title: In situ medical simulation investigation of emergency department procedural sedation with randomized trial of experimental bedside clinical process guidance intervention.
abstract: BACKGROUND
  Patient safety during emergency department procedural sedation (EDPS) can be difficult to study. Investigators sought to delineate and experimentally assess EDPS performance and safety practices of senior-level emergency medicine residents through in situ simulation.
  
  
  METHODS
  Study sessions used 2 pilot-tested EDPS scenarios with critical action checklists, institutional forms, embedded probes, and situational awareness questionnaires. An experimental informatics system was separately developed for bedside EDPS process guidance. Postgraduate year 3 and 4 subjects completed both scenarios in randomized order; only experimental subjects were provided with the experimental system during second scenarios.
  
  
  RESULTS
  Twenty-four residents were recruited into a control group (n = 12; 6.2 ± 7.4 live EDPS experience) and experimental group (n = 12; 11.3 ± 8.2 live EDPS experience [P = 0.10]). Critical actions for EDPS medication selection, induction, and adverse event recognition with resuscitation were correctly performed by most subjects. Presedation evaluations, sedation rescue preparation, equipment checks, time-outs, and documentation were frequently missed. Time-outs and postsedation assessments increased during second scenarios in the experimental group. Emergency department procedural sedation safety probe detection did not change across scenarios in either group. Situational awareness scores were 51% ± 7% for control group and 58% ± 12% for experimental group. Subjects using the experimental system completed more time-outs and scored higher Simulation EDPS Safety Composite Scores, although without comprehensive improvements in EDPS practice or safety.
  
  
  CONCLUSIONS
  Study simulations delineated EDPS and assessed safety behaviors in senior emergency medicine residents, who exhibited the requisite medical knowledge base and procedural skill set but lacked some nontechnical skills that pertain to emergency department microsystem functions and patient safety. The experimental system exhibited limited impact only on in-simulation time-out compliance.
authors.affiliation: From the Department of Emergency Medicine (N.A.S., L.K., F.L.O., D.C.P., G.D.J.), Alpert Medical School, and School of Engineering (G.D.J.), Brown University; Lifespan Medical Simulation Center (L.K., J.A.D.-V., J.D., R.S.A.-R., M.S.J., M.D., F.L.O.); and Emergency Department (J.D., F.G.G.), Rhode Island Hospital, Providence, RI; College of Nursing (J.A.D.-V.), University of Massachusetts Dartmouth, North Dartmouth, MA; Tree-axis (K.O., S.L.), Los Angeles, CA; Office of Clinical Affairs (J.W.G.), University of Michigan, Ann Arbor, MI; and King Abdulaziz Medical City (R.S.A.-R.), National Guard Health Affairs, Riyadh, Saudi Arabia.
authors.forename: Nathan A
authors.initials: NA
authors.lastname: Siegel
authors.forename: Leo
authors.initials: L
authors.lastname: Kobayashi
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Dunbar-Viveiros
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Devine
authors.forename: Rakan S
authors.initials: RS
authors.lastname: Al-Rasheed
authors.forename: Fenwick G
authors.initials: FG
authors.lastname: Gardiner
authors.forename: Krister
authors.initials: K
authors.lastname: Olsson
authors.forename: Stella
authors.initials: S
authors.lastname: Lai
authors.forename: Mark S
authors.initials: MS
authors.lastname: Jones
authors.forename: Max
authors.initials: M
authors.lastname: Dannecker
authors.forename: Frank L
authors.initials: FL
authors.lastname: Overly
authors.forename: John W
authors.initials: JW
authors.lastname: Gosbee
authors.forename: David C
authors.initials: DC
authors.lastname: Portelli
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Jay
mesh_terms: D000328:Adult; D057189:Checklist; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007396:Internship and Residency / Q000458:organization & administration*; D008297:Male; D061214:Patient Safety; D012151:Resuscitation / Q000379:methods*; D000066908:Simulation Training / Q000458:organization & administration*
chemical_list: D006993:Hypnotics and Sedatives