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Background High-fidelity simulations based on real-life clinical scenarios have frequently been used to improve patient care, knowledge and teamwork in the acute care setting. Still, they are seldom included in the allergy- immunology curriculum or continuous medical education. Our main goal was to assess if critical care simulations in allergy improved performance in the clinical setting. Methods Advanced anaphylaxis scenarios were designed by a panel of emergency, intensive care unit, anesthesiology and allergy-immunology specialists and then adapted for the adult allergy clinic setting. This simulation activity included a first part in the high-fidelity simulation-training laboratory and a second at the adult allergy clinic involving actors and a high-fidelity mannequin. Participants filled out a questionnaire, and qualitative interviews were performed with staff after they had managed cases of refractory anaphylaxis. Results Four nurses, seven allergy-immunology fellows and six allergy/immunologists underwent the simulation. Questionnaires showed a perceived improvement in aspects of crisis and anaphylaxis management. The in-situ simulation revealed gaps in the process, which were subsequently resolved. Qualitative interviews with participants revealed a more rapid and orderly response and improved confidence in their abilities and that of their colleagues to manage anaphylaxis. Conclusion High-fidelity simulations can improve the management of anaphylaxis in the allergy clinic and team confidence. This activity was instrumental in reducing staff reluctance to perform high-risk challenges in the ambulatory setting, thus lifting a critical barrier for implementing oral immunotherapy at our adult center. Keywords Medical education, High fidelity simulation based-learning, Anaphylaxis, Allergic emergencies, Anaphylaxis management, Teamwork, Allergy clinic, Ambulatory setting *Correspondence: Ana M. Copaescu ana.copaescu@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Copaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 2 of 11 Background Methods High-fidelity simulations based on real-life clinical Participants scenarios have an essential role in medical education. In January 2018, all staff members from the allergy They are frequently used to improve patient care, clinic at the Centre Hospitalier de l’Université de knowledge and teamwork in different acute care Montréal (CHUM) in Montreal, Canada, including settings such as the intensive care unit or the emergency physicians, allergy-immunology fellows and allergy room [1–5]. Simulations provide a safe environment nurses, were invited to participate in a simulation where clinicians can practice specific skills for acute activity. The activity was repeated in July 2018 with events and build their confidence while standardizing new allergy-immunology fellows, nurses, and allergy- management [1]. This is particularly useful when immunologists who had missed the first activity. Both preparing for rare events seldom encountered in the simulations had identical clinical scenarios, were clinic that can lead to critical consequences if not completed in the same environment and required the appropriately managed. same equipment. The institutional ethics committee During their training, Canadian allergy-immunology approved the research project, and all participants physicians are well prepared to manage anaphylaxis signed informed consent. that responds to epinephrine [6]. However, even well- trained and experienced clinicians have little hands-on experience in the management of severe refractory Clinical scenarios cases of anaphylaxis. As with any office medical Advanced anaphylaxis life support adult scenarios were emergency, these can represent a significant source of developed by a multidisciplinary panel of simulation anxiety for medical and administrative personnel [4]. experts, including two anesthesiologists, two emergency Simulation-based medical education allows trainers physicians, two intensive care specialists, and two allergy to develop specific skills without exposing patients to immunologists. The specific educational objectives of avoidable errors [2, 7]. In addition to clinical knowledge each scenario were based on the competency framework and skills, medical simulations have also been shown from the Crisis Resources Management (Royal College to improve non-cognitive abilities such as teamwork, of Physicians and Surgeons of Canada) [13] as well as the leadership and communication skills [5, 8–10]. This Canadian Medical Education Directions for Specialists is highly relevant given that studies have shown that (CanMEDS) [14] and the School of nursing professional the leading causes for poor patient care in a general practice framework (Faculté des sciences infirmières de practitioner’s office are (1) lack of communication l’Université de Montréal). The team ensured that the between staff members, and (2) lack of equipment and custom-designed scenarios had the necessary complexity, organization in the clinic [1]. Post-simulation surveys responded to specific objectives, and covered the topics have shown that such activities are generally well appropriately. The sequence of activities is illustrated in accepted and appreciated by participants [11, 12]. Fig. 1. A high-fidelity simulation-based training for The first part of the program took place in the high- advanced anaphylaxis life-support was developed and fidelity simulation-training laboratory at the CHUM. This implemented at our center, including high-fidelity state-of-the-art multidisciplinary simulation workshop mannequins and simulated patients in an adult allergy focused on updating the participants’ competencies. outpatient clinic. This initiative was motivated by Participants were divided into groups of 4 to 5 people. a change in the clinic environment with the arrival They attended three allergy scenarios of 10–15 min each of new staff and changes in clinical practice that designed to review specific emergencies that could occur some staff members were less comfortable with, in the clinic: (1) laryngeal angioedema, (2) refractory such as oral immunotherapy and direct penicillin bronchospasm in a patient with aspirin-exacerbated challenges without skin testing. Our main goal was to respiratory disease, and (3) refractory shock leading to assess if critical care simulations in allergy improved cardiac arrest. In the third scenario, participants were performance in the clinical setting. Furthermore, we expected to repeat the epinephrine dose, administer sought to determine the staff members’ perceptions of intravenous fluid, monitor vital signs and initiate the improvement in team performance and the safety of advanced cardiovascular life support while waiting for the anaphylaxis management in the allergy clinic following code team. They were not expected to secure the airway the simulation training. or start the infusion of inotropes themselves but had to C opaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 3 of 11 High-fidelitysimulaon-training in simulaon lab (Allergy staff) January 2018 - Laryngeal oedema (second group in July 2018) - Refractory bronchospasm - Refractory shockleading to cardiac arrest Parcipant quesonnaire using likertscalesand Immediatelyaeracvity open-endedquesons High-fidelitysimulaon in the allergyclinic End of January 2018 (Allergy staff and code team) - Severe anaphylaxis leadingto cardiacarrest - Milder reacons occuring simultaneously August 2018 Semi-structuredinterviews with parcipants Fig. 1 Sequence of activities assist the code team. The actor leading the code played within their given role (e.g. the attendant playing the the role of an ICU fellow with high technical skills who role of the patient would not provide advice on medical had never treated anaphylaxis in the past. For example, he management). The simulation environment was meant would ask the participants’ advice on possible alternatives to reproduce the outpatient allergy clinic in terms of to epinephrine. In the bronchospasm scenario (#2), he seating, such as chairs and stretchers, medical equipment would ask the participants which induction agent to use and available drugs. In this context, as mentioned, the for endotracheal intubation. Furthermore, unless the participants were not expected to perform advanced participants realized the ICU fellow was not providing airway interventions such as intubation or start inotrope sufficient expiratory time, the patient would evolve to infusion. Still, they were expected to administer obstructive shock from hyperinflation. medications to treat anaphylaxis and call for help. Before the simulation, the groups were given time to Depending on the specific scenario, an actor-patient, a familiarize themselves with the simulated environment, high-fidelity simulator mannequin or both were used. the mannequin, the equipment and the available mock A faculty supervisor and a simulation technologist medication. Before each scenario, the participants observed the participants behind a one-way mirror received pre-briefing instructions regarding their during each simulation. They controlled the progression roles (managing physician, second available physician, of the clinical scenario, the mannequin’s voice, and nurse, respiratory therapist, patient, etc.) and a written its vital signs based on the actions of the participants clinical script that introduced the scenario (e.g. involved in the case. A pre-determined algorithm was location, information about the patient, etc.). Allergy- used to help make proper adjustments according to the immunologists and allergy-immunology fellows took learner’s performance. For example, the algorithm would turns playing a physician or a support role while the indicate how to change vital signs parameters after 5 min nurses kept playing their roles. The participants were depending on whether or not intramuscular epinephrine asked to behave as they would in a real-life situation but had been administered. Copaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 4 of 11 Each simulation was immediately followed by a The last section consisted of two open-ended questions debriefing session with the faculty (one debriefing asking for strengths and means to improve the activity. session for each scenario). These meetings lasted 20 min, Six months following the activity, participants who covering various aspects of performance and team had managed real cases of anaphylaxis in the clinic dynamics as well as the scenario’s specific objectives. following the activity were invited to participate in semi- The second part of the program consisted of an structured qualitative interviews. The same researcher in-situ allergy clinic simulation with three actors and conducted the interviews in French and recorded them one high-fidelity mannequin controlled remotely by a for subsequent analysis. We used four open-ended simulation technician. The goal of this simulation was questions, and the interviewer could reformulate them to test processes in a hospital, including the code team, up to three times to allow participants to express their the hospital security and the non-medical personnel. opinions. The first question asked what they thought During the simulation, there were no visual aids, such of the simulation activity in general. The second one as anaphylaxis management posters previously available specifically addressed the management of real-life in the clinic, that could have impacted the participants’ anaphylactic reactions. The third question asked what performance. To reflect the real-life environment, the had been the impact of the simulation training on the team had to manage multiple co-occurring events, management of these cases. The last question asked what including milder reactions and anxiety attacks, with one they thought were the current strengths and weaknesses of the patients progressing to acute respiratory failure of anaphylaxis management in the allergy clinic. and hemodynamic instability secondary to anaphylaxis. At that point, the high-fidelity mannequin replaced the Outcomes actor. The team also had to initiate resuscitation while The primary outcome was to assess if critical care waiting for the code team. The participants knew which simulations in allergy improved the participant’s week but not what day the simulation would take place. perceived performance in the clinical setting (quantitative One physician and two nurses were designated to play and qualitative questionnaires). Two secondary outcomes active roles, while the rest of the participants from the aimed to (1) analyze staff members’ perceptions on the first part were silent observers. The faculty supervisor improvement of team performance using quantitative observed the participants in the treatment room and and qualitative questionnaires (5-point Likert scale relayed information to the simulation technologist, and open questions) and (2) evaluate the impact of who controlled the mannequin from an adjacent room, a simulation activity on the clinical management of following a pre-determined algorithm. A second faculty anaphylaxis using semi-structured qualitative interviews. supervisor would remain in the main challenge room to guide the actors and the nurse that managed the milder reactions. The activity was also followed by a Analyses debriefing session led by simulation experts to which Questionnaire answers were analyzed using descriptive all staff members were invited. Issues such as refractory statistics. Pre-post changes following the simulation anaphylaxis management, crisis management, medication were compared using Wilcoxon signed-ranked test storage and doses, patient transport and logistics were (Graphpad Prism 6). Interview themes based on the explicitly discussed. Gaps in the process were identified, existing literature were identified by two researchers and remediation solutions were suggested during the based on interview transcripts. The inductive method feedback session. using thematic content exploration was used to analyze the interview transcripts to identify common themes and patterns across the data set. Categories were established Data collection and analysis by consensus between the two researchers. After the laboratory simulation activity, the 17 participants filled out an anonymous paper questionnaire Results composed of four parts. The first section consisted of Demographics demographic variables. The second section included nine Four nurses, seven allergy-immunology fellows and six questions aiming to compare the participant’s confidence allergy/immunologists (17 participants) underwent the in their ability to manage similar real-life scenarios before simulation. Among the fellows, 4 (57%) were starting and after the activity, with 5-point Likert scales (Fig. 2). their allergy-immunology training, and 3 (43%) had This was followed by 18 sentences providing feedback more than one year of training. The participants’ on the experience using a 5-point Likert scale (Fig. 3). demographic characteristics are shown in Table 1. Most C opaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 5 of 11 Fig. 2 Variation in confidence level before and after the simulation activity. Dots indicate individual participants’ answers. P-values were calculated using the Wilcoxon matched-pairs signed rank test participants (59%) had little experience in simulation. (82%) and weaknesses (88%) and to improve their Two participants reported that they were managing teamwork skills (94%). However, despite steps taken to more than 20 anaphylactic reactions per year, while the create a safe learning environment lacking judgment, majority (65%) managed between 1 and 10 anaphylactic four participants found the simulation training reactions per year. stressful, and one person indicated feeling somewhat Questionnaires uncomfortable discussing their performance in the Overall, the simulation experience was positively rated group debriefing session. All participants agreed that on the 5-point Likert scale, with most participants this activity should be mandatory for all allergy clinic agreeing that the themes matched their learning personnel. Three participants spontaneously suggested objectives and that the level of difficulty was adequate that this activity should be done once a year to maintain (Fig. 3). Also, 94% (16/17) of the participants competency. considered that the scenarios were representative of As can be observed in Fig. 2, after completing the what could occur in a clinical setting and eight (8/17, simulation-lab activity, participants showed a significant 47%) indicated that they were able to focus during the improvement in their confidence in managing all aspects simulation activity. Eight participants expressed that of acute anaphylaxis except for “code blue” management. the simulation activity allowed them to reproduce The absence of progress for the latter was partly explained the same “feelings” they had while managing a severe by the fact that most of the allergy-immunology fellows, anaphylactic reaction. Most participants thought that who had recently completed their internal medicine the activity allowed them to identify their strengths training, considered that their knowledge of code running Copaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 6 of 11 Fig. 3 Participant’s feedback. The error bars correspond to the 95% confidence interval around the average response was appropriate before the activity. One participant the code signalling was never heard in the building where indicated lower confidence in performing high-risk the allergy clinic is located, leading to a significant delay challenges and leading a code following the high-fidelity in the crash cart’s arrival. This problem was uncovered simulation. This same participant suggested that the during the simulation and resolved with the help of the training met his objectives and should be mandatory. security team. Finally, in the open questions section, 76% of the In a real code blue management four months after participants wrote comments and suggestions indicating the simulation, the gaps mentioned had been resolved. that the activity’s main strengths were its realism, Notably, access to the medication and the material had comprehensive objectives, immediate personalized been facilitated by adding clear written indications debriefing, and team-building advantages. Thus, most of on the walls on where to find different drugs and equipment. A log designed for allergy medication and the written comments about the experience were positive equipment was added to the acute care room to optimize such as “helped increase my knowledge”, “good scenarios”, availability, space and access. New posters indicating and “realistic environment”. The main improvements how to prepare some rarely used drugs were also added. suggested were that it should be repeated (“minimally During the simulation, the recorded time to receive the once a year”) and that it should last longer and have cart transport was 12 min. During the actual code at our additional scenarios. clinic, this delay was reduced to 1 min, representing a 92% improvement. In situ simulation and impact on code blue management at the allergy clinic The in-situ simulation revealed gaps in the process, Interview especially regarding rapid access to medication and Simulation activity material, code signalling, code team response and crash Participants generally agreed that the simulation was cart transport. During this practice, a nurse mentioned a good training activity that allowed them to improve missing some acute management drugs. A major problem anaphylaxis management in real life and helped them identified was that the code signalling for the outpatient feel more comfortable with diagnosis and interventions clinic needed to be relayed by multiple intermediates and in various situations. They agreed that the simulation dispatched to various buildings. During the simulation, environment was similar to what they knew from the C opaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 7 of 11 Table 1 Demographic characteristics (N = 17) by the simulation, where participants felt comfortable making mistakes. Variables N (%) Sex (female) 11 (65) Age (years) Code blue management ≤ 45 10 (59) Overall, the interviews revealed that simulation-based > 46 7 (41) training led to more rapid and orderly responses and Practice setting improved confidence in the participants’ abilities and Community clinic 0 (0) colleagues’ abilities in managing anaphylaxis. During University Hospital (outpatient clinic) 17 (100) the actual code blue management, the team was able Position to stabilize the patient and improvement was noted in Physicians 6 (35) various aspects of the process compared to the in-situ A-I fellows 7 (41) simulation. The physician and nurses involved in the code Nurses 4 (24) felt an improvement in the team dynamic and physical Years of practice environment following the simulation-based training. ≤ 10 9 (53) The managing physician added that he considered that 11–20 2 (12) the training should be done annually for the physicians ≥ 20 6 (35) and the staff because of the paucity of severe refractory Experience in simulation reactions. None 0 (0) Little 10 (59) Management of other real‑life anaphylaxes in the clinic Moderate 6 (35) Regarding anaphylaxis management, a nurse found that A lot 1 (6) the team had sometimes been “disorganized” during the Experience in anaphylaxis management simulation. Still, during a subsequent reaction in the Number of anaphylaxis cases per year clinic, this same participant indicated that “everything None 1 (6) was methodical, and everyone’s role was clear.” One of 1 to 10 11 (65) the physicians echoed this, who mentioned that the 11 to 20 3 (17) staff was “very calm” when managing mild to moderate More than 20 2 (12) anaphylaxis. Three allergy-immunology fellows also mentioned feeling more structured and confident in recognizing anaphylaxis and administering epinephrine. They also adult allergy clinic, even if most allergy-immunology agreed that, in general, the staff was “efficient,” “the fellows (4/5) had not had the chance to manage medication was easily accessible,” and that the health anaphylaxis before the simulation. They appreciated the professionals and patients were “more confident and practice environment and the quality of the material reassured” when confronted with an anaphylaxis available, as well as being able to have a hands-on reaction. approach. Table 2 summarizes the participant’s positive feedback, identified gaps, and narrative comments. Discussion Some nurses found it more difficult to naturally fill Key findings their roles because of the equipment available and the Critical care simulation in anaphylaxis at our center specificities of handling the mannequin. This comment allowed participants to identify their strengths and was echoed by one of the allergy-immunology fellows, weaknesses and improve their teamwork skills. By who mentioned the limitations of the mannequin in conducting post-activity questionnaires and interviews, simulating clinical signs of anaphylaxis. Despite these participants indicated an improvement in several aspects limitations, the activity was appreciated, and there was of crisis and anaphylaxis management. The simulation a consensus that the activity increased confidence and identified a critical gap regarding code blue signalling in reassurance in the allergy clinic. the new building and other gaps in the process, such as The participants underlined essential elements of access to drugs and materials, which were later improved. team-building. It was felt that the simulation helped the Overall the activity was very much appreciated, and the team to “learn to work together.” It clarified expectations participants considered that it should be a mandatory and therefore helped team members to trust one another. yearly training opportunity. This was made possible by the safe environment provided Copaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 8 of 11 Table 2 Summary of qualitative interviews Crisis resource management Positive feedback Gaps identified Narrative comments Communication Understand the role of other health Team disorganized during the “I think it was useful to play the role of the professionals simulation activity nurse in order to realize the time needed to prepare the different things”—First- year allergy-immunology fellow Improved anaphylaxis management “It allowed us to better know each other, to see how others react in stressful situations, and to be able to make mistakes without having a real patient.”—First-year allergy- immunology fellow “The simulation was very, very helpful for myself, the staff, and the security staff. […] We worked really well together.”— Allergy-immunologist Problem-solving Practice environment “The nurses and doctors were efficient and coordinated. The code team Quality of the material available collaborated with the allergy team Hands-on approach in synergy. We need to congratulate them for all the work. This shows the importance of optimal training.”— External observer of real-life code management “The simulation was very, very helpful for myself, the staff, and the security staff. The simulation was responsible for many improvements, including the rapid intervention of the nurses, and the fact that security was there with the cart in less than a minute and the code team in less than two. We worked really well together.”—Allergy-immunologist Resource use Importance of structured simulation Use of sub-optimal simulation “It had been more than 10 years since training equipment my last case of refractory anaphylaxis in the clinic. I was really happy that we had Specificities of handling the performed a revision of the procedure mannequin and medication before”—Allergy- immunologist “The material was already opened and had been used before and some parts were non-accessible or missing and, for example, installing an IV line was impossible. (…) We are used to regularly taking vital signs in an acute situation and the material used during the simulation was different, including the monitor that showed the vital signs, which made the situation a bit confusing.”—Allergy nurse “Conjunctivitis, rhinitis, skin eruption and signs are difficult to reproduce on a dummy but are important elements to get the feeling of where the reaction is heading in real life”.—Second-year allergy-immunology fellow Previous studies mannequins, standardized patients and, 10–12 months Similar reports targeting medical and administrative after the activity, an unexpected in situ simulation [1, 15]. personnel from the community and hospital-based These studies showed improved team management skills allergy clinics have assessed teaching and retention of in areas such as teamwork and situation awareness, as emergency management team skills using high-fidelity well as retention of knowledge and abilities after an initial C opaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 9 of 11 captured during lab simulation (access to material anaphylaxis scenario workshop [15]. Similar studies and medications, code signalling, and intensive care focused on implementing and using an anaphylaxis and response). The main benefits of an actual medical setting allergy-immunology emergencies simulation curriculum simulation described in the literature are the possibility for allergy-immunology trainees [15, 16]. to evaluate participants’ knowledge and competencies The literature on multidisciplinary team dynamics in and the clinical environment to improve patient safety [4, anaphylaxis is scarce. In one of the studies mentioned 5, 7]. above, the authors focused on the importance of engaging the medical and non-medical personnel to clarify their specific roles to avoid confusion and Limitations repetition [1]. In our study, the non-medical personnel This study has limitations. It was performed in a single were also present during the in-situ simulation allowing institution with a limited number of participants. them to witness a severe anaphylaxis management Implementing this type of simulation in other allergy scenario firsthand. In the more general acute settings clinics requires considering numerous factors, such as such as the emergency department, the operating clinic space, material distribution, and staff experience, room and the intensive care unit, there has also been which are expected to vary between centers. Access an interest in characterizing team-based simulation to a high-fidelity simulation lab and costs are essential [5]. A review paper including 17 studies underlined the barriers that could prevent the reproducibility of the importance of this team training program model aimed activity. Here, the recent clinic relocation was used to at increasing authenticity and improving patient care at justify the need for the activity. While all agree that an administrative level [5]. patient safety is paramount, it must be clarified to what Similarly, a systematic review of 38 articles on extent improved team functioning, efficiency and quality simulation activities, including 22 randomized of care resulting from the activity can offset the costs of a controlled trials, found that individual and team simulation-based training. Another significant limitation performances were improved during critical events is that the conclusions of this article are based on a and complex procedures [17]. Our results showed a qualitative assessment of the participant’s perceptions. perceived improvement in crisis team management, Furthermore, the perception of confidence should have and 94% of the participants considered that this activity ideally been measured before and after the intervention. allowed them to improve their teamwork skills. These In our study, this was measured following the essential team-building elements were also reported intervention, which could bias participants’ responses. It during the interviews. Similarly, medical education did not objectively demonstrate improvements in patient programs should focus on developing simulation outcomes attributable to the activity, which would have training to ensure teamwork skill-building through required a prospective experimental design looking at practice and repetition [3, 18]. patient outcomes or crew resource management skills The questions concerning participants’ confidence assessed by an external observer [21]. Quantifying the before the activity revealed that some staff members value of this qualitative benefit represents an important had insecurities regarding the appropriate management area of future research [17]. of anaphylactic reactions. We showed that confidence could improve after simulation training. This was also Implications reflected in the interviews, where participants reported In an era where virtual reality is increasingly used as an improvement in their own and other staff members’ simulation technology, it is essential to describe our ability to manage anaphylaxis. Some studies focusing simulation program’s success and underline its benefits on emergency responses shared similar conclusions for inter-professional collaboration and patient care. with statistically significant improvement in participants’ confidence after a simulation scenario [19, Conclusion 20]. One participant reported decreased confidence in This study provides critical qualitative data supporting code management or performing high-risk challenges. the positive impact of a high-fidelity anaphylaxis training In light of other answers given by the same participant, activity on anaphylaxis management in the clinical this seems to be explained by the discovery of practice. Participants deemed the activity instrumental unsuspected knowledge gaps, which led the participant in improving staff readiness and decreasing reluctance realizing that they were not as performant as they to perform challenges or procedures at high risk of would have liked. anaphylaxis in the ambulatory setting. It provides further The in-situ simulation proved essential for identifying evidence that high-fidelity simulations should be included and solving gaps in the process that could not be in the continuous medical education curriculum for Copaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 10 of 11 Charles-Le Moyne, Université de Sherbrooke, Greenfield Park, QC, Canada. allergy-immunology specialists to improve patient safety Department of Emergency, CHU Sainte-Justine, Université de Montréal, and team confidence. Other studies are required to guide Montreal, QC, Canada. best teaching practices using tools such as high-fidelity Received: 22 July 2022 Accepted: 14 January 2023 simulation to manage acute allergic reactions. Abbreviations ACLS Advanced cardiac life support References BLS Basic life support 1. Kennedy J, Jones S, Porter N, et al. High-fidelity hybrid simulation of CHUM Centre Universitaire de l’Université de Montréal allergic emergencies demonstrates improved preparedness for office CanMEDS C anadian Medical Education Directions for Specialists emergencies in pediatric allergy clinics. J Allergy Clin Immunol In Pract. 2013;1(6):608–17. Acknowledgements 2. Barni S, Mori F, Giovannini M, de Luca M, Novembre E. In situ simulation in The authors would like to underline the contribution of Mister Jérome Milette, the management of anaphylaxis in a pediatric emergency department. a specialist in clinical simulation and the entire department at the Académie Intern Emerg Med. 2019;14(1):127–32. du CHUM. 3. MacDonald S, Manuel A, Dubrowski A, et al. Emergency management of anaphylaxis: a high fidelity interprofessional simulation scenario Author contributions to foster teamwork among senior nursing, medicine, and pharmacy AC did the literature review and wrote the manuscript draft. PB and FG undergraduate students. Cureus. 2018;10(7): e2915. contributed to the revision of the manuscript for the important scientific 4. Zimmermann K, Holzinger IB, Ganassi L, et al. Inter-professional in-situ content. NN, RG, AR, MB, DC, AR, JP and MV contributed to the simulation simulated team and resuscitation training for patient safety: description activities’ writing, organization and supervision. All authors read and approved and impact of a programmatic approach. BMC Med Educ. 2015;15:189. the final manuscript for publication. 5. Armenia S, Thangamathesvaran L, Caine AD, King N, Kunac A, Merchant AM. The role of high-fidelity team-based simulation in acute care settings: Funding a systematic review. Surg J (N Y ). 2018;4(3):e136–51. AC receives support from the Montreal General Hospital Foundation and 6. Royal College of Physicians and Surgeons of Canada. Objectives of Research Institute of the McGill University Health Centre (RI-MUHC) and was Training in the Subspecialty of Adult and Pediatric Clinical Immunology awarded the University of Melbourne Research Scholarship, The Anna Maria and Allergy. 2012. http:// www. royal colle ge. ca/ rcsite/ ibd- search- e?N= Solinas Laroche Career Award in Immunology and the Anita Garbarino Girard/ 10000 033+ 10000 034+ 42949 67112. Accessed March 29, 2020. Anna Maria Solinas/Dr. Phil Gold Award of Distinction. PB is supported by the 7. Chong M, Pasqua D, Kutzin J, Davis-Lorton M, Fonacier L, Aquino M. Fonds de Recherche du Québec – Santé (281662). Educational and process improvements after a simulation-based anaphylaxis simulation workshop. Ann Allergy Asthma Immunol. Availability of data and materials 2016;117(4):432–3. The datasets used and analyzed during the current study are available from 8. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ the corresponding author upon reasonable request. simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22(6):468–77. 9. Orledge J, Phillips WJ, Murray WB, Lerant A. The use of simulation in Declarations healthcare: from systems issues, to team building, to task training, to education and high stakes examinations. Curr Opin Crit Care. Ethics approval and consent to participate 2012;18(4):326–32. This study was approved by the CHUM ethics committee. The CÉR (Comité 10. Nyssen AS, Larbuisson R, Janssens M, Pendeville P, Mayne A. A d’éthique de la recherche) CHUM number is 18.361. comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators. Anesth Analg. Consent for publication 2002;94(6):1560–5. Written informed consent for study analysis and publication was obtained 11. Coupal TM, Buckley AR, Bhalla S, et al. Management of acute from the interviewed participants. contrast reactions-understanding radiologists’ preparedness and the efficacy of simulation-based training in Canada. Can Assoc Radiol J. Competing interests 2018;69(4):349–55. RG—Investigator for Boehringer Ingelheim, Astra Zeneca, Merk, GSK, Novartis, 12. Weiner J, Eudy A, Criscione-Schreiber L. How well do rheumatology Stallergene, DBV, Sanofi, Green Cross, Advisor committee for Novartis, Aralez, fellows manage acute infusion reactions? A pilot curricular intervention. Mylan, ALK, Presenter for Merk, Pfizer, Astram Aralez, Pediapharm, Novartis. Arthritis Care Res. 2018;70(6):931–7. MV—member of Ezdrips (non-profit organization). PB–PB received research 13. Brindley P, Cardinal P. Optimizing crisis resource management to improve grants from Novartis, Sanofi, Regeneron and DBV Technologies and personal patient safety and team performance. A handbook for all acute care fees from Novartis, Aralez, Sanofi-Genzyme, Bausch Health, ALK, Astra-Zeneca, health professionals; 2017. Valeo and Pfizer, unrelated to this work. AC, FG, NN, AR, MB, DC, AD, JP—No 14. Frank JR, Snell L, Sherbino J. CanMEDS 2015 physician competency conflict of interest. framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. p. 17. Author details 15. Barmettler S, Banerji A, Chaudhary N, Saff RR, Blumenthal KG. Department of Medicine, Allergy-Immunology Division, Université de Implementation and assessment of an anaphylaxis simulation curriculum Montréal, Montreal, QC, Canada. Department of Medicine, Division for Boston-area allergy and immunology trainees. J Allergy Clin Immunol of Allergy and Clinical Immunology, McGill University Health Centre Pract. 2020;8(10):3616–8. (MUHC), McGill University, Montreal, QC, Canada. Department of Medicine, 16. Mawhirt SL, Fonacier L, Aquino M. Utilization of high-fidelity simulation Université de Montréal, Montreal, QC, Canada. Learning and Simulation for medical student and resident education of allergic-immunologic Center, CHUM Academy, Montreal, QC, Canada. Department of Medicine, emergencies. Ann Allergy Asthma Immunol. 2019;122(5):513–21. Allergy-Immunology Division, Université Laval, Quebec, QC, Canada. 17. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation Department of Anesthesiology, Université de Montréal, Montreal, QC, exercises as a patient safety strategy: a systematic review. Ann Intern Canada. Department of Anesthesiology, Montreal Neurological Institute Med. 2013;158(5 Pt 2):426–32. and Hospital, Montreal, QC, Canada. Department of Emergency, Université de Montréal, Montreal, QC, Canada. Department of Emergency, Hôpital C opaescu et al. Allergy, Asthma & Clinical Immunology (2023) 19:9 Page 11 of 11 18. Niell BL, Kattapuram T, Halpern EF, et al. Prospective analysis of an interprofessional team training program using high-fidelity simulation of contrast reactions. AJR Am J Roentgenol. 2015;204(6):W670–6. 19. Cristallo T, Walters M, Scanlan J, Doten I, Demeter T, Colvin D. Multidisciplinary, in situ simulation improves experienced caregiver confidence with high-risk pediatric emergencies. Pediatr Emerg Care. 2018. https:// doi. org/ 10. 1097/ PEC. 00000 00000 001623. 20. Espey E, Baty G, Rask J, Chungtuyco M, Pereda B, Leeman L. Emergency in the clinic: a simulation curriculum to improve outpatient safety. Am J Obstet Gynecol. 2017;217(6):699.e1-699e13. 21. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2003;90(5):580–8. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? 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"Allergy, Asthma & Clinical Immunology" – Springer Journals
Published: Jan 29, 2023
Keywords: Medical education; High fidelity simulation based-learning; Anaphylaxis; Allergic emergencies; Anaphylaxis management; Teamwork; Allergy clinic; Ambulatory setting
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