A comparison of paediatric airway anatomy with the SimBaby high-fidelity patient simulator

Background

The SimBaby high-fidelity patient simulator is a widely used paediatric simulator for the training of standard and critical airway management scenarios. Furthermore this simulator is frequently used for the evaluation of different airway devices and techniques. However, the anatomic structures of the SimBaby have not been compared to actual patients’ anatomy.

Methods

The CT radiographic measures of the upper airway anatomy of two SimBaby simulators were compared to MRI images of the upper airway of 20 children aged 1-11 months who underwent routine MRI scans under sedation for diagnostic purposes. Various distances of the tongue, soft palate and pharynx, cross sectional areas and volumes of anatomic structures of the upper airway including the retroglossal airspace were compared.

Results

The SimBaby's retroglossal airspace volume greatly differed from the measurements in patients (SimBaby 5.3 ± 0.4 vs. 1.9 ± 0.8 cm³ in infants, p < 0.01). Furthermore the distance from the alveolar process of the mandible to the posterior pharyngeal wall was larger in the SimBaby than in infants (5.8 ± 0.1 vs. 4.5 ± 0.5 cm, p < 0.001) and dimensions of the epiglottis and pharynx were larger in the Simbaby.

Conclusion

The anatomic features of the SimBaby do not adequately simulate the upper airway anatomy of infants. These results imply inadequate realism of this simulator for airway training and compromise the validity of comparative trials of different airway devices with the SimBaby as airway model.     

人工气道不同气囊压对气道损伤及误吸的影响

目的:气囊压力在气道管理中有重要的意义,过低可致吸入性肺炎的发生率升高,过高可损伤气道黏膜.本研究旨在探讨不同气囊压力对人工气道的影响.方法:选取我院ICU建立人工气道行机械通气患者96例,随机分为A组、B组和C组,采用POTEX专用气囊压力表观察气囊内压分别为35 cmH2O、30 cmH2O、25 cmH2O,于插...     

Reflection on a patient's airway management during a ward-based resuscitation

BACKGROUND: The bag-valve-mask (BVM) system is a common adjunct used during adult resuscitation to ventilate the lungs and deliver oxygen to patients in cardiopulmonary arrest. Gastric inflation, regurgitation and aspiration are well-documented complications of BVM ventilation, which can have serious consequences for patients. AIM: The aim of this paper is to review the cause of gastric inflation, regurgitation and aspiration during BVM ventilation and to consider techniques that have been suggested to reduce these problems. METHOD: Using a reflective model, the author revisits an actual cardiac arrest, and within a structured framework considers the event itself, the context of the event and looks at ways in which practice could be improved in future. RESULTS: It is clear from the evidence that a reduction in peak airway pressure can reduce the risk of gastric inflation, regurgitation and aspiration. A review of the available research strongly suggests that in expert hands, the most effective means of reducing peak airway pressure is by reducing tidal volume by using a smaller bag. CONCLUSION: Although the evidence, as presented, for a reduction in bag size is convincing, there appears to be a problem that less regular users do not appear to be able to produce effective tidal volumes when using a smaller bag. If a reduced bag size is standardized, further research using a diverse group of health care workers with the BVM is required before a clear policy can be achieved. It is likely that training and practice will be shown to be important for nursing staff expected to use the smaller BVM.     

Learning about new anesthetics using a model driven,full human simulator

Objective.New pharmacological agents are introduced into medical practice at an ever-increasing pace. Teaching how to use new medications in the clinical setting presents educational challenges and puts patients at risk. Methods.Patients and clinical settings in which remifentanil might provide clinical advantages over existing anesthetics were identified. A simulator curriculum was developed to demonstrate the use of remifentanil in the sample cases. The simulation was designed to highlight the clinical advantages and potential side effects of remifentanil. A screen displaying the concentrations of remifentanil in plasma and in the hypothetical effector site was developed. A simulator was modified (addition of an infusion pump and a pharmacokinetic screen display) and transported to several cities in the U.S.A. An instructor guided small groups of anesthesiologists and anesthetists through a structured program that enabled participants to observe drug effects in simulated patients. Results.There were 836 participants in the remifentanil program, which was offered in 58 cities in the U.S.A. Surveys were completed by 574 anesthesiologists. There was a significant difference in comfort level for using remifentanil after the session compared to before (Chi-square, p< 0.001.) The statement: Clinical simulation experience is a means to learn about new agents like remifentanilwas rated as excellent by 81% and as good by 19% of participants. No participant found the experience to be not useful. Conclusions.Patient simulation is a novel method of introducing new drugs to the medical community and is perceived by anesthesia providers as a valuable addition to available teaching methods.     

Emergency skill training--a randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching

Introduction

The “4-stage approach” has been widely accepted for practical skill training replacing the traditional 2 stages (“see one, do one”). However, the superior effectiveness of the 4-stage approach was never proved.

Objectives

To evaluate whether skill training with the 4-stage approach results in shorter performance time needed for a successful percutaneous needle-puncture cricothyroidotomy, and consequently in a reduced number of attempts needed to perform the skill in <60 s compared to traditional teaching.

Trial design

Randomized controlled single-blinded parallel group study at the University Hospital Bern.

Methods

With IRB approval and informed consent 128 undergraduate medical students were randomized in four groups: traditional teaching, no stage 2, no stage 3, and 4-stage approach for the training of cricothyroidotomy. Everyone watched a video of the cricothyroidotomy as stage 1 followed by skill training in the respective teaching group. Participants had to perform the cricothyroidotomy 10 times on skin-covered pig larynxes. Performance time was measured from skin palpation to trachea ventilation. Study participants filled out a self-rating on competency during the training.

Results

Performance time for each attempt was comparable in all groups and improved similarly to reach a performance time of <60 s. Self-rating revealed that all groups felt equally competent throughout.

Conclusions

Even if the 4-stage approach is widely accepted and used as a didactic method for skill teaching we could not find evidence that its use or omitting stage 2 or 3 results in superior learning of an emergency skill compared to traditional teaching.     

以案例为基础的学习法在临床诊断学教学中的应用

以案例为基础的学习法(CBL)在医学、商学和法学领域应用日益广泛,CBL在医学教育领域一直受到人们的关注。笔者将CBL应用在临床诊断学教学,以真实的临床场景为基础培养医学生临床实践技能和正确诊断思维,培养学生使用所学理论知识和推理能力来解决临床问题。CBL具有参与性和启发性,能有效提高医学生的分析和解决问题能力,有助于医学生的逻辑推理能力和综合诊断技能的培养并在未来的职业发展过程中灵活运用其诊断技能。CBL能有效提高学生临床诊断技能,在临床诊断学教学中取得了较好效果,值得重视和推广。     

Nursing students learning transfer from classroom to clinical practice: An integrative review

AimThe aim of this integrative review was to examine the theoretical, qualitative, quantitative and mixed-methods literature focused on how nursing students transfer learning from theory courses into clinical practice.BackgroundAs nursing curriculum aligns with the growing body of nursing knowledge, nursing students continue to develop their knowledge base and skill sets to prepare for future nursing practice. The bulk of this preparation involves developing connections between classroom/lab knowledge and further demonstrating those connections in clinical practice. However, the extant state of evidence on undergraduate nursing students’ learning transfer has not yet been synthesized.DesignThis integrative review was conducted using the Whittemore and Knafl framework.Review methodsEight databases were searched in June 2022: MEDLINE, APA PsycInfo, EMBASE, Web of Science, CINAHL, ERIC, Academic Search Complete and Education Research Complete. Literature was included if it focused on undergraduate nursing students who have participated in at least one clinical practicum and reported on learning transfer in clinical settings. Only English-language, peer-reviewed literature was included. Two researchers independently assessed the eligibility of articles at the title-and-abstract level and at the full-text level, followed by an assessment of methodological quality. The Joanna Briggs Institute’s critical appraisal checklists were used to assess theoretical papers and literature reviews and the mixed-methods appraisal tool (MMAT) was used to appraise all studies. Reference lists of included articles were searched for additional relevant literature. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines.ResultsTwenty-eight articles met our inclusion criteria and were included in this review, including 20 qualitative studies, one quantitative study, three mixed-methods studies, three theoretical articles and one integrative review. The results of this review highlighted that numerous facilitators and barriers influence nursing students’ ability to transfer learning within clinical learning environments. Facilitators included having knowledgeable and supportive educators and nursing staff, using strategies to promote connections, fostering reflection and aligning theory and practice. Barriers included unclear connections between course content, incongruencies between classroom and practice, lack of nurse role models, lack of real-world applicability and unsupportive nurse educators.ConclusionsThe information generated from this integrative review provides evidence about barriers that can be mitigated and facilitators that can be leveraged to facilitate undergraduate nursing students’ learning transfer into clinical practice. The findings also highlighted gaps in evidence surrounding the need to understand how nursing students transfer learning from classroom settings to clinical practice settings.     

Teaching respiratory physiology: clinical correlation with a human patient simulator

In recent years students have increasingly objected to laboratory exercises involving animal subjects. We have replaced the valuable animal experiments with demonstrations using a full-scale human patient simulator. In small groups first-year medical students observe realistic clinical situations such as opioid-induced hypoventilation, pneumothorax, and pulmonary edema. Students obtain information through physical examination, arterial blood gas analysis and chest radiography. They practice interventions such as providing supplemental oxygen and mask ventilation, monitor the results, and develop a basic differential diagnosis and treatment plan. We utilize the clinical context to review fundamental concepts of respiratory physiology including the alveolar air equation and oxyhemoglobin dissociation curve. The students give these laboratory exercises uniformly superior evaluations. This revised version was published online in July 2006 with corrections to the Cover Date.     

FIRST2ACT: educating nurses to identify patient deterioration - a theory-based model for best practice simulation education

Delayed assessment and mismanagement of patient deterioration is a substantial problem for which educational preparation can have an impact. This paper describes the development of the FIRST²ACT simulation model based on well-established theory and contemporary empirical evidence. The model combines evidence-based elements of assessment, simulation, self-review and expert feedback, and has been tested in undergraduate nurses, student midwives and post-registration nurses. Participant evaluations indicated a high degree of satisfaction and substantial self-rated increases in knowledge, confidence and competence. This evidence-based model should be considered for both undergraduate and post-registration education programs.     

Iranian nurses' perceptions of theoretical knowledge transfer into clinical practice: a grounded theory approach

Since nursing education was transferred to universities in Iran, the public and health administrators have criticized Iranian nurses because of poor-quality patient care. It seems that nurses are not able to transfer the taught theoretical knowledge in academia into practice. This paper attempts to provide an insider view of why the taught theoretical knowledge in academia might be difficult to enact in the clinical setting. Using the grounded theory approach, individual in-depth interviews and participant observation were undertaken with a purposive and theoretical sample of 26 participants in Tehran University of Medical Sciences. The data were analyzed using the constant comparative method. The findings showed that, in spite of increased academic input into nursing education, clinical behaviors in both the education and practice settings were perceived as "traditional routine-based".     

试析导致临床误诊误治的管理性因素

在导致临床误诊误治的诸多因素中，医院管理机制的缺陷是不可忽视的重要因素，主要表现为基础医疗护理质量环节薄弱，医生缺乏临床实践经验和诊治病人的整体观，缺乏良好的职业道德和责任心，因此，在当前医疗市场竞争愈加激烈的形势下，医院管理者必须要清醒地认识到误诊误治的管理因此，转变观念，与时俱进，通过改变医学教育模式，规范在职继续医学教育方法，提高临床医生把握最新医学信息的能力，加强三级检诊和多科会诊制度，提高医务人员的道德修养，从源头上防范人为性误诊误治的发生，将临床医学螺旋式地推向新的阶段。     

A novel method to detect accidental oesophageal intubation based on ventilation pressure waveforms

Background

Emergency endotracheal intubation results in accidental oesophageal intubation in up to 17% of patients. This is frequently undetected thereby adding to the morbidity and mortality. No current method to detect accidental oesophageal intubation in an emergency setting is both highly sensitive and specific. We hypothesized that, based on differences between the mechanical properties of the oesophagus and the trachea/lung, ventilation pressures could discriminate between tracheal and oesophageal intubation. Such a technique would potentially not suffer some of the limitations of current methods to detect oesophageal intubation in emergency conditions such as noisy environment (making clinical assessment difficult) or low/no flow states (reducing the applicability of capnometry). The aim of our study was thus to develop and assess a technique that may more rapidly and accurately differentiate oesophageal from tracheal intubation based on airway pressure gradients.

Materials and methods

Forty adult patients undergoing elective surgery were included. In 20 patients the trachea was intubated with an endotracheal tube; in 20 patients the oesophagus was purposefully intubated using an Easytube^® (Rüsh, Germany). In all patients, a thin air-filled catheter was inserted through the tube lumen until its tip was 1 cm from the distal end, and connected to a pressure transducer. Pressure was recorded simultaneously from a second catheter at the proximal end of the tube. For the first three manual ventilations in each patient, a parameter (D) based on temporal (dP/dt) and spatial (dP/ds) pressure gradients (and reflecting flow divided by elastance) was calculated and evaluated for its ability to discriminate between oesophageal and tracheal intubation.

Results and discussion

For all tracheal ventilations, D-values were >0.5 (range 0.6-47.9), while for all oesophageal ventilations D-values were <0.5 (range 0.0005-0.07).

Conclusion

This technique has the potential to provide a diagnosis of failed intubation within seconds with high sensitivity and specificity.     

护理临床判断能力的研究进展

护理临床判断是临床实践的必备技能，也是临床决策的前提。培养护理临床判断能力在全球老龄化背景下显得尤为突出。国外对此进行了有益的探索，而国内相关研究鲜有报道。文章对国内外护理临床判断的相关研究进行综述，并在此基础上提出培养护理临床判断能力的可行路径，包括积极开展反思实践、情景模拟教学、形成性评价和老年护理教学研究。     

From competence to capability: a study of nurse practitioners in clinical practice

Aims and objectives. This research aimed to understand the level and scope of practice of the nurse practitioner in Australia and New Zealand further using a capability framework. Background. The original study, from which the present paper was developed, sought to identify competency standards for the extended role of the nurse practitioner in Australia and New Zealand. In doing so the researchers became aware that while competencies described many of the characteristics of the nurse practitioner they did not manage to tell the whole story. In a search of the literature, the concept of capability appeared to provide a potentially useful construct to describe the attributes of the nurse practitioner that went beyond competence. Design. A secondary analysis of data obtained from interviews with nurse practitioners working in Australia and New Zealand was undertaken. These data had previously been obtained in a study to identify nurse practitioner competencies. The analysis described in this paper investigated whether or not the components of capability would adequately explain the characteristics of the nurse practitioner. Methods. Fifteen nurse practitioners were interviewed from Australia and New Zealand. A secondary (deductive) analysis of interview data using capability as a theoretical framework was conducted. Results. The analysis showed that capability and its dimensions is a useful model for describing the advanced level attributes of nurse practitioners. Thus, nurse practitioners described elements of their practice that involved: using their competences in novel and complex situations as well as the familiar; being creative and innovative; knowing how to learn; having a high level of self‐efficacy; and working well in teams. Conclusions. This study suggests that both competence and capability need to be considered in understanding the complex role of the nurse practitioner. Relevance to clinical practice. The dimensions of capability need to be considered in the education and evaluation of nurse practitioners.     

血压测量教学中学生不易掌握环节的调查分析

目的对学生在学习血压测量过程中不易掌握环节进行调查分析,从而为教学提供基础资料。方法按照规定学时在血压测量示教、练习后,教师通过目测、询问、考试等方法找出学生操作与教材不符的环节并进行分析。结果学生操作不符合教材规范环节依次为:充气(97.0%)、放气(72.2%)、听诊器胸件位置(56.0%)、袖带松紧度(54.3%)、搏动音听诊(49.7%)。不同学制之间差异无统计学意义。结论血压测量操作教学中,应强调听诊器胸件放于肱动脉搏动点上;用3种方法可替代教材对于充气的要求;开始学习放气宁慢勿快;初学者最好裸露整个上臂练习;舒张压强调以搏动消失为准。