All residents, consultant physicians and nurses with special training in emergency medicine in our department mandatorily participated in our sedation training. Our emergency department is a university major trauma centre with about 42,000 emergency admissions per year.
Structure and content of the training course
The first step of the education concept is independent study of a hand-out that has to be completed before the simulation, providing theoretical information about sedation, the ED sedation concept and underlying guidelines. The aim of this step is to familiarise participants with the general concept and to ensure a baseline knowledge about the topic. With regards to content, our concept is based on the guidelines of the American College of Emergency Physicians Clinical Policies Subcommittee [
15]. Because the discussion about the best medication used for sedation procedures in the ED (ketamine, midazolam, propofol, fentanyl) is still on-going [
16‐
18], we deliberately did not dictate any specific medication, but demonstrated the advantages and disadvantages of all available medication and provide a standardized framework for the safe conduction of sedation, regardless of the specific medication used.
The training day, as a second step, starts with a short theoretical repetition of the concept and focuses on questions of the participants. This step was introduced to provide participants with the opportunity to clarify any questions that might have arisen during step 1 and to lower the threshold to engage in the simulation activities of step 3.
The third step consists of three simulated scenarios with supervision, interposed with airway skills training. This step is conducted to practice the concepts introduced during the first two steps and to provide participants with the opportunity to train in sedation as well as to increase their familiarity with complications that might arise.
The case scenarios were practiced in real work surroundings with an interprofessional real life team consisting of physicians and nurses. All simulation cases are practiced with a computer-enhanced mannequin simulator (SimMan 3G, Laerdal Medical, Norway). According to our concept, a sedation team consists of at least two trained staff members, including at least one physician. After each case scenario, medical issues as well as human factors were debriefed using video-assistance by an interprofessional (nurse/physician) and interdisciplinary (emergency medicine/anaesthesia) instructor team. Each instructor (6 in total) had a minimum of 1 year of experience in simulation/debriefing and was trained in a simulation instructor course of several days duration. One supervising instructor was present at all training courses in order to ensure continuity in teaching techniques, as well as in the medical contents.
A special focus of our simulation scenarios was on the prevention of possible complications and on emergency procedures. We emphasised the importance and implementation of capnography, as recommended in procedural sedation guidelines and research [
19,
20]. The training session included the use of a structured pre-sedation checklist (available on request), including a team timeout, as well as the development and documentation of emergency strategies.
In the airway skill training, we formed small groups of 2–3 participants. Each group was trained using an Adult Airway Management Trainer Manikin (Laerdal, Norway). The airway skills course focussed on bag-valve ventilation techniques (single and two-handed approach), with simple tools such as nasopharyngeal and oropharyngeal airway devices, including insertion techniques, indications and pitfalls. As a rescue tool, the insertion of an laryngeal mask was taught. We did not teach orotracheal intubation in order to lower participants’ anxiety and - most importantly - because the necessary routine to master orotracheal intubation safely would be very difficult to ensure and maintain in our ED setting. All airway tools introduced during training, as well as the necessary medication, are now provided in the ED in a special sedation procedure box and all participants have been familiarised with the equipment provided in the ED through the training.
In the simulation based team training courses, we used three standardised scenarios (available upon request). In each scenario, the focus is on a special medical topic frequently encountered in our ED (e.g., luxated shoulder), as well as on crisis resource management (CRM). For crisis resource management, we used the CRM principles as conceptual framework, as outlined by Gaba and Rall [
21‐
24]. Regarding medical factors, we focused on the main complications that arise in sedation procedures (apnoea, circulatory problems and potentially obstructed airways).
Before and after the simulation-based training course, we used a custom questionnaire to assess confidence and familiarity with the sedation concept, awareness of emergency procedures, knowledge of the sedation medication and knowledge of CRM principles. The acceptance of the specified statements had to be indicated on a 11-point Likert scale ranging from 0 (completely disagree) to 10 (completely agree). All measurement instruments are available upon request.
As the last and fourth step, the simulation-based training day was followed by a separate individual practical learning experience in the department of anaesthesia, where participants further practiced bag-ventilation and the use of the simple airway tools they were familiarized with during training.
Because of the suspected infrequency of sedation procedures and subsequent possible lack of regular experience, we conduct monthly refresher trainings of 3 h duration for all trained staff.
Implementation and clinical outcome
Starting with the roll-out of the program, it is now mandatory to conduct procedural sedation in our ED in accordance to the trained standards. Every sedation procedure is under on-going evaluation through a questionnaire (available upon request) and the documentation in the patients chart. General factors (type of intervention, administered medication, timeline of the intervention and ER visit as well as reported adverse events) are routinely recorded in the patient chart. Overall satisfaction of the patient, as well as pain experienced during the procedure are monitored. The perceived usefulness of the sedation training for the actual sedation team is further assessed. Additionally, we screened the charts of all patients who underwent a sedation retrospectively for adverse events. To evaluate the usefulness of the sedation program for ED workflow, we compared age, gender, the American Association of Anaesthesiologists - scale (ASA), time to procedure (defined as time until procedure was begun), time for procedure (defined as duration of procedure) and time to discharge in patients sedated for the reduction of a luxated shoulder by the trained ED team in 2015 with the patients treated by anaesthesia teams in 2014.
The study protocol was assessed by the Ethics Committee of the Canton Bern, Switzerland (Req-2016-00134) and was classified as quality control investigation. Therefore no informed patient consent is necessary according to Swiss law.