hypothesized that integrating in situ simulation (ISS) into a hospital-wide, mass-casualty response exercise would enhance realism and our ability to identify latent safety threats (LSTs). Methods Using ISS we created a simulated mass shooting scenario with 20 patients, played by actors in full moulage, presenting to a large tertiary care hospital over a 50-minute period. Results Integrating ISS into our exercise created a realistic experience for the participants involved and improved participant education, while imparting enough systemic stress to expose LSTs associated within patient care and hospital policy. Conclusion Overall, ISS was successfully used and enhanced a large-scale test of our hospital's mass-casualty response plan.

ObjectivesAudit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region.MethodsWe conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups.ResultsA total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners.ConclusionThis study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

Importance Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. Objectives To determine resuscitation team members' perceptions of the Situational Awareness Display's utility. Design We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. Setting Dual site tertiary care level 1 trauma centre in Ottawa, Canada. Participants We recruited by email physicians, nurses and respiratory therapist. Intervention Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. Main outcomes and measures Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. Results We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4-5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display's utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. Conclusion Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care.

Background In order to enhance patient safety during resuscitation of critically ill patients, we need to optimize team communication and enhance team situational awareness but little is known about resuscitation team communication patterns. The objective of this study is to understand how teams communicate during resuscitation; specifically to assess for a shared mental model (organized understanding of a team’s relationships) and information needs. Methods We triangulated 3 methods to evaluate resuscitation team communication at a tertiary care academic trauma center: (1) interviews; (2) simulated resuscitation observations; (3) live resuscitation observations. We interviewed 18 resuscitation team members about shared mental models, roles and goals of team members and procedural expectations. We observed 30 simulated resuscitation video recordings and documented the timing, source and destination of communication and the information category. We observed 12 live resuscitations in the emergency department and recorded baseline characteristics of the type of resuscitations, nature of teams present and type and content of information exchanges. The data were analyzed using a qualitative communication analysis method. Results We found that resuscitation team members described a shared mental model. Respondents understood the roles and goals of each team member in order to provide rapid, efficient and life-saving care with an overall need for situational awareness. The information flow described in the interviews was reflected during the simulated and live resuscitations with the most responsible physician and charting nurse being central to team communication. We consolidated communicated information into six categories: (1) time; (2) patient status; (3) patient history; (4) interventions; (5) assistance and consultations; 6) team members present. Conclusions Resuscitation team members expressed a shared mental model and prioritized situational awareness. Our findings support a need for cognitive aids to enhance team communication during resuscitations. Electronic supplementary material The online version of this article (doi:10.1186/s12245-017-0149-4) contains supplementary material, which is available to authorized users.

Selon l’etat du patient, limitez le nombre de membres de l’equipe presents dans la chambre et etablissez une boucle de communication avec une personne a l’exterieur qui sera responsable de faire passer les fournitures et les medicaments supplementaires. La personne chargee de l’

Limit the number of in-room team members depending on the patient’s condition and delegate an outside-room “runner” to provide additional outside-room equipment and medications. The airway manager should be experienced enough to achieve greater than 85% first-pass success for endotracheal

Emergency medicine (EM) residency programmes in Canada have recently introduced competency-based medical education (CBME), and the first stage of the curriculum focuses on standardising learner competency.1 Introductory residency boot camps provide a focused opportunity to address varying levels of medical knowledge and procedural competency prior to the start of residency.2–4 There are currently no papers that report on the landscape of EM orientation programmes outside of the American context. The Department of Emergency Medicine (DEM) at the University of Ottawa (uOttawa) offers one of Canada’s largest EM training programmes, and its curriculum includes a robust boot camp for incoming residents. The objective of this descriptive review is to describe uOttawa’s DEM resident boot camp curriculum. This will provide a framework for the development and refinement of introductory EM boot camps at other universities, which will help with the standardisation of learner competency prior to the start of residency. The uOttawa’s DEM boot camp was originally implemented in 2012 in response to a needs assessment identifying initial knowledge and skills necessary for starting EM residents. Based on continual feedback from instructors and participants, the curriculum has undergone several revisions to hone content, learning objectives and modes of educational delivery. The boot camp is delivered in July over 2 …

Introduction: Extracorporeal Life Support in the context of cardiac arrest (ECPR) is an emerging resuscitative therapy which has shown promising results for patients who may not otherwise survive. As a resource-intensive intervention, ECPR requires carefully selected patients to maximize its potential benefits and mitigate undue harm. This retrospective health records review sought to identify the characteristics of cardiac arrest patients presenting to two academic tertiary care Emergency Departments (EDs) in order to assess the feasibility and impact of an ECPR program. Methods: We reviewed charts for all patients aged 18-75 years old presenting to two Academic Teaching Hospitals with out-of-hospital or in-ED refractory cardiac arrest from January 2015 to December 2016. Based on a review of existing ECPR literature, we defined two sets of liberal and restrictive criteria associated with survival and applied these to our cohort for possible initiation of ECPR. The chart review was completed by one of the principal investigators, with 10% of charts randomly reviewed by a second investigator to ensure good inter-agreement. Any discrepancies or ambiguities found in the review were resolved collaboratively between both investigators. Results: A total of 220 charts were identified and 191 deemed eligible for inclusion in the study. The median age was 59 (IQR: 49.5-67) years and the cohort was 72% male. The initial presenting rhythm was identified as VT/VF in 47% of patients. 65% of arrests were witnessed, with immediate bystander CPR performed on 50% patients and an additional 12% receiving CPR within 10 minutes of collapse. 60% of patients had cardiac arrest lasting less than 75 minutes. 69% of patients were identified as having a reversible cause of cardiac arrest. A favorable premorbid status was identified in 76% of patients. Application of our two sets of ECPR inclusion criteria revealed that 17% and 3% of patients for the liberal and restrictive criteria respectively, would have been candidates for ECPR. Conclusion: At our centre, we identified that in a two-year period, 3% to 17% of cardiac arrest patients presenting to the ED would have met inclusion criteria for ECPR, translating to an additional 0.2-1.4 patients per month admitted for critical care. These findings would suggest that the implementation of an ECPR program at our institution has the potential to have a positive impact for patients with only a relatively low volume of patients requiring additional resources.

Introduction / Innovation Concept: During Emergency Department (ED) resuscitation of critically ill patients, effective teamwork and communication among various healthcare professionals is essential to ensure favorable patient outcomes and to minimize threats to patient safety. However, numerous individual and system factors create barriers to effective team functioning. Simulation center- based training has been used to improve Crisis Resource Management skills among physician and nursing trainees, but in-situ simulation is a relatively new concept in adult Emergency Medicine in North America. Methods: To enhance patient care and team effectiveness, an ED nursing and physician group was created to develop and implement a novel interprofessional in-situ simulation program in two Canadian, academic tertiary-care emergency departments. Departmental approval and financial support was obtained and sessions commenced in January 2015. Curriculum, Tool, or Material: Monthly high-fidelity simulation sessions are held in the ED resuscitation rooms at both campuses of our hospital. Each session is facilitated and debriefed by simulation-trained Emergency Medicine faculty and senior residents, a nurse educator and a research assistant. Technical support is provided by our simulation center staff. Participants are recruited from the physicians, residents, nurses, respiratory therapists and other support staff working in the ED. To minimize the impact on patient care, two additional nurses are scheduled to cover nursing assignments on “sim days”. Simulations are limited to fifteen minutes, followed by a twenty minute debriefing. Conclusion: We have successfully developed and implemented an interprofessional in-situ simulation program in our ED. Participant feedback has been overwhelmingly positive. Lack of financial support, reluctance of staff to participate, and overwhelmed resources are some of the challenges to running a program like this in a busy ED environment. However, there are clear benefits: empowering team members, culture change, identification of latent safety threats, and a perception of improved teamwork and communication.

Introduction: Emergency Department (ED) resuscitation is a complex, high-stakes procedure where positive outcomes depend upon effective interactions between the healthcare team, the patient, and the environment. To this end, resuscitation teams work in spaces designed to optimize workflows and ensure that necessary treatments and skillsets are available when required. However, systematic failures in this environment cannot always be adequately anticipated, exposing patients to opportunities for harm. As part of a new interprofessional education initiative, this prospective, observational study sought to characterize latent threats to patient safety (LST’s) identified during the delivery of in-situ, simulated resuscitations in two Canadian, tertiary care, academic Emergency Departments. Methods: In-situ simulation sessions were delivered on a monthly basis in the EDs of each hospital campus, during which a variety of simulated resuscitation scenarios were run with distinct teams of ED healthcare professionals. A research assistant was present throughout each session and documented LST’s identified by simulation facilitators and participants during the case and debriefing. Data were entered into a master table and grouped thematically for analysis. Results: After a pilot run-in, 10 in-situ simulation sessions were delivered, involving 27 cases and reaching 180 ED healthcare professionals (25 attending MD, 37 resident MD, 59 RN, 24 RT). 83 latent safety threats were identified through these sessions (mean 3.1 LSTs per case) of which 52 were determined to be “actionable”. Corrective mechanisms have been initiated in 72% of these cases (e.g., new education campaigns and in-servicing, equipment provisioning, equipment checklists). Conclusion: In-situ simulation, beyond its role as a training tool for developing Non-Technical and Crisis Resource Management skills, can be effectively used to identify systematic deficits and knowledge gaps that could expose critically ill patients to harm. Effective quality improvement and continuing education programs are essential to translate these findings into more resilient patient care.