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4-to-3 lane conversions, often called road diets, have been implemented throughout the U.S. as a means to reduce crashes. However, the reduction in lanes has led to community wide concerns across the country regarding the possible negative effect on emergency responses. This study investigates the impact of 4-to-3-lane roadway conversions on emergency response in Iowa through surveys and a retrospective analysis of EMS data. The 170 survey responses were analyzed descriptively, and a text analysis was done on two open text survey questions. Generalized linear models were constructed to examine the impact of lane conversions on emergency response times. Over half of EMS respondents believed there was no effect or a positive effect on responses, while 40% believed there was a negative effect. The negative effect was often attributed to driver confusion on how to properly yield to EMS vehicles. Despite the differing perceptions, EMS response rates from before to after the implementation of 4-to-3 lane conversions did not meaningfully differ. Overall, there was a lack of evidence of an effect of 4-to-3 lane conversions on EMS response rates in Cedar Rapids, Iowa. However, survey results showed that public guidance on how to properly respond to the presence of EMS vehicles on these roadways may be needed. This study provides evidence for addressing local concerns about road diets and emergency response to add to other known safety benefits. Results of this analysis may be applicable to other lane conversion sites when appropriately combined with local context relevant to the target area., Competing Interests: Declarations of Interest: None

Aim: The aims of this study were to evaluate the demographics and crash profiles of road traffic-related traumatic brain injury (TBI) patients treated at two emergency departments in the Republic of Moldova, and to identify areas for prevention., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Deterrence of risky driving behavior is important for the prevention of crashes and injuries. Traffic law enforcement is a key strategy used to decrease risky driving, but there is little evidence on the deterrent effect of issuing warnings versus citations to drivers regarding the prevention of future crashes. The purpose of this study was to 1) investigate the difference between citations and written warnings in their association with future crash culpability and 2) investigate whether drivers who were issued written warnings or citations have different associations with future crash culpability likelihood than those without prior citations or written warnings., Methods: Data for this study included Iowa Department of Transportation crash data for 2016 to 2019 linked to data from the Iowa Court Case Management System. A quasi-induced exposure method was used based on driver pairs involved in the same collision in which one driver was deemed culpable and one was non-culpable. Conditional logistic regression models were constructed to examine predictors of crash culpability. The main independent variable was traffic citation and warnings history categorized into moving warning, non-moving warning, moving citation, non-moving citation, or no citation or warning in the 30 days prior to the crash., Results: The study sample included a total of 152,986 drivers. Among drivers with moving violations, previously cited drivers were more likely to be crash culpable than previously warned drivers (OR = 1.64, 95% CI = 1.29-2.08). Drivers with prior non-moving citations were less likely to be the culpable party in a crash than a driver who had no recent warnings or citations (OR = 0.72, 95% CI = 0.58-0.89). Drivers with prior warnings (moving or non-moving) did not appreciably differ in crash culpability relative to drivers who had not received any citations or warnings in the previous 30 days., Conclusions: Drivers with prior moving citations were more likely to be culpable in a future crash than drivers with prior moving warnings, which may relate to overall driving riskiness as opposed to effectiveness of citations in deterring risky driving behaviors. Results from this study also suggest that officer discretion was being appropriately applied by citing the riskiest drivers, while giving lower risk drivers warnings. Results from this study may be useful to support strengthening of state driver improvement programming., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Motor vehicle crashes among teen drivers often involve passengers in the teen's vehicle and occupants of other vehicles, and the full cost burden for all individuals is largely unknown. This analysis estimated direct hospitalisation and emergency department charges for teen-involved crashes by teen culpability, comparing charges for the teen driver, passengers and occupants of other vehicles., Methods: Probabilistic linkage was performed to link the Iowa police crash reports with Iowa emergency department and Iowa hospital inpatient data. Teen drivers aged 14-17 involved in a crash from 2016 through 2020 were included. Teen culpability was determined through the crash report and examined by teen and crash characteristics. Direct medical charges were estimated from charges through linkage to the Iowa hospital inpatient and the Iowa emergency department databases., Results: Among the 28 062 teen drivers involved in vehicle crashes in Iowa between 2016 and 2020, 62.1% were culpable and 37.9% were not culpable. For all parties involved, the inpatient charges were $20.5 million in culpable crashes and $7.2 million in non-culpable crashes. The emergency department charges were $18.7 million in teen culpable crashes and $6.8 million in teen non-culpable crashes. Of the $20.5 million total inpatient charges in which a teen driver was culpable, charges of $9.5 million (46.3%) were for the injured teen driver and $11.0 million (53.7%) for other involved parties., Conclusions: Culpable teen-involved crashes lead to higher proportions of injury and higher medical charges, with most of these charges covering other individuals in the crash., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Motorcycle fatality rates are increasing, and impaired driving is a major contributing factor. Impaired driving laws are a main component of state efforts to reduce drunk driving, but motorcycle crash charge and conviction outcomes have yet to be studied. The purpose of this study was to evaluate driver charge and conviction outcomes following alcohol-related motorcycle crashes., Methods: Data for this study were drawn from Iowa crash, charge, and conviction data from 2011 to 2018. The study sample included 480 alcohol-influenced drivers (428 motorcyclists and 52 other vehicle drivers) involved in motorcycle crashes. Driver crash-related charges were categorized by type: Alcohol, Moving Violations, and Administrative/Miscellaneous. Factors associated with convictions were determined and estimated with multivariable logistic regression models. The main factor of interest was charge combination., Results: Over three-quarters (78.5%) of the 480 alcohol-influenced drivers in crashes received any charge type and 68.1% received an alcohol-related charge. Among drivers with any charge, 88.6% were convicted, and among drivers with alcohol charges, 87.2% were convicted on an alcohol charge. After adjusting for BAC, drivers with a combination of Alcohol, Administrative, and Moving Violation charges had more than three times the odds of conviction of any charge compared to drivers with alcohol only charges (OR = 3.21, 95% CI = 1.00-10.26). However, charge combinations had little impact on alcohol-related convictions., Conclusions: Convictions were more likely when the impaired driver was charged with multiple types of offenses than with a single offense. An increased variety of charges was not associated with greater rates of conviction on alcohol-specific charges, which had high conviction rates overall., Practical Applications: Law enforcement officers should be informed that lesser infractions impact driver conviction outcomes in alcohol-related crashes and procedures for issuing charges should be evaluated to assure equitable enforcement and to hold drivers accountable for unsafe driving behaviors., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 National Safety Council and Elsevier Ltd. All rights reserved.)

Background: Low-middle-income countries experience among the highest rates of traumatic brain injury in the world. Much of this burden may be preventable with faster intervention, including reducing the time to definitive care. This study examines the relationship between traumatic brain injury severity and time to definitive care in major trauma hospitals in three low-middle-income countries., Methods: A prospective traumatic brain injury registry was implemented in six trauma hospitals in Armenia, Georgia and the Republic of Moldova for 6 months in 2019. Brain injury severity was measured using the Glasgow Coma Scale (GCS) at admission. Time to definitive care was the time from injury until arrival at the hospital. Cox proportionate hazards models predicted time to care by severity, controlling for age, sex, mechanism, mode of transportation, location of injury and country., Results: Among 1135 patients, 749 (66.0%) were paediatric and 386 (34.0%) were adults. Falls and road traffic were the most common mechanisms. A higher proportion of adult (23.6%) than paediatric (5.4%) patients had GCS scores indicating moderate (GCS 9-11) or severe injury (GCS 0-8) (p<0.001). Less severe injury was associated with shorter times to care, while more severe injury was associated with longer times to care (HR=1.05, 95% CI 1.01 to 1.09). Age interacted with time to care, with paediatric cases receiving faster care., Conclusions: Implementation of standard triage and transport protocols may reduce mortality and improve outcomes from traumatic brain injury, and trauma systems should focus on the most severe injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Pediatric restraint use has increased over time in the United States, but motor vehicle crashes remain a leading cause of death for children under age 18. Age-appropriate use of safety restraints (safety seats, booster seats, seat belt) and statewide child restraint laws can greatly reduce injury or death in the event of a crash. Surveillance of pediatric restraint use and compliance with policy can inform prevention efforts. This study aims to examine time trends in pediatric restraint use and compliance with pediatric passenger laws in Iowa by rurality and age., Methods: Fourteen years of Iowa observational pediatric restraint use data (2006-2019) are included in this cross-sectional study. Proportions of restrained youth by year, age, and rurality (rural, urban) were calculated. Log-linear models were used to compute the Annual Percent Change (APC) by year to explore trends in restraint use over time by rurality and by age group., Results: A total of 42,007 observed pediatric passengers with complete data from 2006 to 2019 were included in this study. Restraint use increased across all years and all age groups observed, with the largest increases among the older pediatric age groups. However, restraint use was consistently highest among the youngest child passengers. With all study years combined, the odds of being compliantly restrained were 13% lower in rural areas (OR = 0.87, 95% CI = 0.80, 0.95) compared to urban areas., Conclusions: Restraint use was lower in rural areas and among older pediatric passengers, suggesting targeted efforts to increase restraint use among these groups may have the greatest impact on overall occupant protection.

Introduction: Rural crashes result in fatality rates twice as high as urban, after accounting for vehicle miles traveled, and those involving farm vehicles tend to be the most severe. Farm vehicle crash interventions have focused on the farm equipment (e.g., lighting and marking) or the farm vehicle operator (e.g., training), despite crashes being most frequently caused by other vehicle driver actions. Community-based campaigns focused on rural drivers have potential to influence driver behavior. The objective of this study was to describe the role, formation, and lessons learned from a community advisory board (CAB) in the development and dissemination of a community-based rural roadway safety campaign., Methods: The CAB provided campaign input through quarterly meetings and email. The campaign had three main CAB and crash data-informed messages: 1) Slow Down, 2) Leave More Space, and 3) Avoid Passing. The CAB led campaign activities to publicize the message, distribute swag, and organize event logistics. To evaluate CAB effectiveness and inform future community engagement efforts, we conducted in-depth, semi-structured telephone interviews with CAB members in July 2020. Interviews were transcribed, coded, and codes were categorized into five main themes., Results: Overall, CAB membership was described as an overwhelmingly positive experience in terms of the CAB structure, culture fostered among the group, responsibilities, and time commitment. Board members reported successful campaign implementation, gave positive feedback regarding the research team's engagement efforts, and provided valuable recommendations for future campaigns (e.g., adding social media components, expansion of CAB age and industry diversity, and increasing group bonding activities)., Conclusions: Results from this study demonstrate the instrumental role and logistics involved in engagement of community advisors for the development and implementation of a rural roadway safety campaign. Steps and lessons from this study can be applied to other community-level injury and violence prevention topics, with a particular focus on rural communities., Competing Interests: Declaration of competing interest The authors do not have any competing interests to declare.

Introduction: Crash data suggest an association between driver seatbelt use and child passenger restraint. However, community-based restraint use is largely unknown. We examined the association between driver seatbelt use and child restraint using data from a state-wide observational study., Methods: Data from Iowa Child Passenger Restraint Survey, a representative state-wide survey of adult seat belt use and child passenger safety, were analyzed. A total of 44,996 child passengers age 0-17 years were observed from 2005 to 2019. Information about driver seatbelt use and child restraint was directly observed by surveyors and driver age was reported. Logistic regression was used to examine the association between driver seatbelt use and child restraint adjusting for vehicle type, community size, child seating position, child passenger age, and year., Results: Over the 15-year study period, 4,114 (9.1%) drivers were unbelted, 3,692 (8.2%) children were completely unrestrained, and another 1,601 (3.6%) children were improperly restrained (analyzed as unrestrained). About half of unbelted drivers had their child passengers unrestrained (51.8%), while nearly all belted drivers had their child passengers properly restrained (92.3%). Compared with belted drivers, unbelted drivers had an 11-fold increased odds of driving an unrestrained child passenger (OR = 11.19, 95%CI = 10.36, 12.09). The association between driver seatbelt use and child restraint was much stronger among teenage drivers. Unbelted teenage drivers were 33-fold more likely (OR = 33.34, 95%CI = 21.11, 52.64) to have an unrestrained child passenger., Conclusion: These data suggest that efforts to increase driver seatbelt use may also have the added benefit of increasing child restraint use. Practical applications: Enforcement of child passenger laws and existing education programs for new drivers could be leveraged to increase awareness of the benefits of seatbelt use for both drivers themselves and their occupants. Interventions aimed at rural parents could emphasize the importance of child safety restraints., (Published by Elsevier Ltd.)

Introduction: The aging population has been rapidly growing in the United States (U.S.). In line with this trend, older adults' mobility and transportation safety are an increasing priority. Many states have implemented driver licensure laws specific to older adults to limit driving among the elderly with driving skill decline. Evaluations of these laws have primarily focused on their safety benefits related to older drivers' fatal crash rate or injury rate. However, very few studies investigated licensure law effects on older adults' mobility., Objective: The objective of our study is to evaluate the association between older driver licensure laws and older adult daily traveling and passenger exposure., Methods: The 2003-2017 American Time Use Survey (ATUS) data were linked with statewide driver licensure law provisions. Adults aged 55-64 years were used as the reference group to control for the effects of non-licensure-law factors (e.g., economic trend). We used modified Poisson regressions with robust variance to estimate the relationships between licensure law provisions and the likelihoods of older men and women's daily traveling and passenger behaviors., Results: Laws requiring a vision test at in-person renewal were associated with increased daily traveling likelihood for women aged 75 years or older, primarily as a passenger. Laws requiring a knowledge test were related to a reduced daily overall traveling likelihood for women aged 75 years or older., Conclusions: In general, licensure law provisions are not strongly related to older adults' mobility, in particular for older male adults. Older female adults' daily mobility may be more likely to be influenced by the change of licensure laws than older male adults. The existence of gender-based disparities in responding to licensure laws requires future studies to account for the gender difference in estimating the effects of those traffic policies on older adults' mobility and traffic safety.

This randomized controlled trial evaluated the impact of integrating Steering Teens Safe, a parent communication intervention, with feedback from an in-vehicle video recording system. In-vehicle video systems that trigger a recording when the vehicle exceeds a g-force threshold have been used to provide feedback to young drivers. Few of these programs have involved parental engagement. Parent-teen dyads were randomized to three groups and 150 dyads completed the study. All groups received an in-vehicle video system that recorded driving events. The control group received no feedback or intervention. In the first intervention group, teens received real-time feedback, and parent-teen dyads received summary feedback, based on information recorded by the in-vehicle system. The second intervention group received the same feedback, plus parents were taught strategies to improve communication with their teen about safe driving. The primary outcome variable was unsafe driving event rates per 1000 miles driven and the primary independent variable was group assignment. Generalized linear models were used to calculate effect estimates. Compared with the control group, the Event Recorder Feedback group had a rate ratio of 0.35 (95% CI = 0.24 - 0.50) and the combined intervention group (Event Recorder Feedback and parent communication) had a rate ratio of 0.21 (95% CI = 0.15 - 0.30). Furthermore, the combined intervention group had a significantly lower event rate than the Event Recorder Feedback only group (rate ratio = 0.60, 95% CI = 0.41 - 0.87). While in-vehicle feedback systems can help reduce unsafe driving events in early independent driving, teaching parents strategies for effective communication with their young driver may further improve impact., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Efforts to encourage bicycling to school have increased in the United States. However, little is known about how parent-child communication affects bicycle safety. The purpose of this study was to examine parent-child agreement on biking instructions and their correlation with the early adolescents' real-world riding behavior., Methods: Parent-child dyads were asked open-ended questions about instructions they had given/received about bicycling. Answers were then coded into nine categories (e.g., crossing the road, bicycle control/handling). Distributions of parent-child agreement on parent-given bicycle safety instructions were examined in relation to the adolescent's real-world riding behaviors., Results: 36 parent-child dyads were included. Average age was 11.9 (Range: 10-15) for adolescents and 43.3 (Range: 30-59) for parents. Common parental instructions included: wear helmet, ride on sidewalk, and trip routing specifications. High 'ride on sidewalk' instruction (38.9% both parent and adolescent, 22.2% parent only, 16.7% adolescent only) was concerning due to potential driveway conflicts. Agreement between parents and adolescents on reported instructions was low, overall. Mean safety-relevant event rates in real-world cycling did not differ significantly between bicycle safety instruction agreement groups (both parent & adolescent reported, parent only, adolescent only, neither). The proportion of time an adolescent rode on different infrastructure types (sidewalk, street, etc.) did not vary between dyads reporting parents had given instructions to ride on the sidewalk and those who had not., Conclusions: Results highlight lack of agreement between parents and adolescents on cycling instructions the adolescent receives from the parent. Parent instructions to adolescents regarding bicycling safety were not associated with actual riding behaviors. Results suggest parent messaging to adolescents may be ineffective. Given parents are in a position of influence, results indicate a need for parental training on effective safety-related communication strategies to assist them in capitalizing on their parental role to increase their child's safety., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: There are a plethora of child bicycle safety education programs worldwide. However, the content and durations vary widely from program to program and no gold standard has been established. The main objective of this project was to create an inventory of youth bicycle safety education programs and their content, approaches, and age and developmental considerations. Methods: Methods used to gather program information included web and online database searches, extraction from personal lists, and a widely distributed online survey. A total of 89 programs met inclusion criteria and were reviewed (78 from the United States and 11 from other countries). Results: Over half (56.2%) of the included programs were not explicitly age specific, meaning that the content was not appropriately designated by age and developmental cut points. Many programs had target age groups, but these were often very wide age ranges (e.g., all elementary school-age children) resulting in content too advanced for the youngest children. Only 12.4% of included programs had published program evaluations and their scientific rigor varied widely. Main results from this inventory revealed a weak evidence base for program effectiveness due to lack of program evaluations. Results also highlighted a need for age, development, and skill-level considerations in youth bicycle education programs. Conclusions: This study provides a comprehensive list of program components and approaches that can be used as a foundation upon which child bicycle education standards can be evaluated and built, with the long-term goal of increased childhood safety.

Among roadway users, bicyclists are considered vulnerable due to their high risk for injury when involved in a crash. Little is known about the circumstances leading to near crashes, crashes, and related injuries or how these vary by age and gender. The purpose of this study was to examine the rates and characteristics of safety-relevant events (crashes, near crashes, errors, and traffic violations) among adult and child bicyclists. Bicyclist trips were captured using Pedal Portal, a data acquisition and coding system which includes a GPS-enabled video camera and graphical user interface. A total of 179 safety-relevant events were manually coded from trip videos. Overall, child errors and traffic violations occurred at a rate of 1.9 per 100min of riding, compared to 6.3 for adults. However, children rode on the sidewalk 56.4% of the time, compared with 12.7% for adults. For both adults and children, the highest safety-relevant event rates occurred on paved roadways with no bicycle facilities present (Adults=8.6 and Children=7.2, per 100min of riding). Our study, the first naturalistic study to compare safety-relevant events among adults and children, indicates large variation in riding behavior and exposure between child and adult bicyclists. The majority of identified events were traffic violations and we were not able to code all risk-relevant data (e.g., subtle avoidance behaviors, failure to check for traffic, probability of collision). Future naturalistic cycling studies would benefit from enhanced instrumentation (e.g., additional camera views) and coding protocols able to fill these gaps., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Bicycling has become increasingly popular in the United States in recent years for both recreation and utilitarian purposes. Yet, attributes of the bicycle riding experience and riding differences between adults and children and males and females are not well documented. Most existing data on bicycling trip characteristics are based on self-reported interviews or surveys, which are prone to recall bias. The purpose of this exploratory study was to capture naturalistic bicycling data to examine trip characteristics and compare exposure classification accuracy between GPS and video data. We enrolled 10 children and 10 adults and captured their bicycling trips for one week each using PedalPortal, a GPS-enabled helmet camera data capture and coding system developed by the authors and a team of engineering students. Overall, 261 trips, 57 hours, and 670 miles of bicycling were captured. The video data allowed for correct classification of riding location (sidewalk, bicycle lane, street, etc.), an advantage over GPS data alone. Child trips were significantly shorter in both time and distance than adult trips (p<0.01). The majority of male trips were commutes (69.8% child, 60.5% adult), while female trips were more evenly distributed among commute, non-commute utilitarian, and recreation. Adults primarily chose paved streets with no bicycle facilities, but also sought out on-road bicycle facilities (bike lanes and shared lane markings). Children rode most frequently on sidewalks. Results from this study demonstrate that the addition of video data can improve classification of bicycling exposure and differences by age and gender that can help planners and engineers better understand bicyclist behavior variations and increase safety by selecting appropriate and targeted countermeasures.

Objective: The purpose of this study was to describe disaster preparedness strategies and behaviors among rural families who have children with special health care needs and to examine the effect of self-efficacy and response-efficacy on disaster preparedness., Methods: Data for this study were drawn from the baseline surveys of 287 rural families with children with special health care needs who were part of a randomized controlled trial examining the impact of an intervention on disaster preparedness. Distributions of child, parent, and family characteristics were examined by preparedness. Linear regression models were built to examine the impact of self-efficacy and response-efficacy on level of disaster preparedness., Results: Disaster preparedness (overall, emergency plan, discussion/practice, and supplies) was low (40.9-69.7%) among study families. Disaster preparedness was found to increase with each unit increase in the level of self-efficacy and family resilience sources across all 4 categories of preparedness., Conclusions: Disaster preparedness among rural families with children with special health care needs is low, which is concerning because these children may have increased vulnerability to adverse outcomes compared to the general population. Results suggest that increasing the levels of self-efficacy and family resilience sources may increase disaster preparedness.

Purpose: We critically reviewed recent parent-directed teen driving interventions to summarize their success in meeting stated goals; identify promising intervention components and knowledge gaps; aid in the selection, adaptation, and dissemination of effective interventions; and guide future research efforts., Methods: We focused on interventions that included a direct parent component, explicitly stated outcomes related to the teen and/or their parents, were evaluated for parent or teen outcomes, targeted drivers younger than the age of 21 years, and had at least one evaluation study published since 1990 and in English. We conducted a comprehensive systematic search of 26 online databases between November 2013 and January 2014 and identified 34 articles representing 18 interventions., Results: Several interventions-in particular, those that had an active engagement component, incorporated an in-vehicle data recorder system, and had a strong conceptual approach-show promise in improving parental supervisory behaviors during the learner and early independent phases, increasing teen driver skill acquisition, and reducing teens' risky driving behaviors., Conclusions: We identify essential characteristics of effective parent-involved teen driving interventions and their evaluation studies, propose a comprehensive and multitiered approach to intervention, and discuss several research areas and overarching issues for consideration., (Copyright © 2015 Society for Adolescent Health and Medicine. All rights reserved.)

Objectives: To examine pre-licensure agreement on driving expectations and predictors of teen driving expectations among parent-teen dyads., Methods: Cross-sectional survey of 163 parent-teen dyads. Descriptive statistics, weighted Kappa coefficients, and linear regression were used to examine expectations about post-licensure teen driving., Results: Teens reported high pre-licensure unsupervised driving (N = 79, 48.5%) and regular access to a car (N = 130, 81.8%). Parents and teens had low agreement on teen driving expectations (eg, after dark, κw = 0.23). Each time teens currently drove to/from school, their expectation of driving in risky conditions post-licensure increased (β = 0.21, p = .02)., Conclusions: Pre-licensure improvement of parent-teen agreement on driving expectations are needed to have the greatest impact on preventing teens from driving in high risk conditions.

Purpose: To determine whether simulation training of ultrasound (US)-guided central venous catheter (CVC) insertion skills on a partial task trainer improves cannulation and insertion success rates in clinical practice., Method: This prospective, randomized, controlled, single-blind study of first- and second-year residents occurred at a tertiary care teaching hospital from January 2007 to September 2008. The intervention group (n = 90) received a didactic and hands-on, competency-based simulation training course in US-guided CVC insertion, whereas the control group (n = 95) received training through a traditional, bedside apprenticeship model. Success at first cannulation and successful CVC insertion served as the primary outcomes. Secondary outcomes included reduction in technical errors and decreased mechanical complications., Results: Blinded independent raters observed 495 CVC insertions by 115 residents over a 21-month period. Successful first cannulation occurred in 51% of the intervention group versus 37% of the control group (P = .03). CVC insertion success occurred for 78% of the intervention group versus 67% of the control group (P = .02). Simulation training was independently and significantly associated with success at first cannulation (odds ratio: 1.7; 95% confidence interval: 1.1-2.8) and with successful CVC insertion (odds ratio: 1.7; 95% confidence interval: 1.1-2.8)--both independent of US use, patient comorbidities, or resident specialty. No significant differences related to technical errors or mechanical complications existed between the two groups., Conclusions: Simulation training was associated with improved in-hospital performance of CVC insertion. Procedural simulation was associated with improved residents' skills and was more effective than traditional training.

Purpose: To design an independent rater (IR) direct observation system to monitor invasive procedures performed by residents in the hospital setting., Method: The authors recruited, trained, and tested nonphysicians to become IRs for an Agency for Healthcare Research and Quality-funded study evaluating the impact of partial task simulation training of ultrasound-guided central venous catheter (CVC) insertion on skills transfer at a major academic medical center. IR applicants completed four hours of training: a two-hour didactic session and a two-hour testing session, including observation of 5 of 10 choreographed CVC insertion videotapes and completion of a 50-data-point procedural checklist. Eligibility to be hired as an IR included timing the procedure accurately, detecting technical errors and complications, and completing the procedural checklist accurately., Results: Thirty-eight IR trainees completed the training module and videotape examinations. Twenty-seven (71%) trainees met criteria to be hired IRs by accurately assessing the duration of the procedure to within one minute, validating the checklist to within 95% accuracy, and detecting technical errors/complications to within a 3% margin of error. The authors found no association between educational level and hired status, and all 13 IRs assessed after the study had maintained their skills., Conclusions: Recent innovations in procedural training with partial task simulation trainers necessitate developing methods to measure skills transfer from the simulator to the clinical setting. This description of a nonphysician IR direct observation system for CVC insertion offers a feasible tool that may be generalized to monitoring other invasive procedures.

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.