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Objectives Team situational awareness (TSA) is critical for effective teamwork and supports dynamic decision-making in unpredictable, time-pressured situations. Simulation provides a platform for developing and assessing TSA; but these efforts are limited by suboptimal measurement approaches. The objective of this study was to develop and evaluate a novel approach to TSA measurement in interprofessional emergency medicine teams. Methods We performed a multicenter, prospective, simulation-based observational study to evaluate an approach to TSA measurement. Interprofessional emergency medical teams, consisting of emergency medicine resident physicians, nurses, and medical student, were recruited from the University of Washington (Seattle, WA) and Wayne State University (Detroit, MI). Each team completed a simulated emergency resuscitation scenario. Immediately following the simulation, team members completed a TSA measure, a team perception of shared understanding item, and a team leader effectiveness measure. Subject matter expert reviews and pilot testing of the TSA measure provided evidence of content and response process validity. Simulations were recorded and independently coded for team performance using a previously validated measure. The relationships between the TSA measure other variables (team clinical performance, team perception of shared understanding, team leader effectiveness, and team experience) were explored. The TSA agreement metric was indexed by averaging the pairwise agreement for each dyad on a team, and then averaging across dyads to yield agreement at the team level. For the team perception of shared understanding and team leadership effectiveness measures, individual team member scores were aggregated within a team to create a single team score. We computed descriptive statistics for all outcomes. We calculated Pearson's Product-Moment Correlations to determine bivariate correlations between outcome variables with two-tailed significance testing (p < 0.05). Results A total of 123 participants were recruited and formed 3-person teams (n = 41 teams). All teams completed the assessment scenario and post-simulation measures. Team situational awareness agreement ranged from 0.19 to 0.9 and had a mean (SD) of 0.61 (0.17). Team situational awareness correlated with team clinical performance (p

OBJECTIVES To determine the impact of a low-resource-demand, easily disseminated computer-based teamwork process training intervention on teamwork behaviors and patient care performance in code teams. DESIGN A randomized comparison trial of computer-based teamwork training versus placebo training was conducted from August 2010 through March 2011. SETTING This study was conducted at the simulation suite within the Kado Family Clinical Skills Center, Wayne State University School of Medicine. PARTICIPANTS Participants (n = 231) were fourth-year medical students and first-, second-, and third-year emergency medicine residents at Wayne State University. Each participant was assigned to a team of four to six members (nteams = 45). INTERVENTIONS Teams were randomly assigned to receive either a 25-minute computer-based training module targeting appropriate resuscitation teamwork behaviors or a placebo training module. MEASUREMENTS Teamwork behaviors and patient care behaviors were video recorded during high-fidelity simulated patient resuscitations and coded by trained raters blinded to condition assignment and study hypotheses. Teamwork behavior items (e.g., "chest radiograph findings communicated to team" and "team member assists with intubation preparation") were standardized before combining to create overall teamwork scores. Similarly, patient care items ("chest radiograph correctly interpreted"; "time to start of compressions") were standardized before combining to create overall patient care scores. Subject matter expert reviews and pilot testing of scenario content, teamwork items, and patient care items provided evidence of content validity. MAIN RESULTS When controlling for team members' medically relevant experience, teams in the training condition demonstrated better teamwork (F [1, 42] = 4.81, p < 0.05; ηp = 10%) and patient care (F [1, 42] = 4.66, p < 0.05; ηp = 10%) than did teams in the placebo condition. CONCLUSIONS Computer-based team training positively impacts teamwork and patient care during simulated patient resuscitations. This low-resource team training intervention may help to address the dissemination and sustainability issues associated with larger, more costly team training programs.

Objectives Human patient simulation (HPS), utilizing computerized, physiologically responding mannequins, has become the latest innovation in medical education. However, no substantive outcome data exist validating the advantage of HPS. The objective of this study was to evaluate the efficacy of simulation training as compared with case-based learning (CBL) among fourth-year medical students as measured by observable behavioral actions. Methods A chest pain curriculum was presented during a one-month mandatory emergency medicine clerkship in 2005. Each month, students were randomized to participate in either the CBL-based or the HPS-based module. All students participated in the same end-of-clerkship chest pain objective structured clinical examination that measured 43 behaviors. Three subscales were computed: history taking, acute coronary syndrome evaluation and management, and cardiac arrest management. Mean total and subscale scores were compared across groups using a multivariate analysis of variance, with significance assessed from Hotelling's T2 statistic. Results Students were randomly assigned to CBL (n= 52) or HPS (n= 50) groups. The groups were well balanced after random assignment, with no differences in mean age (26.7 years; range, 22–44 years), gender (male, 52.0%), or emergency medicine preference for specialty training (28.4%). Self-ratings of learning styles were similar overall: 54.9% were visual learners, 7.8% auditory learners, and 37.3% kinetic learners. Results of the multivariate analysis of variance indicated no significant effect (Hotelling's T2 [3,98] = 0.053; p = 0.164) of education modality (CBL or HPS) on any subscale or total score difference in performance. Conclusions HPS training offers no advantage to CBL as measured by medical student performance on a chest pain objective structured clinical examination.

Summary Objective We sought to evaluate the knowledge of probable outcome by medical personnel for in-hospital and out-of-hospital cardiac arrests, and self-reported history of CPR training referrals for family members of cardiac patients. Methods One hundred people from each of three population lists were randomly selected at a large, urban school of medicine and affiliated medical center: (1) year III and IV medical students; (2) residents in family medicine, emergency medicine, internal medicine, anesthesia, and surgery; (3) attending physicians in the same departments. A questionnaire was distributed that elicited estimates of in-hospital and out-of-hospital cardiac arrest (IHCA and OHCA, respectively) survival rates, and CPR training referral history. Estimates were compared against published data for accuracy (IHCA: 5–20%; OHCA 1–10%) Results The overall response rate was 63%. Accurate in-hospital cardiac arrest estimates [% (95% CI)] of survival were provided by 51.1% (36.8–63.4%), 47.3% (35.9–58.7%), and 36.7% (23.2–50.2%) of students, residents, and attending physicians, respectively. Accurate out-of-hospital estimates of survival were provided by 51.1% (36.8–63.4%), 52.1% (40.6–63.5%), and 70.8% (57.9–83.7%), respectively. Most thought that family members of cardiac patients ought to be CPR trained (92.6%). However, few had referred any for training in the past year (16.5%). There was strong support across respondent groups for including death notification information in the ACLS training program, with 80.4% of all respondents in favor. Conclusions This study demonstrates that medical experience is not associated with accurate estimates of cardiac arrest survival. Overwhelmingly, medical personnel believe family members should be trained to perform CPR, however, few refer family members for CPR training.

To determine whether the presence and behavior of a family witness to cardiopulmonary resuscitation (CPR) impacts critical actions performed by physicians.This was a randomized comparison study of physicians' performance during a simulated cardiac arrest with three different family witness states.This study was conducted at the Wayne State University Eugene Applebaum College of Pharmacy and Health Science's Center for Healthcare Simulation.Second-year and third-year emergency medicine (EM) residents from the Wayne State University Department of Emergency Medicine-affiliated residency programs and Michigan State University-affiliated EM residency programs.Thirty teams comprised of one second-year and one third-year EM resident were randomly assigned to one of the three groups: 1) no family witness; 2) a nonobstructive "quiet" family witness; and 3) a family witness displaying an overt grief reaction.Each pair was assessed for time to critical actions (e.g., minutes to CPR and drug administration) and for resuscitation-based performance outcomes (e.g., number of shocks) during a simulated cardiac arrest. The time to critical events was similar across groups with respect to initiating CPR, attempting to intubate the patient, and pronouncing the death of the patient. However, the time to deliver the first defibrillation shock was longer for the overt reaction witness group (2.57 minutes) as compared with the quiet (1.77 minutes) and no family witness (1.67 minutes) groups. Additionally, fewer total shocks were delivered in the overt reaction witness groups (4.0 minutes) vs. the quiet (6.5 minutes) and no family witness groups (6.0 minutes).The presence of a family witness may have a significant impact on physicians' ability to perform critical actions during simulated medical resuscitations. Further study is necessary to see if this effect crosses over into real clinical practice and if training ameliorates this effect.

Of 691 healthy (untreated) villagers of Tecumseh, Michigan (average age 32.6 years), 99 had a clinical blood pressure exceeding 140/90 mmHg. Thirty-seven per cent of these borderline hypertensives had increased heart rate, cardiac index, forearm blood flow and plasma norepinephrine. These subjects had elevated self-determined home blood pressure (average of 14 measurements). The present hyperkinetic borderlines had elevated blood pressure at 5, 8, 21 and 23 years of age and their parents also had higher blood pressure. The prevalence of high blood pressure in Tecumseh, its long history, elevated blood pressure readings outside the physician's office and family background of hypertension, suggests that the hyperkinetic state is a significant clinical condition. Previous studies on hospital-based populations proved that the hyperkinetic state is caused by an excessive autonomic drive. The association of the hyperkinetic state with elevated norepinephrine in this study suggests that a sympathetic hyperactivity is present in a large proportion of unselected subjects with mild blood pressure elevation.

During a survey of young subjects not receiving treatment for hypertension in Tecumseh, Michigan, clinic and self-monitored blood pressures taken at home (14 readings in 7 days) were obtained in 737 subjects (387 men, 350 women, average age 31.5 years). Hypertension in the clinic was diagnosed if the clinic blood pressure exceeded 140 mm Hg systolic or 90 mm Hg diastolic. In the absence of firm criteria for what constitutes hypertension at home, subjects whose average home blood pressure was in the upper decile of the whole population were considered to have hypertension at home. By these criteria, 7.1% of the whole population had "white coat" hypertension (i.e., high clinic but not elevated home readings). The prevalence of "sustained" hypertension (i.e., high readings in the clinic and at home) was 5.1%. Subjects with white coat and sustained borderline hypertension in Tecumseh were very similar. Both groups showed, at previous examinations (at ages 5, 8, 21, and 23 years), significantly higher blood pressure readings than the normotensive subjects. As young adults (average age 33.3 years), the parents of both hypertensive groups had significantly higher blood pressure readings than the parents of normotensive subjects. Both hypertensive groups had faster heart rates, higher systemic vascular resistance, and higher minimal forearm vascular resistance. Both hypertensive groups were more overweight, had higher plasma triglycerides, insulin, and insulin/glucose ratios than normotensive subjects. The white coat hypertensive group also had lower values of high density lipoprotein than the normotensive group. White coat hypertension is a frequent condition.(ABSTRACT TRUNCATED AT 250 WORDS)

Receiving (http://www.drhem.com) is a powerful web-based tool that encompasses web 2.0 technologies. “Web 2.0” is a term used to describe a group of loosely related network technologies that share a user-focused approach to design and functionality. It has a strong bias towards user content creation, syndication, and collaboration (McGee 2008). The use of Web 2.0 technology is rapidly being integrated into undergraduate and graduate education, which dramatically influences the ways learners approach and use information (Sandars 2007). Knowledge transfer has become a two-way process. Users no longer simply consume and download information from the web; they create and interact with it. We created this blog to facilitate resident education, communication, and productivity. Using simple, freely available blog software (Wordpress.com), this inter-disciplinary web-based forum integrates faculty-created, case-based learning modules with critical essays and articles related to the practice of emergency medicine (EM). Didactic topics are based on the EM model and include multi-media case presentations. The educational modules include a visual diagnosis section (VizD), United States Medical Licensing Examination (USMLE) board-style cases (quizzER), radiographic interpretation (radER), electrocardiogram interpretation (Tracings), and ultrasound image and video clip interpretation (Morrison's Pouch). After viewing each case, residents can submit their answers to the questions asked in each scenario. At the end of each week, a faculty member posts the answer and facilitates an online discussion of the case. A “Top 10 Leader Board” is updated weekly to reflect resident participation and display a running tally of correct answers submitted by the residents. Feedback by the residents has been very positive. In addition to the weekly interactive cases, Receiving also includes critical essays and articles on an array of topics related to EM. For example, “Law and Medicine” is a monthly essay written by an emergency physician who is also a lawyer. This module explores legal issues related to EM. “The Meeting Room” presents interviews with leading scholars in the field. “Got Public Health?”, written by a resident, addresses relevant social, cultural, and political issues commonly encountered in the emergency department. “Mini Me” is dedicated to pediatric pearls and is overseen by a pediatric emergency physician. “Sherwin's Critical Care” focuses on critical care principles relevant to EM and is overseen by a faculty member. As in the didactic portion of the website, residents and faculty members are encouraged to comment on these essays and articles, offering their own expertise and interpretation on the various topics. Receiving is updated weekly. Every post has its own URL and tags allowing for quick and easy searchability and archiving. Users can search for various topics by using a built-in search feature. Receiving is linked to an RSS (Really Simple Syndication) feed, allowing users to get the latest information without having to continually check the website for updates. Residents have access to the website anytime and anywhere that the internet is available (e.g., home computer, hospital computer, Iphone™, BlackBerry™), bringing the classroom to them. This unique blend of topics and the ability to create a virtual interactive community creates a dynamic learning environment and directly enhances resident education. Receiving serves as a core educational tool for our residency, presenting interesting and relevant EM information in a collaborative and instructional environment.

The relation between blood pressure level and reactivity to mental arithmetic and isometric exercise was investigated in 169 men and 120 women (average age, 32.3 years) from the village of Tecumseh, Mich. In the entire population, the correlation between baseline blood pressure and blood pressure response to both stressors was not significant. Blood pressure reactivity to both stressors was not increased in participants with borderline hypertension (one clinic reading of more than 140 mm Hg systolic and/or 90 mm Hg diastolic). When subjects were classified according to blood pressure response (below and above the 80th percentile), the hyperreactors to mental and physical stress had normal baseline blood pressure values. The hyperreactors also had clinic-to-home blood pressure differences similar to those of the rest of the population. Participants who had borderline hypertension at age 32 years had significantly elevated blood pressures at ages 5, 8, 12, 21, and 22 years. Those who were hyperreactors at age 32 years had normal blood pressures as children and young adults. Results of the present study lend no support to an association between higher blood pressures and blood pressure hyperreactivity. Study participants in Tecumseh will be recalled for future examinations. The independence of blood pressure levels from blood pressure reactivity offers a unique opportunity to prospectively evaluate their separate effects on cardiovascular morbidity.

The Tecumseh project investigates the evolution of hypertension in a healthy population. Of 946 subjects aged 18 through 38 years, 124 had clinic blood pressure readings higher than 140/90 mm Hg (the mean for borderline hypertensive subjects was 130/94 mm Hg). Compared with normotensive subjects, borderline hypertensive subjects had higher home blood pressures (mean, 12/7 mm Hg higher). Their childhood and postpubertal blood pressures were elevated (6/4 mm Hg higher than normal at age 6 years and 12/7 mm Hg higher than normal at age 21 years), and hypertensive target organ changes were detected. Borderline hypertensive subjects also had elevated minimal forearm resistance (0.22 U higher than normal), decreased stroke index (1.8 mL/m2 lower than normal), and impaired ventricular diastolic relaxation (mitral Doppler peak early diastolic blood flow [E] to peak late diastolic blood flow [A] ratio 0.13 lower than normal). Borderline hypertensive subjects had significant abnormalities in other coronary risk factors (cholesterol levels were 0.39 mmol/L higher, triglyceride levels were 0.45 mmol/L higher, high-density lipoprotein levels were 0.08 mmol/L lower, insulin levels were 38 pmol/L higher, and 16.5% more of them were overweight). Borderline hypertension is neither transient nor innocuous. Its association with other predictors of atherosclerosis calls for clinical attention.

• In Tecumseh, Mich, we obtained blood pressure (BP) selfdetermination data in 608 healthy adults (327 men, 281 women; average age, 32.6 ± 3.5 years) representing a wide range of educational backgrounds. The average (±SD) home BP (average 12.7 readings over 1 week) was 120.7/74.8±10.4/8.6 mm Hg for men and 110.9/69.9±10.1/7.7 for women. One hundred thirty-three subjects remeasured their home BP 1 year later and a strong correlation between the two readings was obtained (r=.70). Large-scale BP self-determination is feasible. Based on the BP distribution in Tecumseh, the upper limit of normalcy for home BP (2 SDs above the mean) is 142/92 mm Hg for men and 131/85 mm Hg for women. ( Arch Intern Med . 1990;150:1209-1213)