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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.

Canadian Surgical Foundations (SF) residency programs transitioned to competency-based medical education in 2018. It is unknown how well the SF curriculum prepares surgery residents to recognize and manage common perioperative patient presentations. We sought to evaluate the national SF curriculum using the Kirkpatrick model of curriculum evaluation.We administered online surveys to 300 first-year English-speaking surgery residents across Canada to assess self-reported confidence in recognizing and managing 7 common perioperative patient presentations at 3 timepoints: pre-SF (July 2019), mid-SF (December 2019), and post-SF (May 2020). We conducted multistation simulation-based objective structured clinical examinations for surgery residents at our institution pre-SF (August 2019) and mid-SF (December 2019), and collected workplace-based assessment (WBA) data, including entrustment scores and narrative feedback, for 6 preselected entrustable professional activities (EPAs) (July 2019 to May 2020).Fifty-five residents (18%) completed pre-SF, 31 (10%) completed mid-SF, and 52 (17%) completed post-SF surveys. Residents' confidence in recognizing 6 out of 7 patient presentations was high pre-SF and did not improve significantly during the SF curriculum except for recognizing poor glycemic control (p0.01). Residents' confidence in managing 7 out of 7 patient presentations improved significantly (p0.05). Objective structured clinical examinations performance did not change significantly between pre-SF and mid-SF (4 [3.5-4.5] vs 4 [3-4]; p = 0.28). Analysis of WBA data showed that residents received high entrustment scores from the start of the SF curriculum. Entrustment scores improved significantly during the SF curriculum for 2 out of 6 EPAs. Only 56% of WBA assessments had narrative feedback, 16% of which had somewhat constructive feedback.Participation in the SF curriculum was associated with improved confidence of surgery residents in managing common perioperative patient presentations, and greater level of entrustment for some EPAs. Consideration should be given to further faculty development to increase the quantity and quality of narrative feedback in the SF curriculum.

ObjectivesTo evaluate the impact and feasibility of multisource feedback compared with traditional feedback for trauma team captains (TTCs).DesignA mixed-methods, non-randomised prospective study.SettingA level one trauma centre in Ontario, Canada.ParticipantsPostgraduate medical residents in emergency medicine and general surgery participating as TTCs. Selection was based on a convenience sampling method.InterventionPostgraduate medical residents participating as TTCs received either multisource feedback or standard feedback following trauma cases.Main outcome measuresTTCs completed questionnaires designed to measure the self-reported intention to change practice (catalytic effect), immediately following a trauma case and 3 weeks later. Secondary outcomes included measures of perceived benefit, acceptability, and feasibility from TTCs and other trauma team members.ResultsData were collected following 24 trauma team activations: TTCs from 12 activations received multisource feedback and 12 received standard feedback. The self-reported intention for practice change was not significantly different between groups initially (4.0 vs 4.0, p=0.57) and at 3 weeks (4.0 vs 3.0, p=0.25). Multisource feedback was perceived to be helpful and superior to the existing feedback process. Feasibility was identified as a challenge.ConclusionsThe self-reported intention for practice change was no different for TTCs who received multisource feedback and those who received standard feedback. Multisource feedback was favourably received by trauma team members, and TTCs perceived multisource feedback as useful for their development.

Emergency medicine (EM) training programs incorporate simulation for teaching as well as formative and summative assessment. The development of a simulation curriculum for Canadian postgraduate EM programs is underway and would be facilitated by a standardized, user-friendly, nationally endorsed simulation template. We convened a nationally representative group of simulation educators to participate in a three-phase process to develop and refine a simulation case template for Canadian EM educators. Participants provided feedback by means of free text comments and focus groups which were analyzed to inform modification of the template. We anticipate that this template will facilitate the sharing of cases across sites and the development of standardized cases for simulation-based assessment.

Background: Patient resuscitation can be overwhelming for junior postgraduate medical residents due to its inherent complexity and high-stakes environment. Emotional states of unpleasant hyperarousal burden cognitive resources, contributing to cognitive overload and performance decline. Our objective is to characterize the associations between pre-scenario emotional state and junior residents’ cognitive load and performance in a simulated-resuscitation, to provide evidence for informed curricular development.Methods: PGY-1 residents self-rated their emotional state before four simulated-resuscitation scenarios, and their cognitive load after. Faculty assessed performance with entrustment scores. Factor analysis identified the principal components of emotional state data. Linear regression models examined the relationship between pre-scenario emotional components, cognitive load, and performance scores. Results: 47/47 medical and surgical residents (100%) participated and completed Emotional State (99.5%) and Cognitive Load (98.9%) surveys. Positive invigoration and negative tranquility were the principal components. Pre-scenario tranquility was negatively associated with cognitive load (b= -0.23, p < 0.0001), and cognitive load was negatively associated with performance scores (b= -0.27, p < 0.0001). Pre-scenario invigoration was negatively associated with cognitive load (b=-0.18,p = 0.0001), and positively associated with performance scores (b= 0.08, p = 0.0193). Conclusion: Amongst junior residents participating in simulated resuscitation scenarios, pre-scenario agitation (negative tranquility) is associated with increased cognitive load, which itself is associated with lower performance scores. These findings suggest residency programs should consider developing curriculum aimed at modulating residents’ emotional agitation and reducing residents’ cognitive burden to improve resuscitation performance., Contexte : La réanimation de patients peut être éprouvante pour les stagiaires postdoctoraux juniors en raison de la complexité qui y est inhérente et de la gravité de l’enjeu. Les états émotionnels désagréables d’hyperexcitation épuisent les ressources cognitives, contribuant ainsi à la surcharge cognitive et à la baisse de la performance. Notre objectif était de mettre en évidence le rapport entre l’état émotionnel des résidents juniors avant une simulation de réanimation d’un côté et leur charge cognitive et leur performance lors de celle-ci de l’autre, pour produire des données probantes pouvant servir à la conception éclairée de programmes d’enseignement.Méthodes : Des résidents de première année ont autoévalué leur état émotionnel avant chacun des quatre scénarios de réanimation simulée, ainsi que leur charge cognitive après les simulations. Des membres du corps professoral ont évalué leur performance par l’attribution de scores de confiance. Les principales composantes des données sur l’état émotionnel ont été déterminées par le biais d’une analyse factorielle. On s’est servi de modèles de régression linéaire pour établir la relation entre les composantes émotionnelles avant la simulation, la charge cognitive et les scores de performance.Résultats : Les 47 résidents en médecine et en chirurgie qui ont participé à l’étude (100 %) ont rempli les questionnaires sur l’état émotionnel (99,5 %) et la charge cognitive (98,9 %). La stimulation positive et la tranquillité négative sont les principales composantes dégagées. La tranquillité avant la simulation était négativement corrélée avec la charge cognitive (b= -0,23, p

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.

Background Self-assessment is a central skill in competency-based medical education (CBME) and should be fostered in order to promote life-long learning. One measure that will guide the development of self-assessment is the alignment between it and external expert assessment. In this study, we explored the qualitative themes in the self-assessment rationale among trainees with incongruent self and faculty-assigned entrustment scores. Methods A total of 40 postgraduate medical trainees completed a four-scenario summative objective structured clinical examination (OSCE) as part of a simulation-based resuscitation curriculum in December 2017. After each scenario, an assessment involving an entrustment score and narrative rationale was completed by both trainee (self) and faculty. The differences between the trainee and faculty scores were calculated for each scenario and summed to give a single "incongruence score". Trainees who consistently scored themselves higher than the faculty were said to have a "positive-incongruence score" and those scoring below the faculty were said to have a "negative-incongruence" score. Through this method, 10 trainees with the highest and lowest scores were assigned to each group and their narrative rationales were coded and thematically analyzed. Results The content of the self-assessment narrative rationale differed between the two groups. Trainees in the positive-incongruence group focused on the concepts of speed and situational management, while trainees in the negative-incongruence group commented on lack of support, and a need to improve communication, diagnosis, and code blue management. The quality of the self-assessment rationale also differed between groups. Trainees in the negative-incongruence group provided higher-quality comments that were more detailed and granular. Conclusion We found differences in the content and quality of the self-assessment rationale between trainees whose self and faculty-assigned assessment is incongruent. This provides insight into how these groups differ and has valuable implications for the development of curricula targeting self-assessment skills.

Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

OBJECTIVES: Trauma resuscitations require competence in both clinical and nonclinical skills but these can be difficult to observe and assess. Multisource feedback (MSF) is workplace‐based, involves the direct observation of learners, and can provide feedback on nonclinical skills. We sought to compare and contrast the priorities of multidisciplinary trauma team members when assessing resident trauma team captain (TTC) performance. Additionally, we aimed to describe the nature of the assessment and perceived the utility of incorporating MSF into the trauma context. METHODS: A convenience sample of 10 trauma team activations were observed. Following each activation, the attending physician trauma team leader (TTL), TTC, and a registered nurse (RN) participated in a semistructured interview. MSF was not provided to the TTC for the purpose of this study because MSF was not part of the assessment process of TTCs at the time of this study and maintaining anonymity may have encouraged more honest interview responses. Transcripts from each assessor group (TTL, TTC, RN) were coded and assigned to one of the five crisis resource management skills: leadership, communication, situational awareness, resource utilization, and problem‐solving. Comments were also coded as positive, negative, or neutral as interpreted by the coder. RESULTS: All assessor groups mentioned communication skills most frequently. After communication, the RN and TTC groups commented on situational awareness most frequently, comprising 15 and 29% of their total responses, respectively, whereas 31% of the TTL comments focused on leadership skills. The RN and TTL groups provided positive assessments, with 51 and 42% of their respective comments coded as positive. Forty‐five percent of self‐assessment comments in the TTC group were negative. All (100%) of the TTC and TTL respondents felt that incorporating MSF would add to the quality of feedback, only 66% of the RN group felt that way. CONCLUSIONS: We found that each assessor group brings a unique focus and perspective to the assessment of resident TTC performance. The future inclusion of MSF in the trauma team context has the potential to enhance the learning environment in a clinical arena that is difficult to directly observe and assess.

Introduction Patient-centered care is a core principle of the Canadian healthcare system. In order to facilitate patient-centered care, the documentation of a patient's medical goals and expectations is important, especially in the event of acute decompensation when an informed conversation with the patient may not be possible. The 'Goals of Care Discussion Form (GCF)' at Kingston Health Sciences Centre (KHSC) documents goals of care discussions between patients and healthcare providers. All patients admitted to the Internal Medicine service are expected to have this form completed within 24 hours of admission. Formal measurement of form completion at our center has not previously been done, though anecdotally this form is often incomplete. The purpose of this study is to quantify the rate of completion and assess quality of documentation of the GCF at KHSC. Methods This prospective chart review took place between August 25, 2018, and March 25, 2019. Charts were reviewed for the presence of a completed GCF, and the quality of notation was assessed, as appropriate. Given there are no existing tools for assessing the quality of a document such as the GCF, authors TC and JM created one de novo for this study. Extracted data included the amount of time elapsed between admission and completion of the GCF, whether the 'yes/no cardiopulmonary resuscitation (CPR)' order in the patient's chart aligned with their wishes as outlined on the GCF, and whether or not a patient's GCF was uploaded to the hospital's electronic medical record (EMR). Results Two hundred sixteen charts were reviewed. Of these, 136 (63.0%) had a complete GCF. The mean GCF quality score was 3.4/7 (95% CI [3.2, 3.6]). The mean time elapsed from admission to the completion of the GCF was 1.5 days (95% CI [0.6, 2.4]). There were 130 charts with both a complete GCF and a 'yes/no CPR' order, and of these, 20 (15.4%) showed a discrepancy. Eighty-six (63.2%) of the completed GCFs were uploaded to the EMR. Discussion and conclusions The rate of GCF completion at KHSC is noticeably higher than expected based on the previous literature. However, our assessment of the quality of completion indicates that there is room for improvement. Most concerning, discrepancies were found between the 'yes/no CPR' order in a patient's chart and their stated wishes on the GCF. Furthermore, less than two-thirds of completed GCFs were found to have been uploaded to the hospital's EMR. Given the emphasis on patient-centered care in the Canadian healthcare system, our findings suggest that improvement initiatives are needed with respect to documenting goals of care discussions with patients.

ObjectivesTo address the increasing demand for the use of simulation for assessment, our objective was to review the literature pertaining to simulation-based assessment and develop a set of consensus-based expert-informed recommendations on the use of simulation-based assessment as presented at the 2019 Canadian Association of Emergency Physicians (CAEP) Academic Symposium on Education.MethodsA panel of Emergency Medicine (EM) physicians from across Canada, with leadership roles in simulation and/or assessment, was formed to develop the recommendations. An initial scoping literature review was conducted to extract principles of simulation-based assessment. These principles were refined via thematic analysis, and then used to derive a set of recommendations for the use of simulation-based assessment, organized by the Consensus Framework for Good Assessment. This was reviewed and revised via a national stakeholder survey, and then the recommendations were presented and revised at the consensus conference to generate a final set of recommendations on the use of simulation-based assessment in EM.ConclusionWe developed a set of recommendations for simulation-based assessment, using consensus-based expert-informed methods, across the domains of validity, reproducibility, feasibility, educational and catalytic effects, acceptability, and programmatic assessment. While the precise role of simulation-based assessment will be a subject of continued debate, we propose that these recommendations be used to assist educators and program leaders as they incorporate simulation-based assessment into their programs of assessment.

ObjectiveThe main objective of this study was to use the principles of cognitive load theory to design a curriculum that incorporates a progressive part practice approach to teaching ultrasound-guided (USG) internal jugular catheterization (IJC) to novices. A secondary objective was to compare the technical proficiency of residents trained using this curriculum with the technical proficiency of residents trained with the current local standard of a single simulation session.MethodsThe experimental group included 16 residents who attended three 2-hour sessions of progressive part practice in a simulation lab. The control group included 46 residents who attended the current local standard of a single 2-hour simulation session just prior to their intensive care unit rotation. Technical proficiency was assessed using hand motion analysis and time to procedure completion.ResultsAfter three sessions, median scores for right hand motion (RHM) (34.5; [27.0-49.0]), left hand motion (LHM) (35.5; [20.0-45.0]), and total time (TT) (117.0 s; [82.7-140.0]) in the experimental group were significantly better than the control group (pp=0.01, pp=0.02, respectively).ConclusionThese results support multiple sessions of progressive part practice in a simulation lab as an effective competency-based approach to teaching USG IJC in preparation for the clinical setting.

Vascular injuries represent a significant burden of mortality and disability. Blunt injuries to the neck vessels can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiography and managed with either antiplatelet medications or anticoagulation. In contrast, patients with penetrating injuries to the neck vessels require airway management, hemorrhage control, and damage control resuscitation before surgical repair. The keys to diagnosis and management of peripheral vascular injury include early recognition of the injury; hemorrhage control with direct pressure, packing, or tourniquets; and urgent surgical consultation.

Within competency-based medical education, self-regulated learning (SRL) requires residents to leverage self-assessment and faculty feedback. We sought to investigate the potential for competency-based assessments to foster SRL by quantifying the relationship between faculty feedback and entrustment ratings as well as the congruence between faculty assessment and resident self-assessment.We collected comments in (a) an emergency medicine objective structured clinical examination group (objective structured clinical examinations [OSCE] and emergency medicine OSCE group [EMOG]) and (b) a first-year resident multidisciplinary resuscitation "Nightmares" course assessment group (NCAG) and OSCE group (NOG). We assessed comments across five domains including Initial Assessment (IA), Diagnostic Action (DA), Therapeutic Action (TA), Communication (COM), and entrustment. Analyses included structured qualitative coding and (non)parametric and descriptive analyses.In the EMOG, faculty's positive comments in the entrustment domain corresponded to lower entrustment score Mean Ranks (MRs) for IA (11.1), DA (11.2), and entrustment (11.6). In NOG, faculty's negative comments resulted in lower entrustment score MRs for TA (11.8 and10) and DA (12.4), and positive comments resulted in higher entrustment score MRs for IA (15.4) and COM (17.6). In the NCAG, faculty's positive IA comments were negatively correlated with entrustment scores (ρ = -.27, P = .04). Across programs, faculty and residents made similar domain-specific comments 13% of the time.Minimal and inconsistent associations were found between narrative and numerical feedback. Performance monitoring accuracy and feedback should be included in assessment validation.

Innovation Concept: EM Sim Cases is an innovative, open-access website that was created in 2015 to publish medical simulation resources including standardized, peer-reviewed simulation cases. Herein we describe our interim analysis. Methods: We performed a massive online needs assessment using a methodology previously described by Chan et. al. to determine how we can shape EM Sim Cases to meet the needs of learners and educators who use it. We engaged with simulation experts from the Emergency Medicine Simulation Education Research Collaborative to design a Google Forms survey using best practices in survey design. We distributed the survey to our target community of practice via Twitter, email, and a blog post published on emsimcases.com. Curriculum, Tool, or Material: We received 81 responses from simulation educators representing 8 medical specialties and 13 countries. Most survey respondents identified themselves as staff physicians (n = 44) and specialized in emergency medicine (n = 39). They had 0-21+ years of experience. 37% of respondents (n = 30) stated that material from EM Sim Cases makes up 25% or more of their simulation curriculum. Several respondents noted that using this content made them feel more confident and more current. Respondents praised EM Sim Cases for a well-organized case format, the proper level of detail, consistency between case designs, and the wide variety of cases. Suggested improvements included an opportunity to directly comment on cases and more cases in pediatric, rural, and advanced airway management situations. Suggestions were made to improve the navigability of the website. Respondents wanted to see additional blog content on debriefing strategies and self-made task/skill trainers. Conclusion: EM Sim Cases is a novel, free open-access simulation resource. Using a massive online needs assessment we were able to determine future directions including case topics, website reorganization, and educational material. We were also able to capture how impactful a resource like this can be to clinical and educational practice outside of the simulation setting.

Competency-based curricula require the development of novel simulation-based programs focused on the assessment of entrustable professional activities. The design and delivery of simulation-based programs are labor-intensive and expensive. Furthermore, they are often developed by individual programs and are rarely shared between institutions, resulting in duplicate efforts and the inefficient use of resources. The purpose of this study is to demonstrate the feasibility of implementing a previously developed simulation-based curriculum at a second institution. We sought to demonstrate comparable program-level outcomes between our two study sites. A multi-disciplinary, simulation-based, resuscitation skills training curriculum developed at Queen's University was implemented at the University of Saskatchewan. Standardized simulation cases, assessment tools, and program evaluation instruments were used at both institutions. Across both sites, 87 first-year postgraduate medical trainees from 14 different residency programs participated in the course and the related research. A total of 226 simulated cases were completed in over 80 sessions. Program evaluation data demonstrated that the instructor experience and learner experience were consistent between sites. The average confidence score (on a 5-point scale) across sites for resuscitating acutely ill patients was 3.14 before the course and 4.23 (p < 0.001) after the course. We have described the successful implementation of a previously developed simulation-based resuscitation curriculum at a second institution. With the growing need for competency-based instructional methods and assessment tools, we believe that programs will benefit from standardizing and sharing simulation resources rather than developing curricula de novo.

Over the past decade, simulation-based education has emerged as a new and exciting adjunct to traditional bedside teaching and learning. Simulation-based education seems particularly relevant to emergency medicine training where residents have to master a very broad skill set, and may not have sufficient real clinical opportunities to achieve competence in each and every skill. In 2006, the Emergency Medicine program at Queen's University set out to enhance our core curriculum by developing and implementing a series of simulation-based teaching sessions with a focus on resuscitative care. The sessions were developed in such as way as to satisfy the four conditions associated with optimum learning and improvement of performance; appropriate difficulty of skill, repetitive practice, motivation, and immediate feedback. The content of the sessions was determined with consideration of the national training requirements set out by the Royal College of PhysiciansSurgeons of Canada. Sessions were introduced in a stepwise fashion, starting with a cardiac resuscitation series based on the AHA ACLS guidelines, and leading up to a more advanced resuscitation series as staff became more adept at teaching with simulation, and as residents became more comfortable with this style of learning. The result is a longitudinal resuscitation curriculum that begins with fundamental skills of resuscitation and crisis resource management (CRM) in the first 2 years of residency and progresses through increasingly complex resuscitation cases where senior residents are expected to play a leadership role. This paper documents how we developed, implemented, and evaluated this resuscitation-based simulation curriculum for Emergency Medicine postgraduate trainees, with discussion of some of the challenges encountered.

Introduction: Identification of latent safety threats (LSTs) in the emergency department is an important aspect of quality improvement that can lead to improved patient care. In situ simulation (ISS) takes place in the real clinical environment and multidisciplinary teams can participate in diverse high acuity scenarios to identify LSTs. The purpose of this study is to examine the influence that the profession of the participant (i.e. physician, registered nurse, or respiratory therapist) has on the identification of LSTs during ISS. Methods: Six resuscitation- based adult and pediatric simulated scenarios were developed and delivered to multidisciplinary teams in the Kingston General Hospital ED. Each ISS session consisted of a 10- minute scenario, followed by 3-minutes of individual survey completion and a 7- minute group debrief led by ISS facilitators. An objective assessor recorded LSTs identified during each debrief. Surveys were completed prior to debrief to reduce response bias. Data was collected on participant demographics and perceived LSTs classified in the following categories: medication; equipment; resources and staffing; teamwork and communication; or other. Two reviewers evaluated survey responses and debrief notes to formulate a list of unique LSTs across scenarios and professions. The overall number and type of LSTs from surveys was identified and stratified by health care provider. Results: Thirteen ISS sessions were conducted with a total of 59 participants. Thirty- four unique LSTs (8 medication, 15 equipment, 5 resource, 4 communication, and 2 miscellaneous issues) were identified from surveys and debrief notes. Overall, MDs (n = 12) reported 19 LSTss (n = 41) reported 77 LSTs, and RTs (n = 6) reported 4 LSTs based on individual survey data. The most commonly identified category of LSTs reported by MDs (36.8%) and RTs (75%) was equipment issues while RNs most commonly identified medication issues (36.4%). Participants with □5 years of experience in their profession, on average identified more LSTs in surveys than participants with >5 years experience (1.9 LSTs vs 1.5 LSTs respectively). Conclusion: Nursing staff identified the highest number of LSTs across all categories. There was fairly unanimous identification of major LSTs across professions, however each profession did identify unique perspectives on LSTs in survey responses. ISS programs with the purpose of LST identification would benefit from multidisciplinary participation.

Introduction: Capitalizing on the success of Simulation-Based Education (SBE) in residency-training programs, simulation has been gradually integrated into Continued Professional Development (CPD) programs for Emergency Physicians (EPs) in Canada. This study sought to characterize how Canadian academic emergency medicine (EM) departments have implemented SBE for CPD. Methods: We conducted two national surveys: 1) the National Faculty Simulation Status Assessment Survey, administered by telephone to the simulation directors (or equivalent) at 20 Canadian academic EM sites and 2) the Faculty Simulation Needs Assessment Survey administered online to all full-time EPs across 9 Canadian academic EM sites. Results: The response rates for the National Status and Needs Assessment Surveys were 100% (20/20), and 40% (252/635), respectively. The majority (60%) of Canadian academic EM sites reported utilizing SBE for CPD, though only 30% reported dedicated funding support. EPs reported participating in a median of 3 hours per year of SBE (IQR 1-6 hours). Reported incentivization offered in the form of continued medical education credits varied between simulation directors (67%) and EPs (44%). Simulation directors identified several significant barriers to SBE including a lack of faculty time, fear of peer judgment, and faculty inexperience. In contrast, EP-identified barriers included time commitments outside of shift, lack of opportunities, and lack of departmental. The three most common topics of interest for SBE by EPs were performance of rare procedures, pediatric resuscitation, and neonatal resuscitation. Interprofessional involvement in SBE CPD was valued by both simulation directors and EPs, with most EPs (79%) indicating it is useful. Conclusion: Most Canadian EPs and simulation directors recognize the value of SBE for CPD, yet it is only utilized, infrequently, by 67% of Canadian academic EM departments for this purpose. This may be explained, in part, by poor incentivization for participation. Simulation directors and EPs noted different barriers to SBE implementation for CPD suggesting the need for dialogue to improve utilization. As SBE for CPD is incorporated more frequently, and at more sites, content should be guided by local needs assessments with an emphasis on interprofessional participation.

ObjectiveTo develop a simulation-based curriculum for residents to learn ultrasound-guided (USG) central venous catheter (CVC) insertion, and to study the volume and type of practice that leads to technical proficiency.MethodsTen post-graduate year two residents from the Departments of Emergency Medicine and Anesthesiology completed four training sessions of two hours each, at two week intervals, where they engaged in a structured program of deliberate practice of the fundamental skills of USG CVC insertion on a simulator. Progress during training was monitored using regular hand motion analysis (HMA) and performance benchmarks were determined by HMA of local experts. Blinded assessment of video recordings was done at the end of training to assess technical competence using a global rating scale.ResultsNone of the residents met any of the expert benchmarks at baseline. Over the course of training, the HMA metrics of the residents revealed steady and significant improvement in technical proficiency. By the end of the fourth session six of 10 residents had faster procedure times than the mean expert benchmark, and nine of 10 residents had more efficient left and right hand motions than the mean expert benchmarks. Nine residents achieved mean GRS scores rating them competent to perform independently.ConclusionWe successfully developed a simulation-based curriculum for residents learning the skills of USG CVC insertion. Our results suggest that engaging residents in three to four distributed sessions of deliberate practice of the fundamental skills of USG CVC insertion leads to steady and marked improvement in technical proficiency with individuals approaching or exceeding expert level benchmarks.

Background Postgraduate medical education programs would benefit from a robust process for training and assessment of competence in resuscitation early in residency. Objective To describe and evaluate the Nightmares Course, a novel, competency-based, transitional curriculum and assessment program in resuscitation medicine at Queen's University in Kingston, Ontario, Canada. Methods First-year residents participated in the longitudinal Nightmares Course at Queen's University during the 2015–2016 academic year. An expert working group developed the entrustable professional activity and curricular design for the course. Formative feedback was provided following each simulation-based session, and we employed a summative objective structured clinical examination (OSCE) utilizing a modified Queen's Simulation Assessment Tool. A generalizability study and resident surveys were performed to evaluate the course and assessment process. Results A total of 40 residents participated in the course, and 23 (58%) participated in the OSCE. Eight of 23 (35%) did not meet the predetermined competency threshold and required remediation. The OSCE demonstrated an acceptable phi coefficient of 0.73. The approximate costs were $240 per Nightmares session, $10,560 for the entire 44-session curriculum, and $3,900 for the summative OSCE. Conclusions The Nightmares Course demonstrated feasibility and acceptability, and is applicable to a broad array of postgraduate medical education programs. The entrustment-based assessment detected several residents not meeting a minimum competency threshold, and directed them to additional training.

Introduction / Innovation Concept: Junior residents are often the first physicians who attend to the acutely unwell floor patient, especially at night and on weekends. The ‘Nightmares Course’ at Queen’s University was designed to address an Entrustable Professional Activity (EPA) relevant to several residency programs at the ‘Foundations of Discipline’ level of training: “to manage the acutely unwell floor patient for the first 5-10 minutes until help arrives”. In keeping with competency based medical education principles, this course offers longitudinal and repetitive practice and assessment. We have also designed a summative objective structured clinical exam (OSCE) in order to identify trainees who require additional remedial practice of this EPA. Methods: We developed simulated cases that reflect common but “scary” calls to the floor. We then, using a modified Delphi process with experts in resuscitation, defined relevant milestones applicable to the Foundations of Discipline level of training in order to inform our formative assessment. We also modified the Queen’s Simulated Assessment Tool (QSAT) to adopt CBME terminology and this will be used to provide a summative assessment during a four-scenario OSCE in the spring. Residents with QSAT scores below the competency threshold will be enrolled in a remediation course. Curriculum, Tool, or Material: Weekly sessions were led by staff physicians and were offered to first-year residents from internal medicine, core surgery, obstetrics and gynecology, and anesthesiology over the academic year. Each resident participated in one session every 4-week block. Sessions were organized into themes such as “shortness of breath” or “decreased level of consciousness” and involved three high-fidelity simulated cases with a structured debrief following each case. Formative feedback was given following each case. Conclusion: The Nightmares Course is a novel simulation-based, multidisciplinary curriculum in resuscitation medicine. It includes longitudinal practice and repetitive assessment, as well as summative testing and remediation of an EPA common to several residency programs.