Validation of Select Procedures, Consultation, and Handovers in a Simulated En Route Care Environment

Projects 1, 2, 3 (Bowyer and Liu): En Route Cricothyroidotomy, Fasciotomy, REBOA and Axillary Artery Exposure.

Objectives/Specific Aims: (1) Define expert performance levels in the skills of Cricothyroidotomy (CRIC), Fasciotomy, REBOA (resuscitative endovascular balloon occlusion of the aorta), and axillary artery exposure. (2) Measure performance of medics, Emergency Department (ED) doctors and surgeons in these procedures. (3) Compare the performance of these subjects to an expert level in simulated combat en route environments (simulated helicopter with motion platform, noise, and multiple distractors).

Hypothesis: These procedures can be performed in a simulated en route environment by physician extenders, surgeons, ED doctors, and medics.

Study Design: Randomized cross-over comparison group study.

Methods: Expert group of experienced military surgeons will be asked to perform CRIC, Fasciotomy and axillary artery exposure, and REBOA once in a static (well-lit room without distractions) and once in a dynamic (helicopter shell on a motion platform) environment randomized such that one-half perform static first and one-half dynamic with cross-over. Performances will be scored by blinded evaluators using currently available and validated metrics. Multidisciplinary providers such as surgeons, non-surgeon physicians, medics, and physician assistants novices (defined as never seen or performed the procedures) will undergo training with validated physical models followed by mentored practice in a static environment for one-half of the subjects and in the dynamic (simulated helicopter) environment for the other half. All subjects will then be 'tested' by asking them to perform these procedures in the dynamic environment while being scored using the currently validated and to be developed metrics.

Project 4 (Ervin and Goolsby): Assessing Effectiveness of Remote Mentorship and Decision Support during En Route Care.

Objectives/Specific Aims: Compare the performance of en route care medics in performing specific procedures in one of three situations: (1) alone without mentorship, (2) with onsite mentorship from an advanced care provider, and (3) with remote mentorship from an advance care provider. Compare the finding of the above indicators between en route care medical providers of different skill and training levels as described above.

Hypothesis: Remote mentorship is feasible and can improve procedure performance.

Study Design: Three-way randomized trial.

Methods: Providers meeting the same selection criteria and receiving the same training on invasive procedures as those participating in the 'En Route Procedures' study will be recruited. Subjects will be randomized to 'on-site mentorship,' 'remote mentorship,' and 'no mentorship' groups. Study Principal Investigators will record the time to decision, time to perform procedures, deviations from protocols or standard practices, recognition/prevention of complications, and effectiveness of patient handoff at end of event.

Project 5 (Shackelford and Lopreiato): Assessing a Military-Specific Handoff Curriculum for En Route Care.

Objective: Determine the effect of standardized handoff training on patient handoff performance during simulated en route care using the I-PASS military handoff tool.

Hypothesis: Standardized patient handoff training will improve handoff outcomes among medical providers in the areas of reduced error rates, clear action plans, clear contingency plans, frequency of questions asked and read back compared to unstructured patient handoffs in a simulated en route environment.

Study Design: Randomized controlled trial.

Methods: Subjects will be randomized into two groups: Control group with no standardized handoff instruction and intervention group with standardized handoff instruction. All subjects will have their handoff performance tested in a simulated en route care environment. Outcome measures will be the rate of errors, omissions, and quality of the handoff between control and intervention groups using a validated checklist.

Military Relevance:

We believe that the results of this study will provide a blueprint for setting the standards for determining skill-specific 'expert' readiness and proficiency; test the feasibility and potential benefits to casualty en route care using remote mentoring and decision support tools; improve patient safety by implementing a joint patient handoff curriculum to standardize patient handoffs throughout the military trauma system.