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Objective: To develop a simulation-based curriculum for residents to learn ultrasound-guided (USG) central venous catheter (CVC) insertion, and to study the volume and type of practice that leads to technical proficiency. Methods: Ten post-graduate year two residents from the Departments of Emergency Medicine and Anesthesiology completed four training sessions of two hours each, at two week intervals, where they engaged in a structured program of deliberate practice of the fundamental skills of USG CVC insertion on a simulator. Progress during training was monitored using regular hand motion analysis (HMA) and performance benchmarks were determined by HMA of local experts. Blinded assessment of video recordings was done at the end of training to assess technical competence using a global rating scale. Results: None of the residents met any of the expert benchmarks at baseline. Over the course of training, the HMA metrics of the residents revealed steady and significant improvement in technical proficiency. By the end of the fourth session six of 10 residents had faster procedure times than the mean expert benchmark, and nine of 10 residents had more efficient left and right hand motions than the mean expert benchmarks. Nine residents achieved mean GRS scores rating them competent to perform independently. Conclusion: We successfully developed a simulation-based curriculum for residents learning the skills of USG CVC insertion. Our results suggest that engaging residents in three to four distributed sessions of deliberate practice of the fundamental skills of USG CVC insertion leads to steady and marked improvement in technical proficiency with individuals approaching or exceeding expert level benchmarks. RÉSUMÉObjectifs: L'étude visait à élaborer un programme de formation axé sur la simulation et conçu à l'intention des résidents en vue de l'apprentissage de la mise en place échoguidée de cathéters veineux centraux (CVC), et à déterminer le nombre et le type d'exercices pratiques permettant d'en arriver à la compétence technique. Méthode: Dix résidents, en deuxième année d'études de cycles supérieurs, en médecine d'urgence et en anesthésie ont participé à quatre séances de formation de deux heures chacune, tenues à deux semaines d'intervalle, dans le cadre d'un programme structuré de pratique intentionnelle sur simulateur, en vue de l'acquisition des compétences de base dans la mise en place échoguidée de CVC. Les progrès réalisés durant la formation ont été suivis de près à l'aide d'un outil régulier de mesure, l'Hand Motion Analysis (HMA), et les valeurs de référence ont été déterminées par l'HMA des experts locaux. À la fin des séances de formation, les compétences techniques enregistrées sur bande vidéo ont fait l'objet d'une évaluation à l'insu par des experts, sur une échelle globale de notation (EGN). Résultats: Au départ, aucun des résidents n'atteignait l'une ou l'autre des valeurs de référence. Au fil de la formation, les mesures de l'HMA des résidents ont révélé une amélioration constante et i...

The 2019 coronavirus disease pandemic is challenging our Canadian emergency departments (EDs) in unparalleled ways. As part of the frontline response, EDs have had to adapt to the unique clinical difficulties associated with the constant threat of COVID-19, developing protocols and pathways in the setting of limited and evolving information. In addition to the disruption of routine clinical care practices, an underlying perception of danger has resulted in a challenging clinical environment in which to make time-sensitive, high-stakes decisions. This has created an urgent need for targeted and adaptive training for all members of the emergency medicine healthcare team. The following commentary reflects the perspective of four emergency medicine simulation educators during the Canadian response to COVID-19. Recognizing that local needs and resources will vary, we highlight three key roles that simulation can play in the adaptive response to COVID-19: protocol development and system testing, provider education, and team-based training. The disruption to our practice as a result of COVID-19 has required us to "build the plane as we fly," and we believe simulation to be a key tool in this process. SIMULATION FOR PROTECTED PROTOCOL DEVELOPMENT AND TESTINGThis pandemic has brought us to uncharted waters and has required the creation of new processes and protected protocols for intubation, code blue responses, and workflows within the ED. Our familiar and reliable system 1 thinking (fast, automatic, unconscious thought processes) frequently applied during high risk events has been supplanted by system 2 thinking (slow, effortful, and deliberate thought processes) due to team safety risks related to viral exposure and infection. 1 For example, the cognitive load required to perform common tasks, such as endotracheal intubation, has increased considerably, creating opportunities for error. In order to support system 2 thinking and mitigate error, protocols and corresponding checklists are required. Simulation allows for a safe, controlled, and iterative approach to protocol design and is well established in this context. 2,3 It seems only natural to apply our experience using simulation for systems testing to ED preparedness for COVID-19.Much like crash testing a car, simulation affords an opportunity for ED and simulation leaders to observe, reflect, and refine proposed protocols without risking harm to the healthcare team (or patient). This process is important to ensure a consistent approach and anticipate downstream implications prior to operationalization. Integrating the Plan-Do-Study-Act conceptual framework for systems improvement into pandemic simulation activities allows for a rapid analysis of novel protocol development. In turn, this enhanced simulation strategy serves to identify the safest and most efficient and pragmatic approach to various emergent situations. Novel pandemic-related protocols and various critical event checklists (e.g., COVID-19 intubation checklist) are From the

ObjectiveSimulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).MethodsSimulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.ResultsTwenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.ConclusionThis study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

Introduction / Innovation Concept: Insertion of an internal jugular (IJ) central venous catheter (CVC) under ultrasound guidance (USG) is a complex skill that requires considerable practice in order to achieve technical proficiency. Simulation allows novices to engage in structured and high volume repetitive practice of USG IJ CVC insertion and to work through a predictable pattern of errors prior to real patient encounters. Based on earlier work on learning curves for CVC insertion, this curriculum uses a model of simulation-based high volume deliberate practice of the fundamental skills of USG CVC insertion, and was designed with careful consideration of the conditions associated with optimal learning and improvement of performance. Methods: Eight residents (post graduate year 2) from the Departments of Emergency Medicine and Anesthesiology engaged in deliberate practice of USG CVC insertion during three two-hour sessions, at 2-week intervals. Progress of the residents was monitored with direct observation and regular hand motion analysis (HMA), which was compared to performance metrics set by a local expert. Curriculum, Tool, or Material: Students reviewed online introductory ultrasound video and articles outlining internal jugular (IJ) and femoral CVC insertion prior to the first session. Session 1 focused on ultrasound skills including knobology, transducer movement, and needle tracking. This was followed by 60 minutes of deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. During sessions 2/3, students practiced complete gowning and draping using sterile technique. This was followed again by deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. Students received coaching and feedback throughout all sessions, with HMA assessment of USG IJ CVC insertion at the beginning and end of each session. After three training sessions, consisting of 85 total attempts, 5/8 residents surpassed the expert benchmark for probe hand motion, 6/8 for needle hand motion, and 1/8 for total procedure time, with the remaining residents approaching the expert benchmark for each metric. Conclusion: We have successfully developed a simulation-based curriculum for USG IJ CVC placement. Residents demonstrated continuous improvement in each session, approaching or exceeding the expert benchmarks by the end of the third session.

Emergency medicine (EM) training programs incorporate simulation for teaching as well as formative and summative assessment. The development of a simulation curriculum for Canadian postgraduate EM programs is underway and would be facilitated by a standardized, user-friendly, nationally endorsed simulation template. We convened a nationally representative group of simulation educators to participate in a three-phase process to develop and refine a simulation case template for Canadian EM educators. Participants provided feedback by means of free text comments and focus groups which were analyzed to inform modification of the template. We anticipate that this template will facilitate the sharing of cases across sites and the development of standardized cases for simulation-based assessment.

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