Hello and welcome!

Hello, my name is Ken Spearpoint and welcome to my blog site.

I qualified as a nurse in 1986 and after working in ICU & CCU, followed by a couple of years of clinical site management, I moved into the resuscitation world and took up my first post as a resuscitation officer in the UK in 1992. I became a nurse consultant in resuscitation in 2004 and led a resuscitation service until my retirement from the NHS in August 2016.

I now work as an academic (Principal Lecturer) in Post Graduate Medicine at the University of Hertfordshire, where I lead the MSc in Medical & Healthcare Simulation. Course details

I also work clinically, as a critical care nurse as part of the match day medical team at Millwall FC.

Hopefully folks will find it interesting and I warmly welcome any opportunities for lively debate.

---

I will post about those issues that are of the most interest to me, therefore they are most likely to cover ;

1. Recovery from cardiac arrest – my current area of research
2. Human factors/ergonomics in medical emergency care – because it is my view that we don’t pay nearly enough attention to human factors science in our education and training.
3. DNACPR / advanced directives / ethical and legal issues – because this is really important and presents significant challenges in day-to-day practice
4. Simulation-based medical education – because it is what I do mostly

---

I will leave the more technically focussed issues to the many excellent, well established web sites out there.

Ken

If you wish, you can follow me on Twitter > @K_G_Spearpoint Twitter

Learning through simulation: The messy reality

Introduction 

In the context of improving patient safety, simulation-based medical education (SBME) is regarded as pivotal in the development of critical non-technical skills & clinical decision-making amongst healthcare professionals (Department of Health, 2011). Through complete task scenario and deliberate practice, SMBE is considered to be well suited to the complexity of clinical performance and utilises a blend of educational strategies to achieve the desired learning outcomes (McGaghie et al, 2011).  

 SBME is strongly under-pinned by constructivist pedagogy, which uses experiential learning constructs and critical reflection (Kolb, 1084). Additionally, SBME also draws on intrinsic and extrinsic motivation (Malone and Lepper, 2007) to promote psychological authenticity during the learning experience (Rudolph, et al, 2007, Dieckmann et al, 2007).  

 Supported by Maslow’s ‘hierarchy of needs’ (1943), some simulation educators have argued that successful SMBE is reliant upon careful, thorough and supportive preparation of participants is necessary to establish a safe and confidential educational space for the participants to perform optimally. In simulation that is aimed at developing crisis resource management / team leadership / team followership knowledge and skills, the utility of SBME can replicate realistic clinical pressure ‘in the moment’. This approach enables participants to more closely feel what is it like to be ‘under-pressure’ in context of their normal clinical work. They should be in a situation where they can conduct clinical decision-making, supported by the knowledge that they are performing in a secure, educational environment. 

 The Messy Reality 

In the last 20 years or so it has become apparent that healthcare, in the context of addressing the patient safety failures, has began to understand, assimilate and apply human factors/ergonomics science (HFE) to the complexity work of inherent in the delivery of healthcare. It is no surprise then, that those of us who are healthcare educators have gone on to appreciate that applying HFE science offers an appealing methodology with which to understand and bridge the performance gap between ‘work-as-imagined’/‘work-as-prescribed and ‘work-as done’ (Shorrock and Williams, 2016). The reality of operational performance has been described as a ‘messy reality’ (Shorrock, 2017)  are there many examples of this occurring in healthcare (Hindsight, 2017). 

Figure 1. The Messy Reality (Steve Shorrock, 2016)

An essential component in the achievement of high-quality SBME outcomes is structured debriefing. Sufficient time, perhaps two to three times more than that afforded to the scenario (Neil and Wooten, 2011) is advocated so that participants can be guided through a deep reflective exploration of the ‘work-as-done’ that unfolded during the scenario. Conventional approaches to debriefing and feedback have been largely based on the Pendleton ‘sandwich’ model (Pendleton, 1998). However, more contemporary methods of debriefing strongly encourage active, reflective participation that include debriefing with good judgement (Rudolph et al, 2007), debriefing as a learning conversation (Denning, 2010) alongside other constructivist models (Fanning & Gaba, 2007; Kriz, 2010) and are evidenced as being effective (Neil and Wooten, 2011). Taking this a step further, by framing debriefing with a combined HFE and constructivist lens is very appealing. 

The educational appeal of integrating HFE into SBME is that is appears to offer a particularly useful adjunct to post-scenario debriefing that incorporates much of the complexity of the ‘messy reality’. Integrating HFE with contemporary debriefing approaches should augment the provision of participants with a safe, reflective platform by providing a clearer focus within which to reflectively discuss their performances within the scenario.  Facilitation of participants to actively, critically reflect as to how and why they conducted their ‘work-as-done’ as the scenario unfolded and how the performance compared to how they imagined the scenario would ‘play out’ to how they perceived they would perform  (work-as-imagined) helps those participants to better understand their performance variability as well as the nature and sources of (self) identified performance gaps. This is of course expected (through facilitated critical reflection) to better enable students to adjust their performance variability to bring it into acceptable limits, that is, provide safer practice when they return to clinical activity.  

In many complex task situations in SBME it may be necessary for learners to reflect and critical evaluate their performance against guidelines / protocols / policies / procedures that ordinarily determine the ‘work-as-prescribed’ elements of healthcare practice (for example, advanced life support or sepsis guidelines). The application of HFE elements in this context further strengthens the focus and authenticity of the participant’s learning experiences and the emergence of important ‘take-away’ points which are intended for learners to continue to reflect on as they translate learning into clinical practice.  

 Conclusions 

The argument that is being presented in this blog is to state that there is significant potential to further improve patient outcomes if a more explicit HFE approach is taken in SBME as it further strengthens the focus of the educational intervention on improving ‘work-as-done’/‘work-as-prescribed’ in the clinical field, it should also promote the ability to adjust to unforeseeable situations that may require and accept adaptive behaviours. If the simulation scenario is purposefully designed to accommodate HFE elements alongside established educational strategies, then we may further improve both educational and patient safety outcomes. Post scenario debriefing, where participants conduct ‘work-as-disclosed’ provides the most favourable opportunity for better learning, providing that it is skilfully facilitated by enthusiastic educators that integrate critical reflection on ‘work-as-done’ alongside ‘work-as-imagined’ and ‘work-as-prescribed’.  

Such an approach would move SBME away from being mostly ‘work-as-imagined’ towards a ‘work-as-done’/‘work-as-prescribed’ perspective, it should effectively reduce individual and team performance variability, promote better decision-making and lead to safer patient care when transferred into clinical practice. 

A blended learning educational strategy that includes the use of authentic, deep immersion SBME is likely to promote patient safety and better improve the behavioural skills associated clinical decision-making, team leadership, team followership and limit performance variability. 

References 

Denning,. K. (2010). Debriefing as a learning conversation. Resuscitation Council UK. On-line. https://mobilesim.files.wordpress.com/2011/03/debrief-as-a-learning-conversation.pdf 

 Department of Health. (2011). A Framework for Technology Enhanced Learning. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215316/dh_131061.pdf 

Dieckmann, P., Gaba, D. and Rall., M. (2007). Deepening the Theoretical Foundations of Patient Simulation as Social Practice. Simulation in Healthcare. 2. 183-193. 

Fanning, R. M., Gaba, D.M. (2007) The Role of Debriefing in Simulation-Based Learning. Simulation in Healthcare, 2, 115-125. 

Hindsight 25 (2017) http://www.eurocontrol.int/sites/default/files/publication/files/hindsight25.pdf 

Kolb, D.A. (1984). Experiential Learning: Experience as the source of learning and development. Prentice Hall. New Jersey. 

 Kriz, W.C. (2010). A systemic-Constructivist Approach to the Facilitation and Debriefing of Simulations and Games. Simulation Gaming. 41(5). 663-680. 

 Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review, 50(4). 370-396.  

McGaghie, W.C., Issenberg, B.S., Cohen, E.R., Barsuk, J.H. and Wayne, D.B. Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A meta-Analytic Comparative Review of the Evidence. Academic Medicine. 86(6). 706-711.   

Neill, M.A. and Wooten, K. (2011) High-Fidelity Simulation Debriefing in Nursing Education: A Literature Review. Clinical Simulation in Nursing, 7,e161-e168. 

Pendleton, D., Schofield, T., Tate, P. and Havelock, P. (1984). The Consultation: An Approach to Learning and Teaching. Oxford University Press. Oxford. 

 Rudolph, J. W., Simon, R., Dufresne, R., Raemer, D.B. (2006) There’s NO Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 1, 49-55. 

 Shorrock, S., and Williams, C. (2016). Human Factors & Ergonomics in Practice. CRC Press. London. 

Shorrock, S. (2017) https://humanisticsystems.com/2017/01/13/the-archetypes-of-human-work/ 

 

 

Hyperventilation in Cardiac Arrest: the Messy Reality

The application of contemporary human factors & ergonomics concepts to healthcare should be considered as essential to the task of improving patient safety. Furthermore, they are crucial to our developing understanding of clinical behaviours. Accordingly, Safety-II approaches should be at the forefront of our thinking and I direct you to this excellent summary > Safety-I and Safety-II

As a fundamental method of understanding human performance variability (and therefore safety), a key concept in Safety-II thinking is to consider the nature of our work and how it varies from the perspective of what we think we will do / have done  – that is, ‘work-as-imagined’ compared the actuality of  what we really did – that is ‘work-as-done’. The following clinical vignette represents an example of ‘work-as-imagined’ virus ‘work-as-done’ from clinical resuscitation practice.

Hyperventilation in Cardiac Arrest : The Messy Reality

The ‘normalised’ unsafe practice of hyperventilation during cardiac arrest management provides a comprehensive example of ‘The messy reality’ . It has become evident, from analysing retrospective observational data, that during the procedure of cardiopulmonary resuscitation (CPR), medical practitioners (usually anaesthetists) almost always deliver too much pressurized oxygen/air to the lungs of patients (both adults and children).

Traditional Safety-I concepts may regard this as a ‘violation’, in that this practice continues to occur despite a succession of recommendations in international guidelines to the contrary, supported by the established and widespread provision of systematic, organised education and training. However, when directly questioned, anaesthetists demonstrate a clear, functional knowledge that such practice is detrimental to patient outcome.

When contemplating this behaviour, we must consider the following. Firstly, there is no intention for airway management practitioners to deliberately hyperventilate a patient. Secondly, these clinicians do not know that they are hyperventilating patients during the period that it is happening.  Thirdly, at the point where the work has been completed (after the clinical intervention has been discontinued) there is not ordinarily any recognition that the patient may have been hyperventilated. Fourthly, despite the fact that this issue is widely known amongst anaesthetists, others (particularly those at the bunt end) would be generally ignorant that such an issue occurs.

[Originally published as part of a series of clinical vignettes at Steven Shorrock’s excellent  blog site (reproduced by kind permission) Humanistic Systems

Recommended further reading varieties of human work

Are human factors the missing link in the chain of survival?

Introduction

Guidelines for resuscitation have been published widely for more than 30 years and since the advent of evidence-based medicine, the development of such guidelines has been achieved through consensus amongst renowned global experts organised by the International Liaison Committee on Resuscitation (ILCOR). Since 2000, comprehensive resuscitation guidelines have been published every 5 years, most recently in October 2015.

A rigorous evidence-based approach was applied to this guideline development, which used the GRADE system (Guyatt, et al, 2008) alongside the ‘population / patient / problem – intervention – comparator – outcome (PICO) method (Center for Evidence Based Medicine, 2009) of identifying published, peer reviewed evidence in order to achieve a consensus on science – the evidence was divided amongst a number of subject specific task forces constructed from a wide range of learned, experienced and committed professionals (Nolan, et al, 2015).

Contemporary clinical guidelines are purposefully constructed to be deliverable and fit for purpose. A key element is the implementation and integration of those guidelines into clinical practice. Accordingly it is necessary to place strong emphasis on getting the message across, transferring the evidence into practice and (hopefully) improving patient outcomes. In the field of resuscitation this is largely achieved through the educational medium of (didactic) life support courses. The education delivered during life support courses is conducted by a cadre of instructors who are required to have successfully completed an instructor course and be subject to peer review / re-certification in 4 yearly cycles.

Whilst it is evident that in addition to the considerable investment and input into education & training, improvements in technology have also influenced guideline development, however, patient outcomes and survivorship from in-hospital cardiac arrest have remained largely unchanged at around 18% (Gwinnutt et al, 2000, Peberdy et al, 2003, Nolan, 2014).

Non-Technical Skills / Human Factors

It is well known that critical care environments, where quick decisions have to be made under intense pressure are a common source of avoidable error and patient-harm (Bucknall, 2010). A recent study by Patterson and colleagues (2015) identified a series of behavioural components that are culturally embedded within the practice of emergency care, which remain poorly understood.

The authors identified the following key characteristics of emergency care that influence (perhaps untrained) human behaviour in ‘high-pressure’ situations;

• Conditions change quickly
• Disruptions and distractions are common
• Poor communication and / or under-developed teamwork are common
• Hospital teams are pseudo-teams as team membership is inconsistent and changes frequently, with little or no pre-established professional rapport.

• Different professional cultures exist
  • Different perceptions
  • Different perspectives
  • Intra-professional tensions
• Crisis management
  • Under-developed organisational skills
  • Lack of experience & situational awareness
  • Incomplete procedural standardisation (e.g. ABCDE assessment, SBAR)

The features highlighted above are recognisable and perhaps typical in medical emergency events and certainly not limited to the emergency department.

Nature and source of error in sub-optimal performance of skills

There are very many publications that outline significant human factors related failures that emerge during attempts to deliver optimal treatment, many indicate guideline deviations, and Reason (1990) described these as attributable to slips, lapses, mistakes and violations.

Recent technological advancements that have enabled defibrillators to capture objective, real-time, in-the-field data has been very useful in that it has provided unique insights into the behaviours of resuscitation teams and actual resuscitation practice.

Publications that have examined detailed data from defibrillator downloads have identified an array of real-time performance errors. Examples of such errors have included inadequate chest compression depth, slow compression rates and incomplete release of the chest (Whitfield et al, 2005, Abella et al, 2007). Other studies have reported delays in defibrillation that included prolonged pre and post shock pauses in chest compression (Edelson et al, 2006), inappropriate defibrillation (Kramer-Johansen et al, 2007) and hyper-ventilation (O’Neill & Deakin, 2007; Treanor & Spearpoint, 2007).

Whilst this evidence has informed our thinking about the performance of ‘work’ in resuscitation, my experience and that of colleagues, continues to suggest that we have yet to significantly understand & address many of the performance shortfalls identified – both from an educational perspective (in our resuscitation training courses), but more importantly, in the field whilst actively engaged in resuscitation.

Moreover, there is evidence of miss-placed, but well-intentioned practices, that attempt to address some of the ‘human factors’ issues that arise in resuscitation practice, which I have previous alluded to in a blog, (https://resuspanopticon.wordpress.com/2015/02/28/the-3-point-pulse-check-cardiac-arrest-patient-safety-an-als-myth-or-best-practice/). One cannot help but think that such situations arise in a lack of application of human factors understanding, specifically the gap between ‘work-as-prescribed’ / ‘Work-as-Imagined’ and ‘Work-as-Done?

 Human Factors Education in Life Support Courses

 The development of team leadership skills has been stated as a key learning outcome in the UK ALS course, however, when one considers the current standards for in-hospital resuscitation teams (Resuscitation Council UK, 2010) it could be argued that leadership has never been appropriately assessed within the national Advanced Life Support course.

The Cardiac Arrest Simulation Test (CASTest) requires that the person being tested is able to lead a (small) team of ALS instructors through a low-fidelity, simulated cardiac arrest scenario. As many who read this will know, one of the instructors guides the student through the assessment and completes a checklist. Successful completion of the CASTest is achieved if the student is able to recall and provide resuscitation by following the correct and appropriate sequence of treatment in accordance with the decision algorithm (‘work-as-prescribed’).

Over the years, many have experienced difficulties during the CAStest, specifically where there remains considerable doubt as to a candidate’s genuine ability to co-ordinate and direct a real cardiac arrest, despite having satisfied all of the criteria on the assessment checklist – many instructors  have been heard to say things like; “…the candidate ‘ticks all the boxes’, but I wouldn’t want them resuscitating a member of my family…”. The elements of our doubts being closely aligned to the characteristics identified in the work of Patterson and colleagues (2015) outlined above. Herein lies a paradox between ‘work-as-prescribed’ and ‘work-as-done’, what exactly are the issues that lead ALS instructors to question the validity of the assessment checklist and doubt the real-life abilities of the person being tested?

It is important to recognise that in recent years that the language of human factors / non-technical skills has appeared with increasing frequency of use within the didactic educational materials of the UK advanced life support course (ALS), which has seen an amended version of the TEAM tool (Cooper et al, 2009) incorporated into the CASTeach (cardiac arrest simulation teaching station). However this has not as yet transferred into the criteria within the ALS CASTest (cardiac arrest simulation test). Some would even argue that summative assessment may not be necessary at all (depending on one’s pedagogical position).

Perhaps we have reached a point where we need to narrow the gap between ‘work-as-prescribed’ and ‘work-as-done’ and place an increased focus on limiting performance variability through better teaching and facilitation of deliberate practice of complete task resuscitation with more time for deeper, broader debriefing. Another important adjustment might be in modifying the approach towards an educational experience (in a psychological safe space) that better prepares participant to systematically co-ordinate and direct an optimal resuscitation attempt?

The model of used in the Advance Resuscitation of the Newborn Infant (ARNI) course, which uses structured simulation teaching would appear to be more fit for purpose and instructors / medical educators have (informally) reported a high-level of satisfaction (https://www.resus.org.uk/information-on-courses/advanced-resuscitation-of-the-newborn-infant/).

Increasing our awareness of the complexity of work in clinical resuscitation through developing an understanding human factors/ergonomics may reap outcome benefits for patients. Being mindful of the significant challenges faced by clinicians in their clinical decision-making is yet to effectively penetrate our educational attention and little of the evidence thus far amassed has been applied the complexities of managing cardiac arrest.

To quote Martin Bromiley in the excellent video Just a Routine Operation (https://vimeo.com/970665 ) “we need to wake up to human factors”.

References

Abella, B., Edelson, D., Kim, S., et al. (2007). CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation. 73. 54-61.

Acute Care – Quality Standards for CPR (2010). Resuscitation Council UK. https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/#team

Bion, J.F., Abrusci, T. and Hibert, P. (2010) Human factors in the management of the critically ill patient. British Journal of Anaesthesia. 105 (1). 26-33.

Bucknall, T. (2010) Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 23. 150-156.

Center for Evidence Based Medicine. http://www.cebm.net/index.aspx?o=1036 [on line]. Retrieved 05/12/2015.

Cooper S, Cant R, Porter J, Sellick K, Somers G, Kinsman L, Nestel D. (2010). Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation. 81(4):446-52.

Edelson, D.P., Abella, B., Kramer-Johansen, J., et al. (2006) Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 71. 137-145.

Guyatt, G.H. et al. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 336. 924-926.

Gwinnutt, C., Columb, M. and Harris, R. (2000) Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation. 47(2).125-135

Kramer-Johansen, J., Edelson, D., Abella, B., et al. (2007) Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts. Resuscitation. 73. 212-220.

Nolan, J.P., Soar, J., Smith, G.B., Gwinnutt, C., Parrott, F., Power, S., Harrison, D.A., Nixon, E., Rowan, K. (2014). Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation.85(8).987-992.

Nolan, J.P. et al. (2015). Part 1: Executive summary 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 95. E1-E31.

O’Neill, J.F., and Deakin, C.D. (2007) Do we hyperventilate cardiac arrest patients? Resuscitation. 73(1) 82-5

Patterson, D.P., Pfeiffer, A.J., Lave, J.R., Weaver, M.D., Abebe, K., Krackhardt, D., Arnold, R.M. and Yealy, D.M. (2015). How familiar are clinician teammates in the emergency department? Emergency Medicine Journal. 32:258–262.

Peberdy, M., Kaye, W., Ornato, J., Larkin, G., Nadkarni, V., Mancini, M., Berg, R., Nichol, G. and Lane-Trultt, T. (2003). Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 58(3). 297-308.

Reason. J. (1990). Human Error. Cambridge University Press. Cambridge.

Resuscitation Council UK (2010). Quality standards for cardiopulmonary resuscitation practice and training. https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/ retrieved 28/11/2015.

Treanor, G. and Spearpoint, K. (2007). Ventilation practice during in-hospital cardiac arrest. Resuscitation. 77.S2.

Whitfield, R., Colquhoun, M., Chamberlain, D., Newcombe, R., Davies, C.S., and Boyle, R. (2005). The Department of Health National Defibrillator Programme: analysis of downloads from 250 deployments of public access defibrillators. Resuscitation. 64. 269-277.

Are human factors the missing link in the chain of survival?

Introduction

Guidelines for resuscitation have been published widely for more than 30 years and since the advent of evidence-based medicine, the development of such guidelines has been achieved through consensus amongst renowned global experts organised by the International Liaison Committee on Resuscitation (ILCOR). Since 2000, comprehensive resuscitation guidelines have been published every 5 years, most recently in October 2015.

A rigorous evidence-based approach was applied to this guideline development, which used the GRADE system (Guyatt, et al, 2008) alongside the ‘population / patient / problem – intervention – comparator – outcome (PICO) method (Center for Evidence Based Medicine, 2009) of identifying published, peer reviewed evidence in order to achieve a consensus on science – the evidence was divided amongst a number of subject specific task forces constructed from a wide range of learned, experienced and committed professionals (Nolan, et al, 2015).

Contemporary clinical guidelines are purposefully constructed to be deliverable and fit for purpose. A key element is the implementation and integration of those guidelines into clinical practice. Accordingly it is necessary to place strong emphasis on getting the message across, transferring the evidence into practice and (hopefully) improving patient outcomes. In the field of resuscitation this is largely achieved through the educational medium of (didactic) life support courses. The education delivered during life support courses is conducted by a cadre of instructors who are required to have successfully completed an instructor course and be subject to peer review / re-certification in 4 yearly cycles.

Whilst it is evident that in addition to the considerable investment and input into education & training, improvements in technology has influenced guideline development, however, patient outcomes and survivorship from in-hospital cardiac arrest have remained largely unchanged at around 18% (Gwinnutt et al, 2000, Peberdy et al, 2003, Nolan, 2014).

Non-Technical Skills / Human Factors

It is well known that critical care environments, where quick decisions have to be made, under intense pressure are a common source of avoidable error and patient-harm (Bucknall, 2010). A recent study by Patterson and colleagues (2015) identified a series of human factors components that are culturally embedded within the practice of emergency care, which remain poorly understood.

The authors identified the following key characteristics of emergency care that influence (perhaps untrained) human behaviour in ‘high-pressure’ situations;

• Conditions change quickly
• Disruptions and distractions are common
• Poor communication and / or under-developed teamwork are common
• Hospital teams are pseudo-teams as team membership is inconsistent and changes frequently, with little or no pre-established professional rapport.

• Different professional cultures exist
  • Different perceptions
  • Different perspectives
  • Intra-professional tensions
• Crisis management
  • Under-developed organisational skills
  • Lack of experience & situational awareness
  • Incomplete procedural standardisation (e.g. ABCDE assessment, SBAR)

The features highlighted above are recognisable and perhaps typical in medical emergency events and certainly not limited to the emergency department.

Nature and source of error in sub-optimal performance of skills

There are very many publications that outline significant human factors related failures to deliver optimal treatment or guideline deviations, and Reason (1990) would describe these as attributable to slips, lapses, mistakes and violations.

Recent technological advancements that have enabled defibrillators to capture objective, real-time, in-the-field data has been very useful in providing unique insights into the behaviours of resuscitation teams and actual resuscitation practice.

A number of publications that have examined detailed data from defibrillator downloads have identified an array of real-time performance errors. Examples of such errors have included inadequate chest compression depth, slow compression rates and incomplete release of the chest (Whitfield et al, 2005, Abella et al, 2007). Other studies have reported delays in defibrillation that included prolonged pre and post shock pauses in chest compression (Edelson et al, 2006), inappropriate defibrillation (Kramer-Johansen et al, 2007) and hyper-ventilation (O’Neill & Deakin, 2007; Treanor & Spearpoint, 2007).

Whilst all of these publications have intended to inform our thinking about human factors in resuscitation, my experience suggests that we have yet to significantly address many of the performance shortfalls identified – both educationally in the courses, and more importantly, in the field whilst actively engaged in resuscitation.

Moreover, there is evidence of miss-placed, but well-intentioned practices, that attempt to address some of the human factors issues that arise in resuscitation practice, which I have previous alluded to in a blog, (https://resuspanopticon.wordpress.com/2015/02/28/the-3-point-pulse-check-cardiac-arrest-patient-safety-an-als-myth-or-best-practice/). One cannot help but think that such situations arise in the presence of an educational / information vacuum?

 Crisis resource Management in Life Support Courses

 The development of team leadership skills has been stated as a key learning outcome in the ALS course, however, when one considers the current standards for in-hospital resuscitation teams (Resuscitation Council UK, 2010) it could be argued that leadership has never been appropriately assessed within the national Advanced Life Support course.

The Cardiac Arrest Simulation Test (CASTest) requires that the person being tested is able to lead a (small) team of ALS instructors through a simulated cardiac arrest scenario. As many who read this will know, one of the instructors guides the student through the assessment and completes a checklist. Successful completion of the CASTest is achieved if the student is able to recall and provide resuscitation by following the correct and appropriate sequence of treatment in accordance with the decision algorithm.

Over the years, I and many instructor colleagues have made comments along the lines of “…the student ‘ticks all the boxes’, but I wouldn’t want them resuscitating a member of my family…”

It is important to recognise that in recent years human factors / non-technical skills have started to appear within the didactic educational materials of the UK advanced life support course (ALS), which has seen an amended version of the TEAM tool (Cooper et al, 2009) incorporated into the CASTeach (cardiac arrest simulation teaching station). However this has not as yet appeared as a pass / fail criterion within the CASTest (cardiac arrest simulation test), which of course may not be necessary (depending on one’s pedagogical position).

Perhaps we have reached a point where we need to place an increased focus on an improved methodology with which to teaching and facilitate the practice of non-technical skills, perhaps as an educational experience (rather than an assessment) that better prepares participant to systematically co-ordinate and direct an optimal resuscitation attempt?

The model of used in the Advance Resuscitation of the Newborn Infant (ARNI) course, which uses structured simulation teaching would appear to be fit for purpose and instructors / medical educators have (informally) reported a high-level of satisfaction (https://www.resus.org.uk/information-on-courses/advanced-resuscitation-of-the-newborn-infant/).

Increasing our awareness of human factors and being increasingly mindful of the challenges faced by clinicians in their clinical decision-making is yet to effectively penetrate our educational attention and little of the evidence thus far amassed has been applied the complexities of managing cardiac arrest.

To quote Martin Bromiley in the excellent video Just a Routine Operation (https://vimeo.com/970665 ) “we need to wake up to human factors”.

References

Abella, B., Edelson, D., Kim, S., et al. (2007). CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system. Resuscitation. 73. 54-61.

Acute Care – Quality Standards for CPR (2010). Resuscitation Council UK. https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/#team

Bion, J.F., Abrusci, T. and Hibert, P. (2010) Human factors in the management of the critically ill patient. British Journal of Anaesthesia. 105 (1). 26-33.

Bucknall, T. (2010) Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 23. 150-156.

Center for Evidence Based Medicine. http://www.cebm.net/index.aspx?o=1036 [on line]. Retrieved 05/12/2015.

Cooper S, Cant R, Porter J, Sellick K, Somers G, Kinsman L, Nestel D. (2010). Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation. 81(4):446-52.

Edelson, D.P., Abella, B., Kramer-Johansen, J., et al. (2006) Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 71. 137-145.

Guyatt, G.H. et al. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 336. 924-926.

Gwinnutt, C., Columb, M. and Harris, R. (2000) Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation. 47(2).125-135

Kramer-Johansen, J., Edelson, D., Abella, B., et al. (2007) Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts. Resuscitation. 73. 212-220.

Nolan, J.P., Soar, J., Smith, G.B., Gwinnutt, C., Parrott, F., Power, S., Harrison, D.A., Nixon, E., Rowan, K. (2014). Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation.85(8).987-992.

Nolan, J.P. et al. (2015). Part 1: Executive summary 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 95. E1-E31.

O’Neill, J.F., and Deakin, C.D. (2007) Do we hyperventilate cardiac arrest patients? Resuscitation. 73(1) 82-5

Patterson, D.P., Pfeiffer, A.J., Lave, J.R., Weaver, M.D., Abebe, K., Krackhardt, D., Arnold, R.M. and Yealy, D.M. (2015). How familiar are clinician teammates in the emergency department? Emergency Medicine Journal. 32:258–262.

Peberdy, M., Kaye, W., Ornato, J., Larkin, G., Nadkarni, V., Mancini, M., Berg, R., Nichol, G. and Lane-Trultt, T. (2003). Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 58(3). 297-308.

Reason. J. (1990). Human Error. Cambridge University Press. Cambridge.

Resuscitation Council UK (2010). Quality standards for cardiopulmonary resuscitation practice and training. https://www.resus.org.uk/quality-standards/acute-care-quality-standards-for-cpr/ retrieved 28/11/2015.

Treanor, G. and Spearpoint, K. (2007). Ventilation practice during in-hospital cardiac arrest. Resuscitation. 77.S2.

Whitfield, R., Colquhoun, M., Chamberlain, D., Newcombe, R., Davies, C.S., and Boyle, R. (2005). The Department of Health National Defibrillator Programme: analysis of

downloads from 250 deployments of public access defibrillators. Resuscitation. 64. 269-277.

The continuing challenges of Do Not Attempt Cardio-Pulmonary Resuscitation orders

Having previously written about compassionate paternalism in the context of end of life care and Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)(Spearpoint, 2014) it was disappointing to read of yet another case in the media spotlight that highlighted the apparent inadequacies of communication skills by medical professionals.

The recent case reported on the BBC News appeared to highlight the considerable limitations of the medical gaze with regard to prioritising the difficult conversations with vulnerable patients and their families that accompany DNACPR decisions.

In a case that mirrors a complaint that was upheld by the health service ombudsman some 24 years ago (Department of Heath, 1991), the family of the patient considered that they had not been made aware of the placement of a DNACPR order, which was something that they discovered 4 days after his death (http://m.bbc.co.uk/news/uk-england-norfolk-31906905).

Since the publication of the first directive from the Chief Medical Officer (Department of Heath, 1991) a series of national guidance documents regarding DNACPR have been (jointly) issued by Royal College of Nursing, The British Medical Association and the Resuscitation Council UK, which were accompanied by a succession of policy upgrades by hospital Trusts.

However, the situation regarding effective and timely communication with patients and their family members continues to provide healthcare professionals with a significant challenge and it is one that contains a considerable paradox. Failure to comply with established law and the associated medico-legal guidelines leaves both the patient and the medical practitioner vulnerable.

It is my experience, that when discussing the difficult issues that surround DNACPR with medical colleagues they almost always appear entirely conversant with the medico-legal position and more than capable of making a confident, guidance / policy compliant decision that is in the best interest of the patient. Such an example is provided here in Phil Berry’s insightful and thoughtful blog.

> https://illusionsofautonomy.wordpress.com

But something happens that makes intelligent, articulate professionals take unnecessary risks when faced with a patient, their family and that DNACPR order.

At that exact moment is the pressure of work and the clinical environment prohibitive to the provision sensitive, compassionate information of this nature? Does the nature of the situation over-ride the usual assured confidence of discussing the advanced care plan with the patient? Are these medical professionals appropriately trained and experienced in conducting difficult conversations? Are patients and relatives given time to contemplate the enormity of the DNACPR decision? Is the patient given permission and time to think it through, discuss it with their loved ones or discuss it with other healthcare professionals? Does the paternalistic culture of the medical gaze come to the fore?

Whatever the situation, the medico-social and culturally determined human factors issues identified above need to be more fully understood in order to inform our thinking towards developing a better, patient-centred approach to this problematic continuum.

By way of a post-script regarding the case in question, it was interesting to note that the coroner considered that the doctors had acted in accordance with local hospital policy guidance http://m.bbc.co.uk/news/uk-england-norfolk-31941596, a situation that appears to continue to support compassionate paternalism.

References

Department of Health (1991). Letter from the Chief Medical Officer to all consultants on resuscitation policy, dated 20.12.1991. PL/CMO (91) 22.

Spearpoint, K. (2014). Compassionate paternalism and the Janet Tracey judgment. International Journal of Palliative Nursing. 20(1). 369.

The 3-point pulse check, cardiac arrest & patient safety: An ALS myth or best practice?

Introduction

Has anyone out there encountered the teaching of the 3-point pulse check? This is the practice whereby the simultaneously manual palpation of 2 femoral arteries and 1 carotid artery is conducted to verify the absence or presence of a pulse during cardiac arrest. It is a technique that appears to have surfaced within Resuscitation Council Advanced Life Support (ALS) course teaching in recent years. Appearing as a simple, common-sense intervention it seems to have developed a momentum that holds appeal to ALS instructors and some appear to consider it as best practice. However, in the interests of clinical & professional clarity and the promotion of better outcomes for patients, it is perhaps timely to take a critically analytical gaze at the published evidence. Accordingly, this review commences with a brief resume of the published evidence around pulse-checking in cardiac arrest, which is then followed by a section that considers the utilisation of the pulse-check at the point-of-care, in the heat of the moment during the crisis of the cardiac arrest.

Pulse checking in cardiac arrest It has long been recognised that the confirmation of an absent pulse in a collapsed person in cardiac arrest is unreliable (Assar et al, 2000) and further studies have indicated that even experienced healthcare professionals find pulse checking challenging in both adult (Perkins et al, 2005) and paediatric resuscitation (Tibballs & Russell, 2008). The publication of Eberle and co-workers (1996) provided very powerful insights into the nature of our technical inadequacies when using manual palpation to ascertain the presence or absence of a pulse, particularly during the initial assessment of the collapsed patient. This evidence has been reflected in contemporary resuscitation guidelines in that successive guideline statements progressively de-emphasised pulse-checking during the initial assessment to the extent that it is no longer recommend in basic life support (Koster et al, 2010). Furthermore, in order to minimise the harmful pauses associated with deleterious outcomes (Edelson et al, 2006), current ALS guidelines strongly emphasise brevity in pulse checking to the extent that it is only recommended in the presence of organised heart rhythms (Nolan et al, 2010). In recognition of the problem, researchers have attempted to provide educational, procedural and technological solutions to provide diagnostic accuracy. In recognition of some of the human factors elements, the work of Perkins and colleagues (2005) aimed at simplifying the assessment process, more recently Tsung & Bliavas (2008) have suggested point-of-care echocardiography as a method of verifying the apparent absence of a pulse. It is interesting to note that the use of multiple point pulse checking by two or more persons palpating an artery was not considered or discussed.

Performing technical skills in medical emergency care

Those who are interested and acknowledge the importance of human factors in the nature and source of error are likely to be familiar with the evidence that indicates that the frequency of slips, lapses and mistakes increases amongst those subject to duress during critical care conditions (Bucknall, 2010). The complexities and limitations of training and performance regarding the human factor basis of error that arises in the situation of crisis resource management are also widely evidenced (Catchpole, 2013). Marsch and colleagues (2005) clearly demonstrated that under simulated conditions, highly trained & experienced ICU staff significantly under-performed when presented with cardiac arrest scenarios and that failure was linked to poor leadership and poor task allocation. It would appear that the addition of un-familiar, non-evidence based processes, such as a 3-point pulse check are unlikely to enhance cardiac arrest management and benefit patient outcome.

Maxims and myths

With regards to the dangers of using personal maxims, many will recall people singing of ‘Nellie the Elephant’ when teaching and practicing chest compressions, another example of one of those common-sense ideas that became a widely accepted ALS myth, far fewer are aware that when tested the use of ‘Nellie the elephant’ in CPR teaching significantly reduced effective compression depth (Rawlins et al, 2009) and the authors recommended that the practice should cease. Others may be interested in the dangerous inaccuracy of the trauma myth of palpating pulses to estimate blood pressure, a technique that over-estimates the systolic… http://rebelem.com/atls-wrong-palpable-blood-pressure-estimates/ (acknowledgements to R.E.B.E.L. EM)

Discussion

My personal experiences of witnessing the 3 point pulse check in clinical practice was disturbing as it was poorly co-ordinated, distracting to the running of the event and delayed definitive care in the context of a defibrillatory shock. Furthermore, having conducted a literature search of both PubMed and Web of Science (using the PICO method) it appears that there is a complete absence of any evidence to support the 3-point pulse check.

Summary

Whilst the evidence is overwhelmingly convincing that manual palpation of major pulses in cardiac arrest is unreliable, there remains a paucity of peer reviewed literature that addresses the ergonomic, bio-semiotic, human factors issues associated with how such techniques are conducted under the duress of cardiac arrest, which merits robust research. Currently there is no evidence to support the deployment of the 3-point pulse check in CASTeach simulation stations, and certainly not in clinical practice. One is therefore drawn to conclude that the 3-point pulse check is a resuscitation myth and its presence in education and clinical practice should be curtailed with immediate effect. If or when you encounter this dogma, I challenge you to be a professional, informed practitioner and politely request the protagonist(s) to provide the evidence-base rationale to support this so-called best practice.

For those of you who are the protagonists, may I challenge you to submit / present an abstract / paper outlining a comprehensive, evidence-based, scientifically tested rationale to support the procedure, perhaps or perhaps join me in an evidence-based , scientific, balanced on-line debate…

References

Assar, D., Chamberlain, D.A., et al. (1998). A rationale for staged teaching of basic life support. Resuscitation. 39.137-143.

Bucknall, T. (2010) Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 23. 150-156.

Catchpole, K. (2013). Spreading human factors expertise in healthcare: untangling the knots in people and systems. Quality and Safety in Health Care. 0:1–5.

Eberle, B., Dick, W.D. et al, (1996). Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 33. 107-116.

Edelson, D.P., Abella, B.S., et al, (2006). Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation. 71. 137-145.

Koster, R.W., Baubin, M.A. et al, (2000). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation. 81. 1277-1292.

Marsch, S., Müller, C., et al. (2004). Human factors affect the quality of cardiopulmonary resuscitation in simulated cardiac arrests. Resuscitation. 60. 51-56.

Nolan, J.P., Soar, J., et al, (2010). European Resuscitation Council Guidelines for Resuscitation Section1. Executive Summary. Resuscitation. 81.1219-1276.

Perkins, G.D., Stephenson, B., Hulme, J. and Monsieurs, K.G. (2005). Birmingham assessment of breathing study (BABS). Resuscitation. 64. 109-113.

Rawlins, L., Woollard, M., Williams, J. and Hallam, P. (2009). Effect of listening to Nellie the Elephant during CPR training on performance of chest compressions by lay people: randomised crossover trial. BMJ. 339. b4707.

Tibballs, J. & Russell, P. (2008). Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest. Resuscitation. 80. 61–64.

Tsung, J.W. & Bliavas, M. (2008) Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: A case series. Resuscitation. 77. 264—269.

Presenting using the P cubed method: A lesson in educational liberation

The adoption of the Ross Fisher’s inspirational model of presenting (presentation cubed podcast) and the decision to move away from using bullet-pointed, text-based presentations required a leap of faith. After years of being psychologically dependant upon reams of text prompts, quotes and references (interweaved with the odd graphic / picture / cartoon) the re-writing of established slide sets for the academic MSc programme that I direct presented a further, significant challenge. I wrestled with the fear that I would not remember all of the details, that I would miss key gems of information and I worried that the students would see things the same, that I would somehow fail to deliver the requisite learning outcomes.

I say this with a modicum of self-awareness in that I have always thought of myself as a reasonably flamboyant, slightly extrovert and passionate presenter, however the P-cubed principle gave me an additional burst of confidence, sufficient to take the risk.

Well, after having delivered a number of P-cubed presentations in recent weeks I have to say the experience has been liberating. I have felt free, unshackled and de-restricted. My worries about recalling the detail were ill-founded, I certainly knew my material, furthermore I felt that I was able to put it across in a much more interesting and student-centred way. I did retain one or two text-based slides, which were focussed upon, in context, with the themes that were running through the subject area. The whole process seemed even more interactive, the students were involved and more participatory than usual, none of them (as far as I could tell) were nodding off or seeking alternative entertainment in the comfort of their smartphones and judging by the informal feedback, the intended learning outcomes were more than adequately met. I was exhausted, but the experience was educationally exhilarating. And…I will be doing this all again on Tuesday.

Many thanks to @ffolliett @inject_orange and @ccpractitioner