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Introduction: With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU. Methods:The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in two rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence pre-/post-simulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t-test. Results:We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N=60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. Post simulation mean ratings of confidence

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SUMMARY INCASE, a web-based electronic learning (e-learning) environment, has been built to enable rapid expertise development in novice-level professional knowledge workers. This paper describes the theoretical underpinnings (constructivist epistemology) behind INCASE and uses a design science methodology to describe its design, construction, instantiation, and validation. The INCASE system addresses a fundamental problem in knowledge worker domains where experience is a necessary component of expertise development and a barrier to the rapid development of domain experts.

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