Resuscitation 80 (2009) 244–248
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Simulation and education paper
Junior physician skill and behaviour in resuscitation: A simulation study夽 Christian Bjerre Høyer a,∗ , Erika F. Christensen b , Berit Eika a a Centre for Medical Education, Faculty of Health Sciences, University of Aarhus, INCUBA Science Park - Skejby, Brendstrupgaardsvej 102, DK-8200 Aarhus N, Denmark b Department of Anaesthesiology, Aarhus Sygehus, University Hospital of Aarhus, Denmark
a r t i c l e
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Article history: Received 30 July 2008 Received in revised form 23 September 2008 Accepted 25 October 2008 Keywords: Advanced Life Support (ALS) Ambulance Cardiac arrest Cardiac massage Cardiopulmonary resuscitation (CPR) Chest compression Circulation Defibrillation Education Emergency treatment Guidelines Mannequin Resuscitation Transport
a b s t r a c t Introduction: Physicians are expected to manage their role as teamleader during resuscitation. During inter-hospital transfer the physician has the highest medical credentials on a small team. The aim of this study was to describe physician behaviour as teamleaders in a simulated cardiac arrest during inter-hospital transfer. Our goal was to pinpoint deficits in knowledge and skill integration and make recommendations for improvements in education. Method: An ambulance was the framework for the simulation; the scenario a patient with acute coronary syndrome suffering ventricular fibrillation during transportation. Physicians (graduation age ≤5 years) working in internal medicine departments in Denmark were studied. The ambulance crew was instructed to be passive to clarify the behaviour of the physicians. Results: 72 physicians were studied. Chest compressions were initiated in 71 cases, ventilation and defibrillation in 72. The median times for arrival of the driver in the patient cabin, initiation of ventilation and chest compressions, and first defibrillation were all less than 1 min. Medication was administered in 63/72 simulations (88%), after a median time of 210 s. Adrenaline was the preferred initial drug administered (58/63, 92%). Tasks delegated were ventilations, chest compressions, defibrillation, and administration of medication (97%, 92%, 42%, and 10% of cases, respectively). Discussion and conclusion: Junior physicians performed well with respect to the treatment given and the delegation of tasks. However, variations in the time of initiation it took for each treatment indicated lack of leadership skills. It is imperative that the education of physicians includes training in leadership. © 2008 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Junior physicians working at internal medicine departments are expected to be capable of initiating resuscitation. In Denmark, they are also expected to accompany patients during inter-hospital transfer, which is done without immediate back-up from senior colleagues. When engaging in inter-hospital transfer, the role of the junior physician changes from subordinate member of the inhospital team to the senior credentialed medical professional on the ambulance team. The most credentialed professional is, by definition, the teamleader if a critical situation arises.1 The teamleader is expected to stand back and keep ‘a bird’s view’, organize the team, delegate tasks and responsibility, assess the patient, decide about
夽 A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.10.029. ∗ Corresponding author. Tel.: +45 8620 5223. E-mail address:
[email protected] (C.B. Høyer). 0300-9572/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2008.10.029
treatment, and make use of resources in- and outside the team.1–6 The teamleader should avoid performing tasks unless absolutely necessary,5 but the need for him to carry out tasks increases, when the size of the team decreases.7 Although formally designated as the teamleader, the junior physicians may find it challenging to stand back from the treatment, as they see their main job in performing tasks by the patient.7 This challenge is intensified because the ambulance crew may be perceived as senior due to experience or age regardless of credential level.1 It has been documented that the quality of care decreases during inter-hospital transfer, possibly due to the use of hospital staff who are not trained sufficiently to undertake the task.8 To our knowledge, studies about behaviour of physicians in resuscitation attempts usually address the in-hospital setting or inter-hospital transfer conducted by specialised teams. This study adds important information about how to improve education early in the career of physicians to increase the quality of care provided during situations such as inter-hospital transfer in which the junior physician must take on the role of teamleader.
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1.1. Aim The aim of the study was to evaluate the behaviour of junior physicians in a setting in which their role is unmistakably that of teamleader in a scenario involving a simulated cardiac arrest during inter-hospital transfer. We evaluated the treatment decisions made and the role of team members, with a special focus on the active delegation of specific tasks by the physician to the ambulance personnel. Check points for our evaluation included time to first ventilation and chest compression, hands-off ratio, time to first defibrillation and medication, and the extent to which each of these tasks were delegated to ambulance personnel. We also noted whether or not the emergency medical technician (EMT) driving the ambulance was asked to assist. Knowledge of junior physician behaviour should enable us to pinpoint the specific behaviours of the junior physicians that may be improved and thereby allow us to make recommendations for targeted improvements in the education of physicians in resuscitation scenarios. 2. Methods 2.1. Study subjects For this study, we included physicians who received their medical credentials within the past five years who served on duty as ‘front-line personnel’ at internal medicine departments at nine different hospitals within Central Region Denmark. The participants were recruited via formal and informal channels. Participants were able to schedule the simulation session using an internet-based booking system, through e-mail, or by telephone.
Fig. 1. Experimental set-up.
The mannequin18 and the enclosed software19 enabled the use of features like simulated breathing and cardiac activity, intravenous access, and 3-lead ECG and defibrillation response capabilities. The mannequin was placed supine on a stretcher with an elevated headrest and supplied with oxygen and infusion of saline (Fig. 1). Cardiac rhythm, peripheral blood saturation, and blood pressure were simulated and monitored on the defibrillator in the ambulance. Two-way communication between physician and mannequin was established using the mannequins’ built-in loudspeaker and a microphone mounted in the ambulance. The author CBH was responsible for the verbal response from the patient.
2.2. Participants The participants were told that they were participating in a study entitled “Education in Treatment of Acute, Severely Ill Patients and Inter-hospital Transfer.” Participation was anonymous, voluntary, and strict confidence about performance was maintained. Written, informed consent was obtained. A briefing session was performed before the simulation and the simulation was followed by a debriefing session. We chose an ‘Intention to Improve’-approach to the participants; that is, giving them a possibility to improve their skills. To ensure a supportive learning environment, we therefore chose to make a scenario in which the patient would always recover. Thus we avoided making the simulation a defeat for the physician by loosing the patient and thereby counteracted negative effects of the participation.9,10 The debriefing session was facilitated by the author CBH and was attended by the participating physician and the ambulance crew and followed generally accepted standards.9,11–16 2.3. Equipment and set-up The simulation was held in an operational ambulance including personnel and equipment (Fig. 1). No changes were made to the ambulance, except for switching the defibrillator from ‘advisory mode’ to ‘manual mode’. This was done to avoid the defibrillators’ advisory voice prompts that would influence or ‘interfere’ with physician behaviour. A medical bag was available as a supplement to the standard ambulance equipment. The bag contained various medications including those necessary for performing cardiac resuscitation.2,17 Ambulance personnel included a paramedic and an EMT as the driver; both qualified in resuscitation (including bag-valve mask ventilation, chest compressions, diagnosis of cardiac arrhythmias, and defibrillation).
2.4. Experimental protocol and scenario The patient in the scenario was a middle-aged male with acute coronary syndrome. Initial treatment was undertaken according to current guidelines20 and primary hospital record was available to the physician. The ambulance was stationary throughout the simulation. Participants were asked to imagine it was on the road in all other aspects. Verbal announcement of the departure of the ambulance initiated the simulation. At this time the patient was awake. Approximately 3 min later, the patient complained of dizziness and nausea after which signs of life disappeared and the patients’ cardiac rhythm changed to ventricular fibrillation (VF). The arrhythmia was refractory to treatment for 300 s (5 min). After 300 s the patients’ cardiac rhythm was changed to pulse-less ventricular tachycardia (pVT) which could be defibrillated to restoration of spontaneous circulation (ROSC). ROSC happened no later than 480 s after the onset of VF.10 To isolate the behaviour of the physician from other personnel, the ambulance crew was instructed to be helpful throughout the simulation but to leave decisions about task assignment and treatment up to the junior physician. As in real life, only the paramedic was in the patient compartment while the EMT was driving the ambulance. The paramedic in the patient compartment was instructed to increase his selfinitiated activity after 2 min of cardiac arrest, while the driver was instructed not to simulate stopping the ambulance (which remained stationary throughout the simulation) unless asked to do so. After 5 min of cardiac arrest, the driver offered his help twice, but only entered the patient compartment if his offer to help was accepted by the physician.
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Table 1 Actions performed during the simulation. It is indicated whether it was performed by the physician; the ambulance crew; or if both parties. Action
Number (% of all)
Ventilations Compressions Defibrillation Administration of drugs
72 (100%) 71 (99.6%) 72 (100%) 63 (88%)
Performed by Physician only
Ambulance crew only
Both physician and ambulance crew
2 (3%) 6 (8%) 42 (58%) 57 (90%)
53 (74%) 37 (52%) 17 (24%) 3 (5%)
17 (24%) 28 (39%) 13 (18%) 3 (5%)
Each simulation was documented by video recordings. Prior to participation in the study, participants were asked to fill in a questionnaire about age, sex, date of birth, date and place of graduation, and participation in pre- and postgraduate resuscitation courses.
For those making use of the driver’s assistance, the driver entered the patient compartment after a median time of 52 s (13–396)[30; 120]. Delegation of tasks was quantified by calculating the number of simulations in which specific actions were performed exclusively by the physician, exclusively by the ambulance crew, or jointly by the physician and the crew (Table 1).
2.6. Statistics
3.4. Outliers
All data from the simulations were extracted by review of the video recordings and entered in a Microsoft Access 2003® database. Calculations were done using Stata I/C 10® . In the following results all values are given as medians followed by range and quartiles (min–max)[25th percentile; 75th percentile]. Both values are given to show variation as well as outliers. Kruskal–Wallis test and Spearman’s Rho were used for analysis of co-variables.
Twenty-eight outlier values divided between 20 cases were identified. They were distributed between all variables, but time to first medication (Fig. 2). Three cases had outlier values in three out of those four variables; however, the distribution of outlier values between the variables did not follow any pattern in those three cases. Two other cases had outlier values in two variables, while 15 cases had outlier values in only one of the four variables.
3. Results
4. Discussion
3.1. Participants
The junior physicians in the study generally performed well with respect to treatment and delegation of tasks. In more than half of the simulations, chest compressions were initiated and first defibrillation was done within the first minute after the onset of VF. Likewise, in more than half of the simulations, the driver arrived to assist within this first minute. Median time for initiation of ventilations was approximately 1.25 min (72 s) and median time for administration of drugs was approximately 2.5 min (210 s). Most simulations included early defibrillation as the median time to first defibrillation was 52 s. Compared to other simulation studies, this is relatively fast: Semeraro et al. studied anaesthesiologists and found that the median time to first defibrillation was 73 s,21 and Iirola et al. found the time to be 143 s, which is almost three times as long as what we observed.22 We found a large variation in the time to first defibrillation; the observed range was 7–252 s. This range is nearly equal to that found by Fielden and Bradbury (11–201 s) in a simulation
2.5. Documentation
In total 72 physicians (36 males, 36 females) were included in the study. The average time since receiving medical credentials was 1.6 years (standard deviation 1.5 years). Physicians graduated from the three Danish medical schools at Universities of Aarhus (55), Copenhagen (9), and Odense (3) and from medical schools outside Denmark (5). There was no statistically significant correlation between the above mentioned variables and the variables measured in the simulations. The same apply to chronological age, sex or self-reported participation in resuscitation courses. 3.2. Treatment Ventilations were initiated in all simulations. The median time to first ventilation was 72 s (14–354)[44; 90]. Chest compressions were initiated in 71/72 simulations (99%). The median time to first compression was 50 s (7–349)[29; 77]. The median hands-off ratio (the ratio between time without chest compressions and the time with a non-perfusing rhythm) was 49% (27–100%)[42%; 59%]. All 72 simulations included defibrillation after a median time of 52 s (7–257)[37; 94]. In 63/72 simulations (88%) at least one drug was administered. The first medication was administered after a median time of 210 s (28–401)[133; 279]. Adrenaline was the first drug used in 58/63 simulations (92%). Other drugs used as primary medication were amiodarone (3 times, 5%), atropine, and morphine (once each, 2% each). 3.3. Delegation of tasks The physicians made use of the driver in 67/72 simulations (93%). In one of these 67 cases, however, the physician immediately returned the driver after telling him that the patient was in cardiac arrest. Five physicians (7%) chose not to use the driver’s help in the resuscitation attempt, even when he offered assistance.
Fig. 2. Timeline for initiation of chest compressions, first ventilation, first DC-shock, arrival of the driver in the patient compartment, and medication time, respectively. Values shown are medians and 25th/75th percentiles (boxes) and lower/upper adjacent values. Dots indicate outliers.
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study on VF in the operation theatre.23 In contrast, Semeraro et al. found a narrower range, 40–130 s.21 Iirola et al. published 25th/75th percentiles [105; 300 s] and, consequently, found a range in their study that is wider than our own. The reported variations in range may be caused by differences in the study populations: Fielden and Bradbury23 included surgeons (n = 23) and anaesthesiologists (n = 25). Semeraro et al.21 included residents (n = 24) and consultants (n = 23) in anaesthesiology, and Iirola et al.21 included anaesthesiologists (n = 37), internists (n = 27), and surgeons (n = 14). In our simulation 25% of defibrillations happened later than 1.5 min (94 s) after onset of VF. This proportion is low compared to Fielden and Bradbury, who found 24/44 (55%) defibrillations happened later than 90 s.23 Adrenaline was the preferred initial pharmacological treatment, which is consistent with current guidelines.2 In nine cases (13%), medication was not administered which is not surprising: Lindekaer et al. studied 80 anaesthesiologists working in pairs and found that adrenaline was administered in only 75% of cases.24 Outlier values were distributed between 16 participants on four different variables. In our opinion this distribution does not suggest any systematic error. However, it is necessary to perform further analysis of demographics and behavioural patterns to identify factors contributing to the delay. 4.1. Delegation Calling for help has been reported as ‘probably the most disregarded factor’ in crisis management.25 In our study, participants were aware of the need to call for help—and most did so (93% of all cases). Ventilations and chest compressions were, in general, delegated to the ambulance crew who were experienced in these skills. However, the median hands-off ratio was 49%. Lower handsoff ratios have been reported: 13–33%.26–28 A possible explanation for the increased size of the hands-off ratio in our study was a lack of delegation. In spite of this, chest compressions were delegated to the ambulance crew in 52% of the simulations. In another 39% of the cases, chest compressions were delegated only partially, which may be interpreted in at least two ways: first, it may reflect initiative by the physician initiating chest compressions immediately on time of diagnosis and thereby decreasing the time to first chest compression. As en example, a physician was observed to initiate chest compressions and mouth-to-mouth ventilations after only 7 s and 22 s after the debut of VF respectively, while the paramedic found the bag-valve-mask. Second, however, it may reflect a lack of adeptness on the part of the physician in utilizing the available resources. Confusion about the physician’s own role may originate from the differences between the in- and inter-hospital environments: in-hospital, the junior physician has a mostly subordinate role, whereas in the inter-hospital situation he is teamleader. As with inhospital resuscitation teams, the physician and the ambulance crew seldom know each other beforehand. One way to ensure proper performance of the team is to ensure the teamleader’s focus on his tasks (assessment, delegation of tasks, e.g.). Another way is to have a consistent and agreed-upon framework for communication.29 Communication and delegation from the teamleader are key elements in Crisis Resource Management (CRM).25,30 It has been shown that CRM training improves the performance of resuscitation teams.31 Establishing training programmes in CRM in healthcare institutions is recommended by the American Institute of Medicine of The National Academies32 and probably should be extended to also include inter-hospital activities.
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4.2. Model Using a setting in which junior physicians are forced to make treatment decisions and allocate resources made it possible to evaluate their behaviour during a resuscitation attempt. Full-scale simulations in genuine surroundings are highly valued by the participants.33 The benefits of using an ambulance setting are that the surroundings and equipment are almost perfectly standardized and interference from a large team overtaking treatment and leadership is avoided. Also, actual equipment is used and personnel are acting in their normal work positions. Furthermore, the use of simulation in actual environments may reveal failure and weaknesses in technical equipment and procedures. An example of this is a study by Kobayashi et al. that revealed difficulties in locating defibrillator cables, e.g.34 Our study revealed a confusing user-interface design in the defibrillator, which led to participants turning off the defibrillator when trying to shock.35 4.3. Limitations An ambulance may be an unfamiliar environment for some physicians as they are trained and accustomed to working in hospitals, not in the inter-hospital setting. Data from this study may not be transferable to the in-hospital setting since senior personnel in the resuscitation team will ensure a higher adherence to guidelines. The study population was recruited from a relatively homogenous group. Still, it can be argued, that differences in clinical experience and knowledge of guidelines may be present and complicate interpretation of results. A number of choices were made to standardize the test situation and to simplify the analysis of the results of this study: (1) using the defibrillators’ ‘manual mode’, (2) passive ambulance crew, and (3) introducing a medical bag unfamiliar to the physician. The absence of these obstacles in real situations would likely improve physician performance. As in all simulation studies, vital signs such as skin pallor and temperature cannot be simulated and participants will be aware that human life is not at stake.15 Still, it is widely acknowledged that performance in a simulator corresponds to abilities in real life.36,37 No matter the treatment given, the patient would regain ROSC after 8 min of cardiac arrest. In order to avoid a miraculous survival without treatment, the ambulance crew would not remain passive throughout the simulation, but increase their activity, including asking leading questions and doing tasks of themselves. Finally, our study included VF for 5 min, followed by pVT for up to 3 min. Although used in other studies, it is debatable if persistent VF/pVT happens frequently enough in real life to justify this simulation sequence.38 Nevertheless, a scenario of this length was necessary to evaluate the use of guidelines, for example, if amiodarone is administered 6 min after the onset of VF as recommended.17 5. Conclusions Our study showed that junior physicians are competent overall in managing resuscitation attempts. However, the study revealed deficiencies in junior physicians’ role as teamleader, especially concerning the delegation of tasks to other personnel. As junior physicians are expected to act as teamleaders in some situations, it may be necessary to emphasize leadership and communication in the education of physicians, and focus not only on algorithms and specific practical skills. In both in- and inter-hospital resuscitations, it is impossible to ensure that team members are familiar with each other as teams
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are established ad hoc. Like task assignment is often standardized in the in-hospital setting, recommendations about, and training in, the formation of the team before and during inter-hospital transfer may be necessary. In short, the key issue is not that the physicians must perform all the practical resuscitation tasks, but the physicians must ensure that these tasks are performed regardless of whether it is by themselves or other trained personnel. Conflicts of interest None. Acknowledgements This study was supported by a grant by the County of Aarhus, Denmark. Ambulances and personnel were sponsored by Falck, Denmark. References 1. Ummenhofer W, Tanigawa K. Prehospital trauma care: scope and practice. In: Søreide E, Grande CM, editors. Prehospital trauma care. 1st ed. New York/Basel: Marcel Dekker Inc.; 2001. p. 1–18. 2. Advanced life support algorithm.Nolan JP, Gabbott DA, Lockey A, Mitchell S, Perkins G, Pitcher JD, et al., editors. European resuscitation council advanced life support course manual. 5th ed. Antwerp, Belgium: European Resuscitation Council; 2006. p. 33–9. 3. ABC of Major Trauma. 3rd ed. London: BMJ Publishing group; 2000. 4. Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: translation to improved team performance. Anesthesiol Clin 2007;25(June (2)):301–19. 5. Sundar E, Sundar S, Pawlowski J, Blum R, Feinstein D, Pratt S. Crew resource management and teamtraining. Anesthesiol Clin 2007;25(June (2)):283–300. 6. Murray WB, Foster PA. Crisis resource management among strangers: principles of organizing a multidisciplinary group for crisis resource management. J Clin Anesth 2000;12(December (8)):633–8. 7. Cooper S, Wakelam A. Leadership of resuscitation teams: lighthouse leadership. Resuscitation 1999;42(September (1)):27–45. 8. Gray A, Bush S, Whiteley S. Secondary transport of the critically ill and injured adult. Emerg Med J 2004;21(May (3)):281–5. 9. Stewart LP. Ethical issues in postexperimental and postexperiential debriefing. Simul Gaming 1992;23(June (2)):196–211. 10. Murray WB. Educational aspects & building scenarios. In: Dunn WF, editor. Simulators in critical care and beyond. Society of Critical Care Medicine; 2004. p. 29–32. 11. Petranek CF, Corey S, Black R. Three levels of learning in simulations: participating, debriefing, and journal writing. Simul Gaming 1992;23(June (2)):174–85. 12. Mort TC, Donahue SP. Debriefing: the basics. In: Dunn WF, editor. Simulators in critical care and beyond. Society of Critical Care Medicine; 2004. p. 76–83. 13. Lederman LC. Debriefing: toward a systematic assessment of theory and practice. Simul Gaming 1992;23(June (2)):145–59. 14. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med 2005;17(3):210–6. 15. Perkins GD. Simulation in resuscitation training. Resuscitation 2007;73(May (2)):202–11.
16. Kneebone R. Evaluating clinical simulations for learning procedural skills: a theory-based approach. Acad Med 2005;80(June (6)):549–53. 17. Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005;67(December (Suppl. 1)):S39–86. 18. Laerdal Medical SN. Resusci Anne Simulator. Internet 2008 May 27;Available at: URL: http://www.laerdal.co.uk/document.asp?subnodeid=11680042. 19. Laerdal Medical SN. Laerdal PC SkillReporting System v. 2.2.1. Internet 2008 May 27;Available at: URL: http://www.laerdal.co.uk/document.asp? subnodeid=24091423. 20. Arntz HR, Bossaert L, Filippatos GS. European Resuscitation Council guidelines for resuscitation 2005. Section 5. Initial management of acute coronary syndromes. Resuscitation 2005;67(December (Suppl. 1)): S87–96. 21. Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation 2006;68(January (1)):101–8. 22. Iirola T, Lund VE, Katila AJ, Mattila-Vuori A, Palve H. Teaching hospital physicians’ skills and knowledge of resuscitation algorithms are deficient. Acta Anaesthesiol Scand 2002;46(October (9)):1150–4. 23. Fielden JM, Bradbury NS. Observational study of defibrillation in theatre. BMJ 1999;318(January (7178)):232–3. 24. Lindekaer AL, Jacobsen J, Andersen G, Laub M, Jensen PF. Treatment of ventricular fibrillation during anaesthesia in an anaesthesia simulator. Acta Anaesthesiol Scand 1997;41(November (10)):1280–4. 25. Voigt AC, Lewis MT, Lu TC. Simulation in crisis management. In: Loyd GE, Lake CL, Greenberg RB, editors. Practical health care simulation. Philadelphia: Elsevier Mosby; 2004. p. 205–44. 26. Hostler D, Rittenberger JC, Roth R, Callaway CW. Increased chest compression to ventilation ratio improves delivery of CPR. Resuscitation 2007;74(September (3)):446–52. 27. Olasveengen TM, Wik L, Kramer-Johansen J, Sunde K, Pytte M, Steen PA. Is CPR quality improving? A retrospective study of out-of-hospital cardiac arrest. Resuscitation 2007;75(November (2)):260–6. 28. Bjorshol CA, Soreide E, Torsteinbo TH, Lexow K, Nilsen OB, Sunde K. Quality of chest compressions during 10 min of single-rescuer basic life support with different compression: ventilation ratios in a manikin model. Resuscitation 2008;77(April (1)):95–100. 29. DeVita MA, Schaefer J, Lutz J, Dongilli T, Wang H. Improving medical crisis team performance. Crit Care Med 2004;32(February (2 Suppl.)): S61–5. 30. Fiedor ML, DeVita MA. Human simulation & crisis-team training. In: Dunn WF, editor. Simulators in critical care and beyond. Society of Critical Care Medicine; 2004. p. 91–4. 31. Cooper S. Developing leaders for advanced life support: evaluation of a training programme. Resuscitation 2001;49(April (1)):33–8. 32. To Err is Human: Building A Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine; 2008. 33. Small SD. Simulation applications for human factors and systems evaluation. Anesthesiol Clin 2007;25(June (2)):237–59. 34. Kobayashi L, Shapiro MJ, Sucov A, et al. Portable advanced medical simulation for new emergency department testing and orientation. Acad Emerg Med 2006;13(June (6)):691–5. 35. Høyer CS, Christensen EF, Eika B. Adverse design of defibrillators: turning off the machine when trying to shock. Ann Emerg Med 2008;52:512–4. 36. Boulet JR, Swanson DB. Psychometric challenges of using simulations for highstakes assessment. In: Dunn WF, editor. Simulators in critical care and beyond. Society of Critical Care Medicine; 2004. p. 119–30. 37. McFetrich J. A structured literature review on the use of high fidelity patient simulators for teaching in emergency medicine. Emerg Med J 2006;23(July (7)):509–11. 38. Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth 1998;45(February (2)):130–2.