title: Testing Confounders in Brain Death Determination: A New Simulation Model.
abstract: BACKGROUND
  Given the rarity of brain death in clinical practice, trainees may complete their training without ever performing a brain death exam. Little is known about the performance of trainees in the evaluation of brain death. The accuracy of brain death determination can be audited and improved through simulation models.
  
  
  METHODS
  A simulated brain death scenario was designed to incorporate numerous potential confounders. We utilized a SimMan 3G mannequin, registered nurse, simulation technician, and a facilitator. Critical care and neurology trainees were evaluated using a 24-point checklist based on the AAN guidelines. Trainees rated their confidence (5 point scale with 1 = novice, 3 = competent, and 5 = fully confident) in the evaluation of brain death and apnea testing before and after completing the scenario. Following the simulation, trainees participated in debriefing sessions involving a review of the checklist and playback of simulation videos.
  
  
  RESULTS
  Forty-one trainees completed the simulation. Trainees successfully completed 352/492 (71.5 %) tasks pertaining to the evaluation of prerequisites and 262/369 (71.0 %) tasks pertaining to the clinical examination. Trainee confidence in the evaluation of brain death (2.12 ± 0.74 vs 3.29 ± 0.62, p = 0.0001) and apnea testing (2.10 ± 0.74 vs 3.59 ± 0.77, p = 0.001) significantly improved.
  
  
  CONCLUSIONS
  We successfully tested a new simulation model which emphasized training in crucial pitfalls. More than one in four trainees performed poorly in the evaluation of prerequisites and the clinical examination. Few trainees considered the possibility of drug or alcohol ingestion. Simulation training improved clinical performance and trainee confidence in the evaluation of brain death.
authors.affiliation: Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. hocker.sara@mayo.edu.
authors.forename: Sara
authors.initials: S
authors.lastname: Hocker
authors.affiliation: Department of Nursing Education, Mayo Clinic, Rochester, MN, USA. schumacher.donna@mayo.edu.
authors.forename: Donna
authors.initials: D
authors.lastname: Schumacher
authors.affiliation: Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. mandrekar.jay@mayo.edu.
authors.forename: Jay
authors.initials: J
authors.lastname: Mandrekar
authors.affiliation: Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. wijde@mayo.edu.
authors.forename: Eelco F M
authors.initials: EF
authors.lastname: Wijdicks
mesh_terms: D000328:Adult; D001926:Brain Death / Q000175:diagnosis*; D002983:Clinical Competence / Q000592:standards*; D003422:Critical Care / Q000379:methods* / Q000592:standards; D003479:Curriculum; D005257:Fellowships and Scholarships / Q000379:methods / Q000592:standards; D006801:Humans; D007396:Internship and Residency / Q000379:methods / Q000592:standards; D008348:Manikins; D009462:Neurology / Q000193:education* / Q000379:methods / Q000592:standards; D000066908:Simulation Training / Q000379:methods*
keywords: Brain death; Curricular milestones; Error in medicine; Medical education; Simulation