A relational coordination framework can be readily applied to both simulation research and application.
Why is this important?
Most simulation research focuses on skills and knowledge (the easiest factors to measure), even though:
- It is clinical outcomes that primarily matter, and;
- Simulation is uniquely positioned to address improvements in the many domains of teamwork.
Brazil et al. applied a relational coordination (RC) framework to understand teamwork-aspects of simulation research, particularly as these impact wider institutional and healthcare system performance.
“The RC framework — shared knowledge, shared goals and mutual respect in the context of communication that is timely, accurate, frequent and problem-solving based — can provide a common language for simulation educators to design and debrief simulation exercises that aim to have a translational impact” (Brazil et al. 2019)
What did they do?
The researchers undertook a narrative survey of staff involved in early major trauma care at a university teaching hospital. Over half of the respondents had participated in the institution’s existing in situ trauma simulation program.
Survey responses were analysed using the RC framework, and found to be consistent with each RC domain. Most notably trauma simulation acted as an enabler of mutual respect and improved communication, along with enhancing the understanding of team roles and prioritising problem-solving focused communication.
The impact of simulation needs to be understood in the context of the greater goal – healthcare system improvement – and that this occurs with pre-existing organisational cultures and relationships. Simulation outcomes goals are not exclusive to small teams or individual performance.
The various domains within the relational coordination framework provide an easy to use guide for understanding, communicating and deploying simulation benefits, drawing a path from the ‘here’ to the ‘there’ of improved outcomes.
“Simulation should be considered as a tool to build and strengthen relationships between practitioners across traditional boundaries.”
This editorial accompanied the 2004 study from Ekman, the first published evidence showing a reduction in awareness when BIS monitoring is used to monitor depth of anaesthesia.
Ekman’s findings were shortly after confirmed by Myles et al. in their landmark 2004 B-Aware Trial.
This editorial and the two related studies are well worth reading to give historical context to the emergence of reliable depth-of-anaesthesia monitors.
Why is this important?
In-hospital cardiac arrest (IHCA) training is an important component of both foundational and continuing medical education. Nonetheless patient survival after IHCA continues to vary across institutions, making it a priority for improvement.
What did they do?
Josey and team set out to identify whether greater hospital use of in-situ AHCI drills (‘in-situ mock codes’ - ISMC) was associated with improved IHCA survival. They measured both hospital-level simulation participation and IHCA discharge survival rates across 26 hospitals in their US multi-state non-profit health system.
And they found?
Hospitals with more active in-hospital cardiac arrest simulation training also had better IHCA survival (43% vs 32%, OR 0.62), even after adjusting for case-mix and acuity.
It is reasonable to conclude that better in-hospital code training leads to better basic & advanced life support and thus better IHCA survival – suggested, for example, by their observation of shorter time to defibrillation during arrest drills among high participation hospitals.
In fact they extraopated that each additional 1.1 drill/100 beds/year equated with one extra life saved. Interestingly the benefit of ISMC held up for large and medium-sized hospitals, but not small hospitals (=< 25 beds).
Whether these results represent a direct casual effect of simulation training to improve survival, or an indirect effect of hospital safety culture on both simulation participation and patient survival, it is nonetheless an important result.
Plus a great example of studying a meaningful outcome (survival to discharge) instead of surrogate markers often employed in resuscitation and simulation research.
Hospitals more actively using in situ cardiac arrest drills show significantly higher survival to discharge after in-hospital cardiac arrest.
Why is this relevant?
Anaesthetists and anesthesiologists have long worried about the recall of labouring women when presented with risk-benefit discussions prior to epidural analgesia or receiving anaesthesia for cesarean section.
This UK survey of over 900 women across 28 Greater London hospitals explored recall of this antenatal and intrapartum information, along with maternal satisfaction.
What did they find?
There was very little recall of receiving either thorough labour analgesia information (9%) or anaesthesia for CS (12%) provided during the antenatal period.
During the interpartum period, fewer than two-thirds (62%) recalled receiving thorough information during labour before insertion, and less than one-third (28%) before Caesarean section anaesthesia.
13% of women did not recall receiving any information before epidural insertion.
These are concerning findings in a modern era where patient autonomy and informed consent are prioritised, and more so where informed decision making may contribute to a positive birth experience.
Interestingly, verbal information appeared best recalled (OR 5.9 to 20.7 across different categories), although this is counter to past studies showing superiority of written information.
Because the 28 hospitals contributing to the survey had large practice differences in how antenatal anaesthetic information was provided, it is difficult to determine whether the provision of information or recall itself is the problem.
Regardless of the cause, a large proportion of pregnant women did not recall being adequately informed before epidural analgesia or caesarean anaesthesia. This needs to be improved.
A significant proportion of women do not recall intrapartum information before labour analgesia (38%) or anaesthesia for cesarean section (72%). Verbally-provided information was best recalled.
Regional anesthesia appears to reduce persistent post-surgical pain in adults after thoracotomy, breast cancer surgery and cesarean section, although evidence is of modest quality.
Why is this interesting?
Lidocaine/lignocaine has been increasingly used intra- and perioperatively as an analgesic adjunct, with further research suggesting a potential neuroprotective effect. Cognitive decline is a common problem following cardiac surgery (40-50%), with lidocaine potentially offering a simple and safe intervention to reduce this complication. Past studies have showed conflicting results.
What did they do?
This Duke University team randomized 478 cardiac surgery patients across multiple centres to lidocaine intraoperatively (1 mg/kg bolus then decreasing infusions across 2.9 / 1.5 / 0.6 mg/kg/h over 48 hours) or blinded control. Cognitive function was assessed at 6 weeks and 1 year.
No difference in cognitive deficit between lidocaine infusion and saline control at either 6 weeks or 1 year.
Intravenous lidocaine infusion remains relatively safe, practical and is still likely a useful analgesic adjunct. Similar to magnesium, which has been shown to be neuroprotective in premature infants but not adult cardiac patients, the problem for lidocaine may well be context rather than physiological benefit itself.
Intravenous lidocaine infusions for 48 hours perioperatively do not reduce postoperative cognitive decline up to 1 year after cardiac surgery.