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King CR, Gregory S, Fritz BA, Budelier TP, Ben Abdallah A, Kronzer A, Helsten DL, Torres B, McKinnon S, Goswami S, Mehta D, Higo O, Kerby P, Henrichs B, Wildes TS, Politi MC, Abraham J, Avidan MS, Kannampallil T. An Intraoperative Telemedicine Program to Improve Perioperative Quality Measures: The ACTFAST-3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332517. [PMID: 37738052 PMCID: PMC10517374 DOI: 10.1001/jamanetworkopen.2023.32517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/30/2023] [Indexed: 09/23/2023] Open
Abstract
Importance Telemedicine for clinical decision support has been adopted in many health care settings, but its utility in improving intraoperative care has not been assessed. Objective To pilot the implementation of a real-time intraoperative telemedicine decision support program and evaluate whether it reduces postoperative hypothermia and hyperglycemia as well as other quality of care measures. Design, Setting, and Participants This single-center pilot randomized clinical trial (Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments [ACTFAST-3]) was conducted from April 3, 2017, to June 30, 2019, at a large academic medical center in the US. A total of 26 254 adult surgical patients were randomized to receive either usual intraoperative care (control group; n = 12 980) or usual care augmented by telemedicine decision support (intervention group; n = 13 274). Data were initially analyzed from April 22 to May 19, 2021, with updates in November 2022 and February 2023. Intervention Patients received either usual care (medical direction from the anesthesia care team) or intraoperative anesthesia care monitored and augmented by decision support from the Anesthesiology Control Tower (ACT), a real-time, live telemedicine intervention. The ACT incorporated remote monitoring of operating rooms by a team of anesthesia clinicians with customized analysis software. The ACT reviewed alerts and electronic health record data to inform recommendations to operating room clinicians. Main Outcomes and Measures The primary outcomes were avoidance of postoperative hypothermia (defined as the proportion of patients with a final recorded intraoperative core temperature >36 °C) and hyperglycemia (defined as the proportion of patients with diabetes who had a blood glucose level ≤180 mg/dL on arrival to the postanesthesia recovery area). Secondary outcomes included intraoperative hypotension, temperature monitoring, timely antibiotic redosing, intraoperative glucose evaluation and management, neuromuscular blockade documentation, ventilator management, and volatile anesthetic overuse. Results Among 26 254 participants, 13 393 (51.0%) were female and 20 169 (76.8%) were White, with a median (IQR) age of 60 (47-69) years. There was no treatment effect on avoidance of hyperglycemia (7445 of 8676 patients [85.8%] in the intervention group vs 7559 of 8815 [85.8%] in the control group; rate ratio [RR], 1.00; 95% CI, 0.99-1.01) or hypothermia (7602 of 11 447 patients [66.4%] in the intervention group vs 7783 of 11 672 [66.7.%] in the control group; RR, 1.00; 95% CI, 0.97-1.02). Intraoperative glucose measurement was more common among patients with diabetes in the intervention group (RR, 1.07; 95% CI, 1.01-1.15), but other secondary outcomes were not significantly different. Conclusions and Relevance In this randomized clinical trial, anesthesia care quality measures did not differ between groups, with high confidence in the findings. These results suggest that the intervention did not affect the targeted care practices. Further streamlining of clinical decision support and workflows may help the intraoperative telemedicine program achieve improvement in targeted clinical measures. Trial Registration ClinicalTrials.gov Identifier: NCT02830126.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Stephen Gregory
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alex Kronzer
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Daniel L. Helsten
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Torres
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shreya Goswami
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Divya Mehta
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Omokhaye Higo
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Paul Kerby
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Troy S. Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha
| | - Mary C. Politi
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
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Abraham J, Meng A, Montes de Oca A, Politi M, Wildes T, Gregory S, Henrichs B, Kannampallil T, Avidan MS. An ethnographic study on the impact of a novel telemedicine-based support system in the operating room. J Am Med Inform Assoc 2022; 29:1919-1930. [PMID: 35985294 PMCID: PMC10161534 DOI: 10.1093/jamia/ocac138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/07/2022] [Accepted: 08/04/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The Anesthesiology Control Tower (ACT) for operating rooms (ORs) remotely assesses the progress of surgeries and provides real-time perioperative risk alerts, communicating risk mitigation recommendations to bedside clinicians. We aim to identify and map ACT-OR nonroutine events (NREs)-risk-inducing or risk-mitigating workflow deviations-and ascertain ACT's impact on clinical workflow and patient safety. MATERIALS AND METHODS We used ethnographic methods including shadowing ACT and OR clinicians during 83 surgeries, artifact collection, chart reviews for decision alerts sent to the OR, and 10 clinician interviews. We used hybrid thematic analysis informed by a human-factors systems-oriented approach to assess ACT's role and impact on safety, conducting content analysis to assess NREs. RESULTS Across 83 cases, 469 risk alerts were triggered, and the ACT sent 280 care recommendations to the OR. 135 NREs were observed. Critical factors facilitating ACT's role in supporting patient safety included providing backup support and offering a fresh-eye perspective on OR decisions. Factors impeding ACT included message timing and ACT and OR clinician cognitive lapses. Suggestions for improvement included tailoring ACT message content (structure, timing, presentation) and incorporating predictive analytics for advanced planning. DISCUSSION ACT served as a safety net with remote surveillance features and as a learning healthcare system with feedback/auditing features. Supporting strategies include adaptive coordination and harnessing clinician/patient support to improve ACT's sustainability. Study insights inform future intraoperative telemedicine design considerations to mitigate safety risks. CONCLUSION Incorporating similar remote technology enhancement into routine perioperative care could markedly improve safety and quality for millions of surgical patients.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alicia Meng
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Arianna Montes de Oca
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mary Politi
- Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Stephen Gregory
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Division of Biology and Biomedical Sciences, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Computer Science & Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
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Fast I, Villafranca A, Henrichs B, Magid K, Christodoulou C, Jacobsohn E. Disruptive behaviour in the operating room is under-reported: an international survey. Can J Anaesth 2020; 67:177-185. [PMID: 31950465 DOI: 10.1007/s12630-019-01540-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the reporting habits of clinicians who have been exposed to disruptive behaviour in the operating room (OR) and assess their satisfaction with management's responses to this issue. METHODS Ethics committee approval was obtained. This was a pre-specified sub-study of a larger survey examining disruptive behaviour, which was distributed to OR clinicians in seven countries. Using Likert-style questions, this study ascertained the proportion of disruptive intraoperative behaviour that clinicians reported to management, as well as their degree of satisfaction with management's responses. Binomial logistic regression identified socio-demographic, exposure-related, and behavioural predictors that a clinician would never report disruptive behaviour. RESULTS Four thousand, seven hundred and seventy-five respondents were part of the sub-study. Disruptive behaviour was under-reported by 96.5% (95% confidence interval [CI], 95.9 to 97.0) of respondents, and never reported by 30.9% (95% CI, 29.6 to 32.2) of respondents. Only 21.0% (95% CI, 19.8 to 22.2) of respondents expressed satisfaction with management's responses. Numerous socio-demographic, exposure-related, and behavioural predictors of reporting habits were identified. Socio-demographic groups who had higher odds of never reporting disruptive behaviour included younger clinicians, clinicians without management responsibilities, both anesthesiologists and surgeons (compared with nurses), biological females, and heterosexuals (all P < 0.05). CONCLUSIONS Disruptive behaviour was under-reported by nearly all clinicians surveyed, and only one in five were satisfied with management's responses. For healthcare systems to meaningfully address the issue of disruptive behaviour, management must create reporting systems that clinicians will use. They must also respond in ways that clinicians can rely on to affect necessary change.
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Affiliation(s)
- Ian Fast
- Department of Anesthesia, Perioperative and Pain Medicine, University of Manitoba, AE200 - 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Alexander Villafranca
- Department of Anesthesia, Perioperative and Pain Medicine, University of Manitoba, AE200 - 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Bernadette Henrichs
- Goldfarb School of Nursing, Barnes Jewish College, St. Louis, MO, USA
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Kirby Magid
- Department of Anesthesia, Perioperative and Pain Medicine, University of Manitoba, AE200 - 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Chris Christodoulou
- Department of Anesthesia, Perioperative and Pain Medicine, University of Manitoba, AE200 - 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Eric Jacobsohn
- Department of Anesthesia, Perioperative and Pain Medicine, University of Manitoba, AE200 - 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada.
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King CR, Abraham J, Kannampallil TG, Fritz BA, Ben Abdallah A, Chen Y, Henrichs B, Politi M, Torres BA, Mickle A, Budelier TP, McKinnon S, Gregory S, Kheterpal S, Wildes T, Avidan MS. Protocol for the Effectiveness of an Anesthesiology Control Tower System in Improving Perioperative Quality Metrics and Clinical Outcomes: the TECTONICS randomized, pragmatic trial. F1000Res 2019; 8:2032. [PMID: 32201572 PMCID: PMC7076336 DOI: 10.12688/f1000research.21016.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction: Perioperative morbidity is a public health priority, and surgical volume is increasing rapidly. With advances in technology, there is an opportunity to research the utility of a telemedicine-based control center for anesthesia clinicians that assess risk, diagnoses negative patient trajectories, and implements evidence-based practices. Objectives: The primary objective of this trial is to determine whether an anesthesiology control tower (ACT) prevents clinically relevant adverse postoperative outcomes including 30-day mortality, delirium, respiratory failure, and acute kidney injury. Secondary objectives are to determine whether the ACT improves perioperative quality of care metrics including management of temperature, mean arterial pressure, mean airway pressure with mechanical ventilation, blood glucose, anesthetic concentration, antibiotic redosing, and efficient fresh gas flow. Methods and analysis: We are conducting a single center, randomized, controlled, phase 3 pragmatic clinical trial. A total of 58 operating rooms are randomized daily to receive support from the ACT or not. All adults (eighteen years and older) undergoing surgical procedures in these operating rooms are included and followed until 30 days after their surgery. Clinicians in operating rooms randomized to ACT support receive decision support from clinicians in the ACT. In operating rooms randomized to no intervention, the current standard of anesthesia care is delivered. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 99% confidence intervals; p-values <0.005 will be reported as providing compelling evidence, and p-values between 0.05 and 0.005 will be reported as providing suggestive evidence. Registration: TECTONICS is registered on ClinicalTrials.gov, NCT03923699; registered on 23 April 2019.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thomas G. Kannampallil
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Mary Politi
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Brian A. Torres
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Stephen Gregory
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - TECTONICS Research Group
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
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Henrichs B, Walsh RP. Intraoperative magnetic resonance imaging for neurosurgical procedures: anesthetic implications. AANA J 2011; 79:71-77. [PMID: 21473229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Intraoperative magnetic resonance imaging (IMRI) for tumor resection allows a neurosurgeon to pinpoint the exact location of the tumor before resection and to navigate to the tumor after the incision is made. Although the anesthetic management is not substantially different from that for other neurosurgical procedures, strategies to keep the patient and operating room personnel safe can be challenging. Because of the risk of injury by the strong force of the magnet, safety precautions with respect to anesthetic delivery must be taken. Ferrous objects must be removed and kept outside the operating room. Only MRI-compatible equipment is allowed in the MRI operating room. This includes the anesthesia machine, anesthesia cart, intubating equipment, monitors, stethoscopes, poles for intravenous solutions, and body warmers. Surgical equipment and instruments must be MRI-compatible. Absolute contraindications to entering the MRI suite include pacemakers, cochlear implants, certain cranial aneurysm clips, and metal joints or implants. Goals of anesthesia delivery during IMRI procedures include the following: (1) promoting the safety of patients and staff, (2) preventing MRI-associated accidents, (3) identifying potential equipment-related hazards, (4) recognizing limitations of physiologic monitoring, and (5) acknowledging other potential hazards such as noise.
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Murray D, Boulet J, Avidan M, Kras J, Henrichs B, Woodhouse J, Evers A. Performance of Residents and Anesthesiologists in a Simulation-based Skill Assessment. Anesthesiology 2007; 107:705-13. [DOI: 10.1097/01.anes.0000286926.01083.9d] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
Anesthesiologists and anesthesia residents are expected to acquire and maintain skills to manage a wide range of acute intraoperative anesthetic events. The purpose of this study was to determine whether an inventory of simulated intraoperative scenarios provided a reliable and valid measure of anesthesia residents' and anesthesiologists' skill.
Methods
Twelve simulated acute intraoperative scenarios were designed to assess the performance of 64 residents and 35 anesthesiologists. The participants were divided into four groups based on their training and experience. There were 31 new CA-1, 12 advanced CA-1, and 22 CA-2/CA-3 residents as well as a group of 35 experienced anesthesiologists who participated in the assessment. Each participant managed a set of simulated events. The advanced CA-1 residents, CA-2/CA-3 residents, and 35 anesthesiologists managed 8 of 12 intraoperative simulation exercises. The 31 CA-1 residents each managed 3 intraoperative scenarios.
Results
The new CA-1 residents received lower scores on the simulated intraoperative events than the other groups of participants. The advanced CA-1 residents, CA-2/CA-3 residents, and anesthesiologists performed similarly on the overall assessment. There was a wide range of scores obtained by individuals in each group. A number of the exercises were difficult for the majority of participants to recognize and treat, but most events effectively discriminated among participants who achieved higher and lower overall scores.
Conclusion
This simulation-based assessment provided a valid method to distinguish the skills of more experienced anesthesia residents and anesthesiologists from residents in early training. The overall score provided a reliable measure of a participant's ability to recognize and manage simulated acute intraoperative events. Additional studies are needed to determine whether these simulation-based assessments are valid measures of clinical performance.
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Affiliation(s)
- David J. Murray
- Carol B. and Jerome T. Loeb Professor in Medicine and Director
| | - John R. Boulet
- Associate Vice President, Research and Data Resources, Foundation for Advancement of International Medical Education and Research, Philadelphia, Pennsylvania
| | | | | | - Bernadette Henrichs
- Co-Director, Nurse Anesthesia Services, Department of Anesthesiology, Washington University School of Medicine
| | - Julie Woodhouse
- Administrator, Washington University Clinical Simulation Center
| | - Alex S. Evers
- Henry E. Mallinkrodt Professor and Chairman, Department of Anesthesiology
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Henrichs B, Rule A, Grady M, Ellis W. Nurse anesthesia students' perceptions of the anesthesia patient simulator: a qualitative study. AANA J 2002; 70:219-25. [PMID: 12078470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The purpose of this study was to describe the perceptions of nurse anesthesia students (NAS) who used a MedSim simulator (MedSim USA, Inc, Ft Lauderdale, Fla) as part of their educational training. A convenience sample of 12 NAS in their first year of clinical training was researched. The researcher analyzed data qualitatively from observations made during 4 different sessions. Session 1 introduced the students to the simulator. Session 2 involved each student performing an anesthetic induction. A minor incident such as hypotension, hypertension, bradycardia or tachycardia occurred in session 3, and a major incident such as cardiac ischemia, anaphylaxis, bronchospasm, or malignant hyperthermia occurred in session 4. Data collection involved observation by the primary investigator, journal entries by the anesthesia students, and focus group interviews with the students. Results of the study indicate that, although students experience feelings of apprehension, uneasiness, or fear during the sessions, they felt it was very educational. Disadvantages include the lack of reality, lack of knowledge on handling crisis events, possibility of fixation errors, and the presence of anxiety. Advantages include improved critical thinking and decision-making skills, increased confidence, and improved clinical preparation. Results can be used to assist instructors in improving the students' learning experiences and to teach more effectively.
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Affiliation(s)
- Bernadette Henrichs
- Washington University Anesthesia Department, Barnes Hospital, St Louis, Mo., USA
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