Use of a Cognitive Aid during Simulated Patient Crisis Improves the Quality of the Transition of Care Process

Annette Rebel1*, Brooke Bauer1, Amy DiLorenzo1, Paul A Sloan1, Regina Y Fragneto1, Faith Lukens1, KariBeth Christie2, Rana Latif 2-4, Zaki Udin Hassan1, Mitzi Schumacher5, and Randall M Schell1 1Department of Anesthesiology, USA 2Department of Anesthesiology and Perioperative Medicine, USA 3Paris Simulation Center, Office of Undergraduate Medical Education, USA 4Outcomes Research Consortium, USA 5Department of Behavioral Science, USA


Introduction
Transfer of patient care between providers is key to safe medical practice and loss of patient information during this process may contribute to undesirable outcomes [1]. With the increase in patient handovers, it is essential that we reduce information loss [2,3]. Research in Transition of Care (ToC) has focused on the handoff quality occurring at shift-ends, which is usually a censusbased process occurring in a structured fashion at a standardized time and location [4][5][6][7][8][9][10][11]. The quality of ToC in crisis situations has not been well assessed [12]. Simulation based research may be an ideal methodology to assess ToC and evaluate options to improve DOI: 10.26717/BJSTR.2019. 22.003693 16357 this process [13,14]. A recent study in graduating medical students indicated a significant information loss during handoff after simulated crisis [15].
It could be postulated that this loss of information is more common among people of less experience, yet recent publications in anesthesiology indicate that regardless of training level, frequency of intraoperative handoffs negatively correlates with patient outcome [16,17]. The impact of anesthesia handover frequency on patient outcomes might be related to information lost during critical times, such as during patient crisis situations [15][16][17]. Cognitive aids decrease loss of information during ToC [8][9][10][11][12][13][14][15][16][17][18][19]. The use of cognitive aids during crisis has been shown to assist providers in performing and prioritizing better in high stress, time sensitive situations [20][21][22][23]. However, compliance with using these cognitive aids has been low [24]. We hypothesized that significant information is lost during the ToC and that the use of a cognitive aid would improve the completeness of the ToC following a crisis simulation.
The aim of this research was to assess: 1.
anesthesiology residents' completeness of ToC in a crisis situation, and 2. whether use of a cognitive aid improves the ToC quality.

Methods
After Institutional Review Board approval, anesthesiology residents in Post-Graduate Year (PGY) 2-4 from the University of Kentucky (UK) were given the option to participate in the project.
All participants provided written consent for data analysis.

Simulation Scenario
The authors developed, by consensus, three patient crisis simulation scenarios. The scenarios, similar in crisis complexity, were randomly assigned to the participants. In each scenario, the anesthesiology resident led a rapid response team through a patient code. After stabilization, the resident transported the patient to the critical care unit (ICU) and transferred care to the critical care physician ( Figure 1).

Statistical Analysis
All scores are reported as mean ± SD. Analysis of variance was performed to identify statistical differences due to training level or assigned scenario. Data were analyzed independently for faculty evaluations from both institutions. For parametric data, the paired t-test was used to assess statistical significance. Statistical significance was assumed if p<0.05. Regression analysis was used to assess inter-rater reliability amongst each faculty evaluation of the ToC process.

Communication, Information Organization and Team Leadership Skills Assessment
Scores for communication skills, information organization and team leadership skills during the scenario rated by faculty from the training institution (UK) and the non-training institution (UL). An analysis comparing score ratings between the faculty from UK and faculty from UL demonstrated significant differences between the assigned scores in all categories, with UK faculty reporting lower scores on average in all three skill categories. However, the overall assessment indicated all professional attributes were rated higher when a cognitive aid was used. Based on faculty ratings from both institutions, the average scores for communication increased significantly from Baseline to ToC CA by 0.08, and the information organization and team leadership scores were significantly higher in ToC CA than at Baseline.

Influence of Training Level
Combined CS for Baseline and ToC CA measurement were

Inter-Rater Reliability
The association between the professional competency scores.
One set of ratings from the non-training institution (UL-2) was not related to any other rater (training or non-training institution); however, UL-1 and UL-3 were closely related ( Figure 3).

Discussion
Accurate and complete information transfer during the ToC process is essential for safe patient care. With increased frequency in patient handovers and the link between communication failures and medical errors , there is a need for increased understanding of this process [30,31]. Several cognitive aids have been developed to improve the thoroughness of the handover process , yet the majority of these tools were designed for use during shift transition, not during critical scenarios 5. Failures of communication occur more frequently surrounding times of crisis , therefore, our goal was to assess the ToC in a crisis simulation and attempt to improve information transfer with a cognitive aid.
The main findings of our study are: developed with a goal of promoting a healthy learning environment to provide safe patient care, with one of its six focus areas being "Transitions in Care" [35].
The use of a cognitive aid in our study was associated with improved completeness of information transfer from 65.7% when it wasn't utilized, to 91.4% when it was. In the last several years, many cognitive aids have been developed attempting to improve handover quality . Although there have been many cognitive aids drafted, no specific formatting has been universally adopted.
There are several limitations in our study including a limited sample size within a single institution. Participants encountered similar simulations for both measurements (baseline and with cognitive aid) so some of the improvement observed may be related to retesting. The relative familiarity of a resident with the cognitive aid could have affected our results. However, residents were not involved in the development of the cognitive aid and it is not routinely used at our hospital. Timing could also be a limitation. Since a repeat study was performed with the same resident population ten months following the Baseline study, the residents' ToC knowledge and skills may have improved in the interim, confounding whether the improvement was due to the use of a cognitive aid. There was improvement in the overall ToC process in our single-center, simulation-based study when a cognitive aid was used. A cognitive aid is beneficial in providing more complete information transfer between care providers, decreasing communication breakdown, and potentially improving patient outcomes.
Further educational research is clearly needed to determine the best evidence for improving ToC to enhance patient safety.