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... CHILD OPPORTUNITY INDEX AND HEALTHCARE ACCESS IN THE INDIANAPOLIS AREA COI Map More Information Layla Wisser, Taylor Hartman, Dr. Emily Young, Dr. Tina Mason Marian University College of Osteopathic Medicine RESULTS BACKGROUND Access to healthcare is a multidimensional concept influenced by many factors Individuals of lower socioeconomic status tend to have a more difficult time accessing care leading to poorer health (McMaughan et al., 2020) The Child Opportunity Index (COI) is a metric of the quality and resources of a given neighborhood (Child Opportunity Index [COI], 2023) Opportunity levels based on 29 indicators 3 domains: educational, health & environmental, social & economic School-based clinics were excluded from detailed analysis due to lack of publicly available information Of the 52 other types of facilities: 13.5% (n=7) offer all their services at no cost 73% (n=38) offer sliding scale payments An analysis of outpatient facilities found that 55.6% (n=25) offer hours outside of standard business hours, with an average of 8 evening and weekend hours per week PURPOSE To identify gaps in access to healthcare surrounding Marian University and correlate with COI CONCLUSIONS METHODS Healthcare facilities included in 46222, 46202, 46224, 46228, 46221, 46208, 46241, and 46254 met one of the following criteria: Website states its purpose to serve people who have lower incomes, are underinsured, or of marginalized communities Free clinics Federally qualified health centers No limits on Medicaid/Medicare patients Publicly accessible data collected: address, days/hours open, payment options, healthcare and language services offered, and availability of telehealth or afterhours phone services Life expectancy at birth for each zip code was collected Areas surrounding Marian University are predominantly low and very low opportunity levels Websites often lacked information or were challenging to navigate Inaccessible for patients There is an opportunity for more accessible healthcare services Marian engagement with community partners LIMITATIONS Potential discrepancies in data collected due to a lack of information available online Information difficult to access/find online Accuracy of website Variety in types of facilities Overlap in services offered leading to subjective sorting NEXT STEPS Directly contacting facilities to verify and expand upon collected data Expanding geographical area REFERENCES Institute for Child, Youth and Family Policy, Heller School for Social Policy and Management, Brandeis University. (2023). Child Opportunity Index (COI). diversitydatakids.org. https://www.diversitydatakids.org/child-opportunityindex. Types of Services Types of Facilities McMaughan, D. J., Oloruntoba, O., & Smith, M. L. (2020). Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging. Frontiers in Public Health, 8, 231. https://doi.org/10.3389/fpubh.2020.00231 Weathers, T., Leech, T., Staten, L., Adams, E., Colbert, J., & Comer, K. (2015, July). Worlds apart: Gaps in life expectancy in the Indianapolis metro area. www.savi.org  ...

... Evaluating the Impact of Slavery on Health Disparities: Elevated Rates of Illness in the African American Community KashMir Foley Abstract The legacy of slavery still shadows the American health-care system The inequalities of the health system were built in from the beginning, said former Harvard College Dean Evelynn M. Hammonds. The legacy of slavery as a persistent issue in the U.S. healthcare system is a complex and deeply rooted problem that stems from historical injustices and systemic inequalities. This issue manifests in various ways, including disparities in health outcomes, access to healthcare, and the overall well-being of African Americans. The roots of this issue trace back to the era of Slavey, where ancestors of African Americans endured harsh living conditions, inadequate nutrition, and limited access to basic healthcare. Slaves faced a higher susceptibility to diseases, leading to negative health outcomes and higher mortality rates. This not only affected slaves, but continues to affect African American descendants negatively. In the modern healthcare system, the legacy of slavery is reflected in persistent health disparities between African Americans and white Americans. Several factors contribute to these disparities, including socioeconomic inequalities, lack of access to quality healthcare, discriminatory practices, and historical mistrust of the healthcare system among African Americans. These persistent health disparities among African Americans in the U.S. are deeply intertwined with the historical legacy of slavery. Recognizing and addressing this legacy is essential for creating a more equitable and just healthcare system. Structural Racism Today Heightened Rates and Incidences of illnesses and diseases are more prevalent in the African American community due to Structural Racism. Diabetes: Higher among adult African Americans at 11.3% compared with White Americans at 6.8%, Hypertension: 41.3% compared to White Americans 28.6% Premature Death from Heart Disease: Higher among African Americans than White Americans (65.5 vs. 43.2 per 100,000 persons). Prostate Cancer: are 208.7 vs 123.0 per 100,000 persons in African Americans vs White Americans A genetic component to these gaps. The indicated stroke patterns highlight the racial disparity : African Americans are at greater risk of stroke than any other group in the US; risk of experiencing a first stroke is about twice as high for blacks than for whites. The Trauma of Enslavement is argued to have been carried by African Americans and manifest in contemporary social, psychological, and physical problems (Akbar, 1996; DeGruy, 2017) As a result, African Americans show comparatively poor physical, psychological, and social health outcomes : Solutions Challenges Further Explanation: Shown above, the high concentration of stroke mortality in the US aligns with the geographic outlines of the locations that slaves were imprisoned. Post traumatic slave syndrome (PTSS) is defined as a condition that exists when a population has experienced multigenerational trauma resulting from centuries of chattel slavery and continues to experience oppression and institutionalized racism today. Major Depressive Disorder: 57% of Black Americans experienced chronic depression with more acute symptoms compared with a rate of 39% among Whites Homicide Rates: Higher among Black Americans compared with White Americans at 23.1 versus 2.7 per 100,000 population African American men are 5 times more likely to be incarcerated than Caucasians at 1,408 versus 275 per 100,000 population Current Poverty Rates: Black Americans is 27.4% compared with 9.9% of White Americans and Black unemployment (13.4%) is double that of White unemployment (6.6%) Geographic Patterns The present findings illustrate the alignment between regions historically marked by high concentrations of enslaved individuals and contemporary patterns of stroke mortality, as evidenced by the Figures. Post Traumatic Slavery Syndrome (PTSS) A 2015 systematic review examined genetic data from 2007 to 2013, to evaluate if racial health disparities in cardiovascular diseases have roots in African American DNA. Results concluded minimal evidence to suggest a genetic component to these gaps. Further reinforcing why we in the field of healthcare must continue to advance a conversation about the true drivers of racial health gaps. To address the health inequities faced by African Americans in the United States, implementing the following reforms within the healthcare system may be effective: Trauma-Informed Care Healing-Centered Engagement Cultural Competency Initiatives Evidence-based policy changes Funding Healthy Equity Research Increasing History teachings centered around Slavery Chronic Disease Management Programs Funding Public Health Literacy Programs Diversifying the Physician Workforce Citations 1.Braveman, P. A., Arkin, E., Proctor, D., Kauh, T., & Holm, N. (2022). Systemic And Structural Racism: Definitions, Examples, Health Damages, And Approaches To Dismantling. Health affairs (Project Hope), 41(2), 171178. https://doi.org/10.1377/hlthaff.2021.01394 2.DeGruy, J. (2017). Post Traumatic Slave Syndrome, Revised Edition: Americas Legacy of Enduring Injury and Healing. Milwaukie, Oregon: Uptone Press. 3.Esenwa C, Ilunga Tshiswaka D, Gebregziabher M, Ovbiagele B. Historical Slavery and Modern-Day Stroke Mortality in the United States Stroke Belt. Stroke. 2018; 49(2): 465469. 4.Halloran, M. J. (2019). African American Health and Posttraumatic Slave Syndrome: A Terror Management Theory Account. Journal of Black Studies, 50(1), 45-65. https://doi.org/10.1177/0021934718803737 5. Scott-Jones, G., CAADC, Kamara, M. R., & PE (2020). The Traumatic Impact of Structural Racism on African Americans. Delaware journal of public health, 6(5), 8082. https://doi.org/10.32481/djph.2020.11.019  ...

... The Need For More Organ Donation Zachary Stephens BMS 515 Public Health and the US Healthcare System Organ Transplantation What is it? Only 3 in 1000 donors end up donating Donated organs must be matched with recipients based on certain criteria (Health Resources and Services Administration) Blood Type Body Size Location Organs only last for an average of 9 hours outside of the body. If a good recipient is not found by then, the organ can not be donated Who needs organ transplants? Organ transplantation is a surgical procedure in which a failing organ is replaced by a healthy organ The healthy organ can come from a deceased or living donation Patients with diseases that lead to organ failure often require organ transplantation Such diseases are End-Stage Renal Disease, heart failure, cirrhosis, cancers, hepatitis, and more (Grinyo) What kinds of donations are there? Donations after life from deceased donors Living donations Different organs such as heart, kidney, liver, pancreas, eyes, lung, and more (Health Resources and Services Administration, 2023) Possible Options Why is There a Need for More Organs? As of September 2023, there were approximately 108,000 people on the organ wait list and only 27,000 transplants were performed (Health Resources and Services Administration, 2023) Every 10 minutes another person is added to the organ wait list 17 people on the wait list die every day 90% of U.S adults support donation but only 60% are signed up to be donors (Health Resources and Services Administration, 2021) Educate the public on the benefits of organ donation (Health Resources and Services Improve organ preservation methods Potential to save up to 8 lives Many people can donate: any age, sex, and ethnicity Allows for donation across larger distances Human organs can only be preserved for an average of nine hours (National Institutes of Health) Which option is better? Of the two options above, improving organ preservation methods is the better option Even if every person in the United States was a donor, only 6 out of every 1000 donors would donate Improving organ preservation allows for less wasting of healthy organs Blastocyst complementation is when induced pluripotent stem cells (iPSCs) are delivered into a host as a blastocyst (Wu) Gene knockouts are used to disable lineage progenitors in the host where tissue and organ generation can be disabled, leaving an empty niche Delivering donor cells to the host at the blastocyst stage would allow the donors cells to grow inside the host and generate an organ that is primarily donor cells (Wu) A study done in 2013 has shown that entire pancreatic epithelium can be grown and chimeric pigs grow into adulthood. However, successful interspecies complementation has only been successful in rat-mouse (Wu) How IBC Could Solve the Demand for More Organ Donation Administration) (Health Resources and Services Administration) Interspecies Blastocyst Complementation (IBC) Why Arent Many Organs Donated? Pigs closely resemble humans in anatomy, organ size, cell cycle characteristics, and genomic similarity, as well as reach maturity in 6 months, which makes them the best option to use as a host species other than humans (Wu). Using IBC to generate human organs using stem cells from the individual on the organ wait list eliminates problems with organ-recipient matching such as blood type. Paired with better organ preservation, IBC could allow for a healthy organ to be donated within 6 months to the individual in need which could prevent wait list deaths Problems with IBC organ generation are public opinion, financial cost, and the actual success of generation Literature Cited Grinyo, J. (2013). Why is Organ Transplantation Clinically Important? Cold Spring Harb Perspect Med. 3(6). doi: 10.1101/cshperspect.a014985 Health Resources and Services Administration. (2023, October). Organ Donation Statistics. U.S. Department of Health Resources and Services Administration. https://www.organdonor.gov/learn/organ-donation-statistics Health Resources and Services Administration. (2021, April). Research Reports. U.S. Department of Health Resources and Services Administration. https://www.organdonor.gov/professionals/grants-research/research-reports Health Resources and Services Administration. (2021, April). Matching Donors and Recipients. U.S. Department of Health Resources and Services Administration. https://www.organdonor.gov/learn/process/matching National Institutes of Health. (2019, September). Extending Preservation Time for Donated Livers. U.S. Department of Health and Human Services. https://www.nih.gov/news-events/nih-research-matters/extending-preservation-time-donated-livers Wu, J. Luengo, P. Gil, M. Cuello, C. Valencia, M. Parrilla, I. Martinez, C. Nohalez, A. Roca, J. Martinez, E. Belmonte, J. (2016). Generation of Human Organs in Pigs via Interspecies Blastocyst Complementation. Reproduction in Domestic Animals. 51(S2), pg 18-24. doi: 10.1111/rda.12796  ...

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... MKT374: Sales Technology and Analytics Fall 2023 Customer Experience in the Age of Artificial Intelligence Hunter Dalton, B.S. Finance and Marketing, December 23 Introduction We are now in an age where a company's competitive advantage is dependent upon its ability to capture, analyze, and understand personalized customer data. Artificial Intelligence (AI) is revolutionizing the way customer experience (CX) teams strategize. CX teams are utilizing AI to rapidly consume and analyze vast amounts of customer data to enhance the customer experience. The number one reason CX teams are adopting AI is in response to consumers expecting a more personalized experience with their brand. Potential AI Utilization in Higher Ed Data & Analysis 60% Companies anticipate substantial growth in AI-driven insights for CX over the next two years 50% The purpose of this research is to demonstrate the importance of adopting AI into CX strategy and provide ways in which companies are utilizing AI to drive improved efficiency and effectiveness in customer facing organizations. This revolutionary approach is transforming the landscape of marketing and sales, driving greater effectiveness and customer engagement from the very start of the customer journey. McKinsey & Company Improve career services Provide personalized student learning Personalize student experience Summary 20% Organizations must utilize AI to achieve a competitive advantage 10% AI capabilities allow CX teams to quickly analyze customer data to CX Strategy Customer Service Product Design User Marketing Experience Campaigns Design Sales Source: IBM Half of companies surveyed have taken concrete action to incorporate AI into CX Using today 54% 12% improve customer experiences Improved customer experience and engagement results in greater Plan to use within two years customer loyalty and satisfaction AI can help organizations reduce costs and improve efficiencies of organizations have improved efficiency and reduced costs after implementing AI into CX solutions. Firms leveraging AI capabilities experience superior CX performance improvements 10% References The AI-Enhanced Customer Experience. IBM Institute for Business Value. www.ibm.com. Deveau, Richella. Griffin, Sonia, & Reis, Steve. AI-Powered Marketing and Sales Reach New Heights with Generative AI. www.mckinsey.com. Edelman, David. Customer Experience in the Age of AI. Harvard Business Review Customer Experience. www.hbr.org. 8% 4% Literature Review Data Review and Analysis Survey Research Review 30% 6% Research Methods Drive admissions personalization to increase retention 40% 0% Purpose Minkara, Omer. Ai in Customer Experience (CX) in 2021: Impact Analysis. Spiceworks - Customer Experience. www.spiceworks.com. 2% 0% Customer Retention Customer Satisfaction Improvement in Customer Effort Score Source: Spiceworks Contact Centers Using AI Capabilities Non-Users Acknowledgement Dr. Lori Rumreich, Professor of Marketing & Sales Byrum School of Business MARIAN.EDU/BUSINESS  ...

... Contrast of Germany and the United States Concern About Global Climate Change Presented by Brad Cline, Drake Campbell, and Caleb Ward School of Global and Cultural Studies, Marian University Indianapolis ABSTRACT AND THESIS RECYCLING PUBLIC TRANSPORTATION While both Germany and America share a commitment to environmental protection, there are notable distinctions in their approaches to addressing the problem. In 2022, Germany recycled about 67% of its waste, while america has only recycled 32% of its waste. Many U.S. cities have adopted single-stream recycling. Germany employs a dual system for waste collection. Germany has several systems and policies, which include: Bottle return system Green Dot Yellow bag/bin America does not have nationwide recycling policies/laws Recycling is a part of living in Germany, it is treated as a culture As of 2021 Germany has established a Automobile tax, that charges 2 to 4 for each gram of carbon dioxide emitted per kilometre Germany is increasing federal funds for local public transport to 1 billion per year from 2021 onwards According to a Bloomberg article, Germans are five times more likely to use public transportation than Americans Germany has the U and S Bahn The U-Bahn covers city areas, whereas the S-Bahn covers city areas up to 60 kilometers outside the city. Because Germany has implemented regulations on environmental policies, the country has become a well known exemplar of waste management. Because America does not have a nationwide policy, instead leaves the issue to states, America is far less environmentally friendly. INTRODUCTION Germany is widely recognized as a global leader in environmental sustainability, boasting a multifaceted approach that encompasses policies, technology, and cultural practices. The country has made substantial strides in promoting environmental conservation, renewable energy adoption, and overall ecological responsibility. While the United States actively participates in being more environmentally friendly, and is making progress, it has not reached results quite like Germany has. With this is mind we take a closer look and compare and contrast the hows and whys of how Germany and America are environmentally friendly in different ways, and the differences between each country. CONCLUSIONS RENEWABLE ENERGY Both Germany and the United States use fossil fuels more than other energy source. 46% of Germanys energy comes from renewable sources. 77% of Germans believe that climate change and the consequences that it may bring are the biggest issue facing humanity in the 21st century. 85.8% of Germans overall have concerns about climate change. 13.1% of the United States energy comes from renewable sources. 37% of Americans think that addressing the issue of climate change should be a prime concern of the president and Congress in 2023, and another 34% think it is an important albeit lower priority. 68% of Americans favor the usage of both fossil fuels and renewable energy sources. Only 31% believe that the country should cease using fossil fuels such as oil completely. As you can see Germany has been more proactive and systematic in implementing eco-friendly policies, particularly in its commitment to renewable energys. The U.S., with its diverse political and economic landscape, has seen variations in environmental policies, however is forced to rely on states for substantial eco friendly efforts. Also the.The role of the private sector and the approach to international agreements also differ between the two countries, with the United states much more inclined to ignore standards and look to the private sector to make environmental efforts REFLECTION/ FRANCISCAN CONNECTION By showing care for the environment of the Earth by avoiding pollution, we are practicing responsible stewardship. LITERATURE CITED Waste management in Germany 2023 - BMUV. (n.d.-a). https://www.bmuv.de/fileadmin/Daten_BMU/Pools/Broschueren/abfallwirtschaft_2023_en_bf.pdf Press and Information Office of the Federal Government. (2020, August 22). Climate-friendly transport. Bundesregierung. https://www.bundesregierung.de/breg-en/issues/climate-action/climate-friendly-transport-1795842 5reasonsGermansride5timesmoremasstransitthanAmericans.(2012,October5).Bloomberg.com.https://www.bloomberg.com/news/articles/2012-10-05/5-reasons-germans-ri de-5-times-more-mass-transit-than-americans Patel, M., von Thienen, N., Jochem, E., & Worrell, E. (2000). Recycling of plastics in Germany. Resources, Conservation and Recycling, 29(1-2), 65-90. Lifecycle Assessment from 1990 to Date. Benefits of the Dual System, www.gruener-punkt.de/en/politics-and-society/policy-making-and-associations/translate-to-englisch-studie-oeko-institut/benefits-of-the-dual-system#:~:text=T he%20comprehensive%20lifecycle%20assessment%20of%20the%20dual%20system,and%20the%20consumption%20of%20fossil%20fuels%20scaled%20do wn. Accessed 8 Nov. 2023.  ...

... TECHNOLOGICAL ADVANCEMENTS There have been major advancements in technology to assist the deaf community over the last 20 years. Technological advancements have challenged the culture and involvement of Deaf citizens within a hearing culture. iHealthAssist is an interactive avatar that individuals of the deaf and hard of hearing community interact with hospitals and healthcare providers using ASL. Providing a seamless and inclusive environment Video to video calls allows individuals, including those who are deaf and hard of hearing, to communicate in real time. Allowing face to face conversations even in distance with the use of apps. Calls can be made by computer, phones, or other communication devices. This has allowed immediate, richer and more inclusive conversations. Cochlear implants are an advancement that has brought on both controversy and encouragement. Advancements early on suggested improvements in speech processing, elimination of background noise, and more authentic acoustic signals are being tested to make speech sound more natural. With advancement, it also puts the future of deaf culture at risk. Studies have shown that the use of cochlear implants is not guaranteed to improve language or cognitive development. Many do not realize that surgery and implantation is the smallest part. Once implanted there are months and even years working with speech therapists learning how to process the device. The influence of technology on the Deaf community is noticeable. Throughout the past decade, the impact of cell phones, Internet, and Cochlear Implants have brought new benefits and new challenges to the Deaf community. While more research and technological advancements would need to be developed for the Deaf community to fully diminish, the likely progression of such technologies have caused individuals to acknowledge that the future of the Deaf community is changing.  ...

... 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Cricoid Pressure: Closing the Knowledge-Practice Gap Jacob M. Brown, BSN, RN Leighton School of Nursing, Marian University Project Chair: Derrianne Monteiro, DNP, CRNA Oct. 8, 2023 Derrianne Monteiro, DNP, CRNA (Oct 8, 2023 20:04 EDT) (Signature) Project Member: (Date) Christina Pepin, PhD, RN, CNE Oct. 8, 2023 (Signature) Date of Submission: Oct. 14, 2023 (Date) 2 Table of Contents Abstract4 Introduction..5 Background.....5 Problem Statement..7 Needs Assessment/Gap Analysis....8 Review of Literature....9 Conceptual Framework..17 Project Aims/Objectives18 SWOT Analysis.19 Project Design/Methods.21 Population/Setting..21 Measurement Tools....21 Data Collection...22 Ethical Considerations...22 Project Evaluation..23 Data Analysis/Results25 Discussion..27 Strengths and Limitations..30 Conclusion.30 References..32 Appendices.36 Appendix A....36 3 Appendix B....37 Appendix C....41 Appendix D...42 Appendix E....43 4 Abstract Background and Review of Literature: Cricoid pressure is a technique of applying digital pressure along the outside of the upper airway to reduce the risk of aspiration of stomach contents during anesthesia induction. Improper placement can cause harm or make endotracheal intubation difficult. No accepted alternative practice exists, but it is performed incorrectly in most attempts. Incorrect placement and amount of force are typical causes of failure to occlude the esophagus and protect the airway There is no standardized training for cricoid pressure. Purpose: This project was developed to determine whether incorporating simulated training, an educational session, and practice applying pressure with force measurement would be able to improve knowledge of and ability to correctly place cricoid pressure. This could determine if such an intervention is a viable option for future standardization of education on the topic. Methods: A quality improvement design was used to test an education/simulation experience using the results of a 12 question pretest-posttest questionnaire and measurement of force placed on an airway manikin during three separate attempts with and without measured force feedback. Implementation Plan/Procedure: A convenience sample of 33 Marian University first-year nurse anesthesia students completed the educational/simulated training experience and practice attempts, and 26 of the students finished the posttest survey to compare against the pretest data. Implications/Conclusion: Average total questionnaire scores improved from 47.9% to 69.1% (p < 0.001) and cricoid pressure deviation from the target range decreased from 4.53 to 1.42 pounds (p < 0.001). There is still some room to improve, but the combined interventions created positive change in both data sets and could be a good starting point for standardizing education to reduce cricoid pressure variability in the clinical practice setting. Keywords: cricoid pressure, Sellick(s) maneuver, practice, education, and training 5 Cricoid Pressure: Closing the Knowledge-Practice Gap Since its description and use in the 1960s, performance of cricoid pressure to reduce the risk of pulmonary aspiration of gastric contents has been considered a standard practice and safety measure for patients undergoing rapid sequence induction and intubation (Landsman, 2004). In more recent years, the effectiveness of this intervention when applied to real patients has been called into question (Zdravkovic et al., 2021). Despite many years of practice, evidence with actual patients is lacking, conflicting, or able to be attributed to confounding variables (Zdravkovic et al., 2021). A major variable that has been described throughout the research on this topic is discrepancies in where and how forcefully pressure is placed on the cricoid cartilage (Andruszkiewicz et al., 2017). One way to begin rectifying this is to ensure a more standardized teaching of cricoid pressure technique in the academic setting (Zdravkovic et al., 2021). Whether or not cricoid pressure is truly effective, in order to ensure its use on patients is safe, proper placement must be ensured, and this can be taught successfully with simulated training (Andruszkiewicz et al., 2017). For this reason, a project designed to standardize student nurse anesthetist training for cricoid pressure placement would be useful to determine the consistent success of placement thereafter as a means to close the gap between the technique known to be effective in simulation and its implementation in the real-world surgical setting. Background Anatomically, the cricoid cartilage is the only cartilaginous structure in the upper airway that is completely circumferential, surrounding the entire trachea (Landsman, 2004). The concept of placing pressure on this cartilage is in theory a method of occluding the esophagus, as this is just posterior to the trachea and the cricoid ring (Zdravkovic et al., 2021). Aspiration of gastric 6 contents is a risk of all general anesthetics, although this risk is further increased by many specific conditions, including pregnancy, diabetes, uncontrolled gastroesophageal reflux disease, or by not fasting prior to surgery, as is the case with many emergent procedures (Bohman et al., 2018). Despite efforts to prevent aspiration, it is a fairly common occurrence in surgical patients, with as many as 19 percent of patients that are treated prophylactically still developing aspiration of gastric contents to some degree, regardless of patient demographic factors (Bohman et al., 2018). Aspiration occurring so frequently is a major concern, given that even in an amount too small to see, it is associated with pneumonia, acute respiratory distress syndrome, and acute respiratory failure (Bohman et al., 2018). Rapid sequence induction (RSI) is the terminology used for securing the airway in patients at high risk for aspiration, grouping together all the standardized prophylactic measures into one procedure, as an alternative to a typical anesthetic induction (Zdravkovic et al., 2021). Cricoid pressure has been instituted as a routine component of RSI, as there currently is no other method of manually attempting to limit the esophageal opening during intubation (Landsman, 2004). Cricoid pressures original use in preventing aspiration in victims of drowning was transferred to anesthetic use and dubbed Sellicks maneuver, named for the man who first described its use for rapid sequence intubation (Landsman, 2004). Studies performed on cadavers have suggested cricoid pressure only provides a benefit against aspiration with force as strong as 30 to 40 Newtons (Landsman, 2004). A major concern with cricoid pressure placement is that 30 to 40 Newtons is a specific value that may not necessarily translate to a measurable amount of force with which a provider attempting the maneuver would be familiar. How much digital pressure does one apply to achieve 30 Newtons? Another major concern is an inconsistency among providers and the ability 7 to identify the cricoid cartilage itself; more than 50 percent of health care workers responsible for airway securement are unable to successfully locate the cricoid in real patient scenarios (Qasem et al., 2019). The problem with this is that with inappropriate force or location, cricoid pressure is certainly not effective at reducing aspiration, and can also cause difficulty achieving optimal view during laryngoscopy for intubation, with 24 percent of cases having reduced visualization (Zdravkovic et al., 2021). Poor view during airway securement is not the only concern, as cricoid pressure is also contraindicated in patients who are actively vomiting, due to the increased pressure in the esophagus and its potential to lead to rupture (Landsman, 2004). This suggests that cricoid pressure being performed incorrectly is actually putting patients at risk for other serious complications on top of failing to reduce the risk for aspiration. Part of the reason the body of research does not explicitly support or reject cricoid pressure is also part of why it is performed incorrectly so often there is no consistent, standardized training for cricoid pressure (Herman et al., 1996). The most training many providers receive during their education is a brief explanation of the technique (Herman et al., 1996). Guided simulation and practice performing cricoid pressure is a strategy that has been shown to provide more consistent, proper technique, but has not been successfully implemented in a widespread manner (Zdravkovic et al., 2021). Problem Statement Cricoid pressure is still a widely practiced intervention in anesthesia, and there is not an accepted alternative at present. Given the dangers and the ineffectiveness of cricoid pressure with improper technique, ensuring adequate education and training prior to clinical use is important to protect patients. Simulated training has proven a successful venture for improving technique, and it could be a method to begin standardizing training for future anesthesia providers. Thus, the 8 following question has been posed: For student registered nurse anesthetists (SRNAs) during RSI checkoffs, does having measurement of force in their simulated training alongside an educational session yield more consistent knowledge and accurate application of cricoid pressure placement and force? Needs Assessment & Gap Analysis At a private liberal arts university in the Midwest, an accredited doctoral nurse anesthesia program incorporates simulated training into its students education, including specific simulated training for RSI. This training includes a basic understanding of when and where to use cricoid pressure and how much force to apply but does not afford a measurable method of teaching what 30 to 40 Newtons of pressure feels like, or where to locate the cricoid cartilage. This is the same area in which, nation-wide, providers have generally not received a standardized training. Current research on cricoid pressure suggests that the first step to fixing this gap between knowledge and practice is to ensure education and training to provide a more consistent approach to cricoid pressure that reduces variability of outcomes (Zdravkovic et al., 2021). In working with this university in its simulated RSI training, this provided an opportunity to develop and refine methods that effectively teach cricoid pressure technique which are easily applied to other educational facilities. The ultimate goal of this was to test methods that facilitate the standardization of education and training for cricoid pressure as it is presently understood. In doing so, this supports further studies that can more conclusively determine if its benefits outweigh its risks. At a minimum, this taught a select group of future anesthesia providers how to properly perform the technique and promote patient safety. 9 Review of Literature To fully understand the facets of cricoid pressure, and to maintain the relevance of a project designed to improve its use and work towards a needed standardization of practice, current literature and objective research data must be examined and incorporated into the project. This should be reviewed in its entirety to best facilitate a successful, meaningful, and conclusive result for the project, and needs to be accomplished prior to its initiation. A comprehensive review of literature is a universally accepted method of achieving this goal. Research Methods To begin the undertaking of this project, a comprehensive review of literature was conducted. A PRISMA diagram detailing the search and selection of research data can be found in Appendix A. This examination of research began in early September 2022 and concluded at the end of November thereafter. Keywords used include cricoid pressure, Sellick(s) maneuver, practice, education, and training. BOOLEAN phrases were created to form combinations that led to a thorough search for relevant research, including cricoid pressure OR Sellick maneuver AND practice OR education OR training. The primary focus of this research was to find any and all studies pertaining specifically to cricoid pressures usefulness or hazards of inappropriate technique, the success or failure of methods to teach and improve localization of the cricoid cartilage, and approaches to teaching practitioners how much pressure to place. PubMed and Medline-Ovid databases were searched extensively, alongside handsearching, and a total of 200 articles were identified, 95 of which were eliminated as duplicates. The remaining 105 were surveyed and limited to 25 based on type of article, topic of research, and publication within five years. Two reports were unavailable for access in entirety and were therefore excluded. Of the 23 full articles viewed, two were highly specific and deemed 10 unrelated to the topic at hand, two were conducted in finite locations that limited their universal application, and three were determined to be too narrative, or merely adjunct in nature, with little original objective data to report. The other 16 articles were all included in the review. Results This comprehensive review of literature revealed multiple avenues of study with a few notable commonalities. Several studies suggest cricoid pressure is ineffective at completely occluding the esophagus or reducing the risk of aspiration (Birenbaum et al., 2019; Bohman et al., 2018; Trethewy et al., 2017; White et al., 2020). Others indicate its utility as a protective measure, even with less force of pressure than previously accepted (Lim et al., 2021; Pellrud et al., 2018; Zeidan et al., 2017). Virtually all the studies concur that present understanding and practice of cricoid pressure is varying, and more often than not, either inaccurate, insufficient, or both (Andruszkiewicz et al., 2017; Bohman et al., 2018; Hee et al,, 2020; Lee et al., 2018; Noll et al., 2019; Qasem et al., 2019; Williams & Umranikar, 2017; You-Ten et al., 2018). With such a widely acknowledged gap in current practice, a good variety of research has been conducted to determine whether it should be used at all and how to teach or improve its use in practice, since it is still being utilized. These studies are listed in a literature review matrix (Appendix B) and can be analyzed collectively to reveal certain recurring themes. Frequency & Dangers of Improper Cricoid Pressure Placement Birenbaum et al. (2019) determined that cricoid pressure was not truly protective at preventing aspiration (p=.14). This study also noted that cricoid pressure was associated with an increased difficulty with intubation determined by increased time to intubate (p<.001) and increased Cormack and Lehane grading score for view of the larynx (p<.001). White et al. (2020) 11 compiled several studies for a separate review, and also determined that cricoid pressure increased the time required to achieve intubation (p<.001). On the other hand, cricoid pressure is performed improperly often, removing its benefits as a practice, and this can often be attributed to a lack of understanding (Andruszkiewicz et al., 2017; Hee et al,, 2020; Lee et al., 2018; Qasem et al., 2019; Williams & Umranikar, 2017; YouTen et al., 2018). Several studies determined that the accuracy of locating the cricoid anatomy was inadequate, 49% for Andruszkiewicz et al. (2017), 59% for Lee et al. (2018), 42% for Qasem et al. (2019), and 30% for You-Ten et al. (2018). Williams & Umranikar (2017) determined that on average, clinicians are about 10mm off from ideal placement on the cricoid cartilage. Studies also determined that force of pressure was inappropriate as much as 83.5% (Andruszkiewicz et al., 2017) and 73.5% (Hee et al., 2020). Other reports of ineffective use of cricoid pressure include Noll et al. (2019), stating that 96% of cricoid pressure attempts were unsuccessful at achieving proper technique, and Bohman et al., (2018) who described that unregulated, unstructured cricoid pressure attempts failed to prevent 19% of patients from developing some degree of aspiration (p=.529). Correctly Locating the Cricoid Cartilage Several studies have used ultrasonography to confirm or test against cricoid cartilage or esophageal localization by practitioners (Lee et al., 2018; Lim et al., 2021; Qasem et al., 2019; Williams & Umranikar, 2017; You-Ten et al., 2018). Of these, Lee et al. (2018), Qasem et al. (2019), Williams & Umranikar (2017), and You-Ten et al. (2018) had participants use the common practice for locating the cricoid cartilage, via the identification of surface landmarks along the upper airway. Lee et al. (2018) and Williams & Umranikar (2017) describe a distance more than 5mm away from the cricoid cartilage in 41% of attempts, averaging 10mm away, and 12 were unable to attribute this to patient demographics including body mass index (p=.539; p=.285), neck circumference (p=.243), age (p=.843), and sex (p=.138). Qasem et al (2019) found that the ability to locate the cricoid cartilage across professions was 42%, with respiratory therapists being significantly faster at identification compared to anesthesia consultants (p<.001), residents (p=.002), and nurses (p=.071). You-Ten et al. (2018) examined participant accuracy after practice with or without an ultrasound, finding the ultrasound group to have 65% accuracy compared to 30% for the control group (p=.025). The ultrasound group had a mean distance from the target that was nearly half the distance of the control, 3.6mm compared to 6.8mm (p=.001) (You-Ten et al., 2018). Lim et al. (2021) used ultrasound guidance to find the esophagus in patients, note its position relative to midline, and observe for esophageal occlusion with cricoid pressure placement. This revealed that 100% of patients with midline esophagus achieved occlusion with cricoid pressure, while only 27% of patients with alternative esophageal alignment were successfully occluded, with no difference in results relative to paralaryngeal pressure placement (p=1.0) (Lim et al., 2021). Determining the Appropriate Amount of Force The universally accepted amount of force to be applied is 30-40 Newtons, but this value is not clearly distinguishable during application, and it may not even be attainable while manipulating the airway (Trethewy et al., 2017). Andruszkiewicz et al. (2017) reported not only that anesthesia personnel could only achieve correct pressure 16.5% of attempts, but that only 18% had a baseline understanding of how much pressure would be appropriate (p<.001). Hee et al. (2020) and Trethewy et al. (2017) both provided real-time feedback of force measurement to some subjects during cricoid pressure placement to assess if this would improve accuracy of force, finding differing results. Hee et al. (2020) found that force of pressure was only 13 appropriate 26.5-33.3% of attempts without feedback, but that with feedback the results improved to 81.1-88.3% (p<.001). Trethewy et al. (2017) found that there was no significant difference in pressures during cricoid pressure before (p=.416) and during intubation (p=.742), but that to achieve 30N, pressures were sufficient before and insufficient during endotracheal tube placement. Comparing these findings to that of Pellrud et al. (2018) and Zeidan et al. (2017) could support an argument for the effectiveness of cricoid pressure with less than 30N in some patients. Both of these studies measured pressure with electronic devices and live subjects, and both determined that the pressure required to occlude the esophagus was on average at or below 30N (Pellrud et al., 2018; Zeidan et al., 2017). Zeidan et al. (2017) determined that male patients on average require 30.8N to occlude, whereas female patients on average require 18.7N (p<.001). Pellrud et al. (2018) found that upper esophageal sphincter pressures with cricoid pressure placed at about 30N increased from between 44-46mmHg to 167-173mmHg, which was determined to be much more than necessary for esophageal occlusion. Educational Tactics to Improve Technique Pulling together varying methods on how to teach this airway management skill effectively, many of these studies also compare simulated training and practice against didactic learning and educational sessions (Beckford et al., 2018; Fischer et al, 2018; Noll et al, 2019; You-Ten et al., 2018). Fischer et al. (2018) and You-Ten et al. (2018), while not directly looking at education on cricoid pressure, both demonstrate the effectiveness of simulated training. YouTen et al. (2018) showed that practice with an ultrasound in simulation improved cricothyroid membrane identification in real patients from 30% to 65% (p=.025) and closed the distance to the cricothyroid target (p<.001). Fischer et al. (2018) showed enhanced performance with 14 coronary angiography and higher test-scoring in general and across categories in a group of medical students who used simulated training compared to those with didactic teaching (p<.001). These students also reported a higher satisfaction with the training provided when compared to those without simulation experience (p<.001) (Fischer et al., 2018). Noll et al. (2019) and Beckford et al. (2018) reveal that simulated training can specifically improve cricoid pressure technique and performance, especially with repetition. Noll et al. (2019) found that while cricoid pressure force was consistently inadequate, practice with a measurement of force followed by subsequent attempts at pressure yielded a 16% increase in success overall (p<.001), and that throughout all 30 cycles performed, each successive attempt was improved (p<.001). Beckford et al. (2018) looked at multiple studies on the education and training of cricoid pressure and concluded that the technical application of pressure is able to be successfully improved through repeated education, and in particular, simulated training efforts (p<.001). Discussion Cricoid pressure has been a long-standing practice yet is still quite controversial a matter. Looking at the collective data and inferences made from the results of these studies, it is apparent that there is still a strong mix of information concerning this topic. Lim et al. (2021) highlights the effectiveness of cricoid pressure at occluding the esophagus as long as it is anatomically midline, while Birenbaum et al. (2019), Bohman et al. (2018), Trethewy et al. (2017), and White et al. (2019) all suggest that cricoid pressure is ineffective as a technique and point out both the dangers of its incorrect use and even some of the reasons why it is being misused. Looking at Trethewy et al. (2017) and the conclusion that force may be involuntarily less than the therapeutic 30N during actual endotracheal tube placement, Pellrud et al. (2018) and Zeidan et 15 al. (2017) suggest that less than 30N may still have protective benefits. Overall, the literature supports the use of simulated training and in particular, practice and repetition with localization and force of application on the cricoid cartilage (Beckford et al., 2018, Fischer et al, 2018; Noll et al., 2019; You-Ten et al., 2019). There is a substantial gap in baseline understanding of placement and force to bridge that has also been identified in the review (Andruszkiewics et al., 2017; Bohman et al., 2018; Hee et al., 2020, Lee et al., 2018; Noll et al., 2019; Qasem et al, 2019; Williams & Umranikar, 2017; You-Ten et al., 2018). To fully address all the concerns mentioned throughout the articles, ultrasound guidance and measurement of force during simulated training of cricoid pressure appears to be a superior method for preparing providers to apply cricoid pressure effectively in the clinical setting, thereby reducing some of the risks associated with improper performance and maximizing the likelihood of protecting the airway from gastric aspiration. The studies that tested localization used some means of comparing a target point to a participant-placed point, using invisible ink, skin markers, and/or stickers (Lee et al., 2018; Qasem et al., 2019; Williams & Umranikar, 2017; You-Ten et al., 2018). The studies that measured force of pressure did so by using a weighted scale, manometer, and/or some other novel electronic force measurement/feedback device (Andruszkiewicz et al., 2017; Hee et al., 2020; Noll et al., 2019; Pellrud et al., 2018; Thethewy et al., 2017; Ziedan et al., 2017). Providing these with feedback during guided practice and simulated training may be the key to standardizing this practice. Recommendations for future studies would be to develop data on long-term success at cricoid pressure after a training session, or recurrent training sessions at specified intervals. Another novel concept would be to test cricoid pressure placement against the incidence of aspiration with pressures outside the range of 30-40N or at a lower range. One additional area of 16 study that would help clear some of the fog surrounding cricoid pressures effectiveness would be to test patients for midline esophageal placement and determine aspiration incidence after cricoid pressure specifically in this population. Additionally, the major concern of inappropriate cricoid pressure placement and lack of proper technique should still be addressed in studies determining a way to effectively standardize correct usage. Recommendations for current practice are to continue educating practitioners on cricoid pressure use and training them on appropriate placement and force. The use of cricoid pressure in clinical practice for RSI is still encouraged, but, as its effectiveness is still uncertain, relieving the pressure as appropriate for conditions that increase esophageal pressure or difficult laryngoscopy. Using ultrasound to properly locate the cricoid cartilage is an option for providers to increase the likelihood of successful pressure, although this is not recommended for urgent situations in which airway securement is the higher priority. Limitations of this review include the confines of the data relative to the broadness of the topic and multiple facets of the issue at hand. There is a notable lack of research determining or specifying varying finger placements and vector of force application to acknowledge other confounding variables in the study of cricoid pressure effectiveness. Studies in the review that themselves have limitations, including sample size or generalizability, may have still been included, as the selection process involved some unavoidable subjectivity relative to exclusionary criteria. Despite these limitations, this literature review is comprehensive in nature, involving all available modern, objective studies of this topic, and helps to identify where questions of effectiveness arise, and how to best address these moving forward. The data analysis supports the need for further provider education on cricoid pressure, regardless of conclusive protective benefits. 17 Conceptual Framework The Revised Iowa Model of Evidence-Based Practice to Promote Excellence in Healthcare was chosen to provide a framework for the successful creation and implementation of this project (Appendix C). The Iowa Model has been used to ensure a project reaches its completion while maintaining its thorough evidence and transition into actual clinical practice (Iowa Model Collaborative, 2017). The application of this model to a project for cricoid pressure technique was accomplished looking in a step-by-step manner at the model and relating each segment to the topic at hand. This model indicates the need to identify an issue or opportunity to improve, which in this instance was the improper use and/or application of cricoid pressure in real patient scenarios that results in not only difficult view for intubations and subsequent longer apneic times for surgical patients, but also definitive failure to produce protection of the airway from potential aspiration of gastric contents (Iowa Model Collaborative, 2017). The question and purpose of this project as determined by the next step in the Iowa Model, was addressed by the PICOT question: For SRNAs during RSI checkoffs, does having measurement of force and point localization methods included in their education and simulated training yield more consistent and accurate application of cricoid pressure placement and force? This question is a priority due to the negative consequences of incorrect cricoid pressure placement and the present scrutiny of cricoid pressure as an effective protective measure in anesthesia practice. After forming a team to develop and implement the project, including the simulation director and educator for practical management of RSI, the next step was forming a body of evidence and examining the present research available on cricoid pressure, determining if the evidence was substantial enough for the project as designed, or if the project needed redirection 18 (Iowa Model Collaborative, 2017). The evidence did not confirm the success of cricoid pressure at preventing gastric aspiration in surgical patients, but it did confirm the frequent improper application of cricoid pressure, continued widespread use of cricoid pressure in practice, and the lack of standardized teaching for cricoid pressure placement (Zdravkovic et al., 2021). This confirmed the education of students in the proper technique of cricoid pressure was an appropriate trajectory for this project. Planning and implementing the practice change via the designated intervention encompassed the next several steps of the Iowa Model, followed by collecting measured data from the implementation phase and determining the effectiveness of the intervention (Iowa Model Collaborative, 2017). This decided whether the project should be disseminated or if further revisions were required prior to attempting to standardize the process. These steps all ensued after the hybrid educational and simulated training session was designed, modified, and delivered to SRNAs, allowing for data collection and analysis to follow. According to the Iowa Model, after the results of this suggested that the intervention was successful, the remaining steps were designed to incorporate the intervention into practice, continue to monitor its results, and eventually circulate the intervention so as to spread its use and adoption as standard practice (Iowa Model Collaborative, 2017). Project Aims/Objectives The current understanding of cricoid pressure among anesthesia providers is subpar, however simulated efforts to correct this have proven successful, particularly so in the event these training efforts include measurement of force and localization for cricoid pressure technique (Andruszkiewicz et al., 2017; Hee et al., 2020; Noll et al., 2019). The primary aim of this project was to determine whether the simulated training session and education provided in 19 conjunction with practicing the proper amount of force improved the students understanding of proper cricoid pressure use and skill applying the technique. Objectives of this project to help attain this goal included: Design a single hybrid educational and simulated training session for the established application technique and clinical use of cricoid pressure during RSI Obtain a weighing scale and test its measurement of force applied to a manikin placed atop Determine the conversion of pounds of force to Newtons of pressure and calculate appropriate force of cricoid pressure in pounds for real-time feedback to be given to the students during the simulated training. Create an appropriate, validated pretest/posttest questionnaire to determine students level of understanding of cricoid pressure use and technique prior to the session and immediately thereafter Collect and analyze the pretest/posttest scores to determine the effectiveness of the education and training session in whole SWOT Analysis Identifying the strengths and weaknesses of the project beforehand can help to avoid pitfalls and augment the positive aspects, improving the overall execution of the project. The strengths of this project stem from its reproducibility and its relevance among the present climate of anesthesia. The project is applicable to students, providing very few risks to anyone involved, and no risks to patients. It identifies a current issue that anesthesia providers face and works towards addressing this. It is a cost-effective, timely project, with very limited resources and expertise required. Some of the projects weaknesses revolve around its size and follow-up, and 20 its anesthesia program specificity. The sample size is a single cohort of anesthesia students, limiting the data and its generalizability. This project hinges on the participation of the students in the chosen cohort, of which, some or many may decline, leading to a very limited pool of data. The opportunity for long-term follow-up with the participants of the project is limited due to the project timeline, limiting the available results of the intervention. Some of the opportunities afforded by this project are to observe the impact of simulated training, educational interventions, and specific measured parameters on cricoid pressure technique and general understanding thereof. Additionally, regardless of the results, the project provides the opportunity to speak on the subject to aspiring anesthesia providers, increasing the chances of successful application of cricoid pressure and/or awareness of the controversy surrounding its use. Another opportunity of this project is to enhance the students education regarding RSI, as the intervention is designed to be an adjunct to the RSI class simulation. Threats to the project are mostly directly related to the convenience sampling from the single anesthesia program. As mentioned, the sample size will already be low, and there is a potential for further decreases as participation is not mandatory. A small sample also increases the likelihood of skewed results from any outliers that misrepresent the population of interest. Another threat to the project is the limited opportunity to offer training sessions as direct adjuncts to RSI simulation, meaning the class is only scheduled for two separate days, and availability to provide a flexible schedule for students to participate is determined by multiple factors unable to be influenced by the project lead. These strengths, weaknesses, opportunities, and threats all balance and create elements of the project that its developers must remain aware of in order to achieve the most successful results. These SWOT analysis characteristics can also be found outlined in Appendix D. 21 Project Design/Methods The primary purpose of this project was to assess anesthesia students understanding of cricoid pressure and its use, the utility of force measurement feedback during cricoid pressure training, and the effectiveness of mixed education and simulation at improving cricoid pressure knowledge and technique, while promoting the correct use thereof through educational intervention. Thus, the design was to utilize a pretest-posttest format, provide a hybrid educational/simulated training experience that incorporated a measurement of cricoid pressure force. The pretest-posttest primarily focused on quantitative data to be used as measures of knowledge of cricoid pressure both before and after the educational session. Cricoid pressure technique was evaluated through comparative measurement of force relative to the presence of real-time feedback in practice. Population/Setting This was done using a convenience sample of students in an accredited nurse anesthesia program from a private liberal arts university in the Midwest. These were doctoral students in their first year of matriculation, without clinical anesthesia experience, who were currently reviewing RSI in a simulation-based course. All of these students who completed the training and testing were considered the participants in this project. The class and training session were conducted at the university in a designated anesthesia simulation center. Measurement Tools A pretest questionnaire was created using the Qualtrics program (Appendix E) and included questions that had been tested for face and content validity by multiple anesthesia providers versed in RSI and cricoid pressure. This was distributed to the participants via email and recorded their answers. The survey included multiple choice, fill-in-the blank, and hotspot 22 questions related to cricoid pressure use, technique, and localization. A common household bathroom scale with a digital numeric display was obtained and used to measure the amount of force in pounds of pressure placed on a manikin of an upper airway. For the purposes of this project, cricoid pressure values within a range of 6.75 to 9 pounds were considered appropriate equivalents to 30 to 40 Newtons. Data Collection The pretest link was sent out to participants within one week prior to the RSI review. The questionnaire link was distributed via email to prospective participants, who were instructed to fill out the survey prior to RSI simulation. Immediately following simulated RSI training, an additional five-to-ten-minute educational session specific to cricoid pressure was provided, and participants were asked to perform cricoid pressure on a manikin once without force feedback, once with, and once more without. A visual reminder of the conversion of Newtons to pounds for each value 10, 20, 30, and 40N was made available to participants during cricoid pressure placement. The measured force of actual pressure placement in pounds per the digital readout from the scale was recorded on paper by the project team during the training session and has been logged separately from the survey data. Participants were asked to fill out the posttest questionnaire moments after finishing cricoid pressure performance. Ethical Considerations Institutional Review Board (IRB) approval was obtained prior to initiating this DNP project. All participants were reminded of their right to refuse to participate in any and all components of the project. At no point was any personally identifiable information recorded about any of the participants. There was little risk of physical or emotional injury to participants, and danger was no greater than for routine simulated practice with RSI. They were not given any 23 bonus, payment, or other coercion to participate. Participants were given all pertinent information prior to agreeing to be part of the project and submitted an implied consent prior to data collection. Participant data has all been stored on a secure laptop, accessible only to the project lead, and personal information was not utilized as part of the data collection. To keep the participant pretest-posttest data associated for statistical analysis, each participant was asked to create a personal code for both tests that consisted only of partial student identification numbers, of which the project lead did not have school server access and could not associate with any individuals. To keep the participant force measurement data impersonal but associated for analysis, random numbers were used to represent individuals, with a value of force obtained for all three attempts logged for each corresponding number. The project team will continue to hold the data on its secure password-protected computer log as its location for a maximum of two years before secure disposal. Project Evaluation Survey data collected via Qualtrics and cricoid pressure force data collected by hand have both been entered separately into Microsoft Excel for statistical analysis and were tested for significance between questionnaire answers before and after the training session, as well as force of pressure before, during, and after feedback. This was accomplished via paired T-testing for test scores before and after the educational session using a resulting p-value of 0.05 or less to indicate statistical significance. The scoring of individual questions has been analyzed in the same fashion to determine areas of strength and weakness of the educational session. The two values collected with the digital readout covered and one value with the digital readout visible were recorded for each individual project participant and these values have been tested for significance in the same manner as the survey data. All of the statistical analyses have been 24 evaluated by the project team to determine the overall effectiveness of the hybrid educational/training session and improvement of cricoid pressure knowledge and technique. Based on the calculations from paired t-testing of questionnaire results and separate ttesting of force measurement before and after feedback, the data comparison is quantifiable. Having descriptive and inferential statistical values to evaluate the success in all avenues of the project, the project team was able to develop conclusions about the success or failure of the interventions provided. Looking at mean and median values, averages were calculated to represent the participant population as a whole. Making inferences using p<0.05 to determine significance, changes in score or accuracy were assessed for any correlation with the instruction provided. Positive correlation for the survey, reflected by an improvement in scores on the questionnaire, would have indicated the educational intervention improved knowledge and understanding of cricoid pressure. Positive correlation of force measurement, determined not by increased value of force, but by increased accuracy of force relative to 30-40N of pressure, would have indicated that the force feedback improved cricoid pressure technique. If both of these interventions have proven to be successful at yielding both of these positive changes, the project team would have been able to conclude the hybrid educational/simulated training is an effective means of teaching cricoid pressure to anesthesia students. If the intervention was unsuccessful, this still developed the anesthesia provider communitys understanding of cricoid pressure education and can help to direct future endeavors at improving practice in this arena. If the intervention was successful, this method of training may provide an affordable, safe, and efficient approach that could help to standardize education on this matter and translate this into improvement in patient outcomes in the clinical setting. 25 Data Analysis/Results The primary data for this project came from two separate sources: the questionnaire answers and the force measurements. The pretest questionnaire was sent to 33 and completed by 32 first-year nurse anesthesia students at Marian University in Indianapolis, with six students declining to complete the posttest within the allotted testing window. This reduced the sample size to 26 for the purposes of comparative analysis. Of the same sample of students polled, all 33 participated in the simulated training, educational session, and practice with force measurement, providing the second set of data. Questionnaire answers and measurements of force in pounds of pressure were compiled and tested for significant changes before and after intervention via Ttesting. Table 1 below outlines the statistical data collected from the questionnaire, and Table 2 outlines the statistical data collected from the measurement of force applied to the airway manikin. All analyses were conducted by testing for significance determined by a p-value < 0.05. 26 Table 1 Pretest-Posttest Questionnaire Results (n=26) Question Number by Topic Number of correct responses Pretest n Question 2 Question 3 13 11 Question 4 Question 10 12 14 Question 5 Question 6 Question 8 Question 11 2 7 7 15 Question 7 Question 9 7 24 p-value: Posttest % n Locating the cricoid cartilage 50 42.3 8 20 % 30.8 76.9 0.134 0.004 92.3 84.6 < 0.001 0.03 38.5 46.2 26.9 73.1 0.003 0.096 1 0.265 80.8 100 < 0.001 0.161 Amount of force applied 46.2 53.8 24 22 When to use or avoid cricoid pressure 7.7 26.9 26.9 61.5 10 12 7 18 Cricoid pressure technique 26.9 92.3 21 26 General information about cricoid pressure Question 12 22 84.6 26 100 0.043 Average level of comfort with cricoid pressure Question 1 Somewhat doubtful to Neutral or Unsure Somewhat confident to Very confident < 0.001 Average Total Score 47.9% 69.1% < 0.001 Posttest total scores improved upon pretest values from an average of 47.9% to 69.1%, with a p-value of < 0.001. Significant improvement was determined in more than half the questions asked, and at least one question in every topic area. Scores decreased on the posttest for question 2 regarding the location in which to place cricoid pressure on a picture of a human neck. All other question score averages either improved or stayed the same. Questions 2, 6, 8, 9, and 11 were not significantly improved on the posttest, though every participant answered question 9 correctly. Overall confidence in ones own ability to perform cricoid pressure improved, with every participant stating either somewhat confident or very confident on the posttest questionnaire. 27 Table 2 Force Measurement Manikin Data (n=33) Measured Amount of Force Average pressure applied (lbs) Average deviation from target range (6.75-9 lbs) Changes in Force Across Attempts Pressure #1 (Blind) Attempt number Pressure #2 (Feedback) Pressure #3 (Blind) 10.88 9.25 7.11 4.53 2.3 1.42 Pressure #1 (Blind) to Pressure #2 (Feedback) Attempt number comparison Pressure #1 (Blind) to Pressure #2 (Feedback) Pressure #3 (Blind) to Pressure #3 (Blind) Change in pressure p = 0.14 p = 0.002 p = 0.019 Change in deviation from target range (6.75-9 lbs) p = 0.012 p < 0.001 p = 0.28 The average force from the first to the third attempt in succession was 10.88, 9.25, and 7.11 pounds of pressure. The average deviation from the goal range of 6.75 to 9 pounds of pressure from the first to the third attempt in succession was 4.53, 2.3, and 1.42 pounds of pressure. The difference in pressure from attempt 1 and attempt 2 to attempt 3 was significant (p = 0.002 and p = 0.019), but the difference between attempt 1 and attempt 2 was not significant (p = 0.14). The change in deviation from the goal range was significant from attempt 1 to attempt 2 and attempt 3 (p 0.012 and p < 0.001) but was not significant between attempts 2 and 3 (p = 0.28). Discussion The increase in total score on the questionnaire suggests a generalized improvement in knowledge about cricoid pressure is related to the simulated training, educational session, and hands-on practice provided. Some questions, specifically numbers 2, 6, 8, 9, and 11, showed no significant change in score, which implies that the subject matter of those questions was less effectively retained by the participants compared to that of the questions in which improvement 28 was statistically significant. Of those questions, three of them pertained to situations in which to use or to avoid the use of cricoid pressure. Based on the overall significant improvement of scores and the specific categories in which improvement was deemed statistically significant, the hybrid intervention was successful at teaching cricoid pressure use and technique to the participants. The posttest average scoring of 69.1% offers more room for improvement, but the directional change was a net positive. The notable area in which the intervention did not improve knowledge of cricoid pressure was the identification of times when cricoid pressure is indicated versus contraindicated, and the ability to locate the cricoid cartilage on a picture of a human neck. These were demonstrated by score decreases or limited increases, with no significant changes found between pretest and posttest values. This affords opportunity to improve upon either the intervention, the questionnaire, or both to fill these gaps. The manikin practice data provided a more distinct global improvement. Average force of pressure started at 10.88 pounds of pressure, outside the range of 6.75 to 9 pounds that equates to the accepted values of 30 to 40 Newtons. The second attempt allowing for view of real time pressure feedback still fell outside this range at 9.25 pound, but the final blinded attempt averaged within the target range, at 7.11 pounds of pressure. This was significantly improved from both the first and second attempts (p = 0.002, p = 0.019), which suggests that repeating the cricoid pressure attempts was successful at improving the participants ability to reach the target value. The average deviation outside the target range shrunk with each attempt, from 4.53 pounds to 2.3 pounds to 1.42 pounds. While the final blind attempt had significantly less deviation from the target range than the first blind attempt (p < 0.001), it was not significantly 29 less than the deviation of the attempt that included feedback (p = 0.28). This information implies that providing feedback was a necessary step in improving the participants ability to reach the target range. The implication of this is that providing a method to practice a force of digital pressure that provides feedback is imperative to ascertaining the correct amount of pressure in situations without an available measurement, such as the actual clinical use or cricoid pressure. Overall, the hybrid simulation, educational session, and practice pressure with feedback served to improve the participants understanding of and ability to perform cricoid pressure. The questionnaire and/or the educational session could still use some fine tuning to improve outcomes further, but as a model for future educational interventions on this topic, this affordable and reproducible method has shown to be a viable option. Strengths and Limitations Some of the strengths of this project were that it required little monetary or human capital and would be relatively simple to replicate. On the scale of an individual university, it would require a thorough understanding of cricoid pressure and the time and resources to teach, demonstrate, and practice cricoid pressure on an airway manikin. The availability of these at the project site was helpful in creating a cohesive project setting and testing the reliability of the pressure output readings on the manikin prior to participant involvement. Combining the RSI simulation class with the education and training session was especially valuable for synergizing the topics and maximizing participation in the intervention. Limitations to the project were relative to the timeframe given. The window of time between project approval and the scheduled RSI simulation class was narrow, allowing little time for participants to fill out the pretest questionnaire in advance of the intervention. The educational session itself was not fully scripted or recorded and may not have been the same for each participant, increasing the variability of its 30 effectiveness. The questionnaire was viewed and validated by a select few CRNAs with experience and expertise performing cricoid pressure, but the verbiage may not have been universally clear and certain questions could still have been subject to individual interpretation. Conclusion After reviewing the body of research presently available about the use of cricoid pressure, it is clear that improper placement is at best a hinderance to achieving endotracheal intubation, and at worst, dangerous or damaging to the patient. It is performed incorrectly more often than not and does not have a standardized training, yet it is still widely utilized in anesthesia practice and has no accepted alternative. Areas of failing in particular are the accuracy of placement and amount of force of cricoid pressure, and this project was developed in an attempt to test a method of standardizing the education and training of cricoid pressure to aspiring anesthesia providers. In combining simulated RSI training with specific education about cricoid pressure, questionnaire results improved from baseline in a significant way, though with room for further enhancement. Providing repeated practice with actual application of force and allowing for participants to view the measurement of that force yielded more effective changes still, improving the likelihood of reaching the target force that correlates with appropriate cricoid pressure without continued visual feedback. These have been determined to beget positive changes in participants knowledge of and ability to place cricoid pressure as per the project aim. Overall, this project has determined that force of pressure can be taught with a few short practice attempts, particularly in which feedback is permitted at least once. Also, knowledge of cricoid pressure utility and technique can be taught with simulated RSI training and a brief educational presentation. This is not to say this is a guaranteed success, but that these interventions can effectively improve current levels of understanding. Future studies may 31 consider more finite or specific areas of knowledge to improve upon in order to refine the educational intervention further. A more thoroughly vetted educational tool and/or questionnaire may be merited for practice standardization, but this project shows that standardized education using these techniques is possible and would make a difference. Eventually this would likely yield better patient outcomes through the avoidance of excessive or subtherapeutic levels of pressure and knowledge of situations in which cricoid pressure is or is not indicated. As the first step in future research on the subject, a standardized education could also lead to a conclusive answer as to the efficacy of cricoid pressure as a clinical technique. 32 References Andruszkiewicz, P., Zawadka, M., Kosiska, A., Walczak-Wieteska, P., & Majerowicz, K. (2017). Measurement of cricoid pressure force during simulated Sellicks manoeuvre. Anaesthesiology Intensive Therapy, 49(4), 283287. https://doi.org/10.5603/ait.a2017.0049 Beckford, L., Holly, C., & Kirkley, R. (2018). Systematic Review and meta-analysis of cricoid pressure training and education efficacy. AORN Journal, 107(6), 716725. https://doi.org/10.1002/aorn.12150 Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., Rohn, A., Compere, V., Benhamou, D., Biais, M., Menut, R., Benachi, S., Lenfant, F., & Riou, B. (2019). Effect of cricoid pressure compared with a sham procedure in the rapid sequence induction of Anesthesia. JAMA Surgery, 154(1), 917. https://doi.org/10.1001/jamasurg.2018.3577 Bohman, J. K., Kashyap, R., Lee, A., He, Z., Soundar, S., Bolling, L. L., & Kor, D. J. (2018). A pilot randomized clinical trial assessing the effect of cricoid pressure on risk of aspiration. The Clinical Respiratory Journal, 12(1), 175182. https://doi.org/10.1111/crj.12508 Fischer, Q., Sbissa, Y., Nhan, P., Adjedj, J., Picard, F., Mignon, A., & Varenne, O. (2018). Use of simulator-based teaching to improve medical students knowledge and competencies: Randomized controlled trial. Journal of Medical Internet Research, 20(9), e261. https://doi.org/10.2196/jmir.9634 Hee, H. I., Wong, C. L., Wijeweera, O., Sultana, R., & Sng, B. L. (2020). Sellick maneuver assisted real-time to achieve target force range in simulated environment: A prospective 33 observational cross-sectional study on manikin. PLOS ONE, 15(2). https://doi.org/10.1371/journal.pone.0227805 Herman, N. L., Carter, B., & Van Decar, T. K. (1996). Cricoid pressure: Teaching the recommended level. Anesthesia & Analgesia, 83(4), 859863. https://doi.org/10.1097/00000539-199610000-00036 Hines, R. L., Jones, S. B., eds. Stoelting's Anesthesia and Co-existing Disease. 8th edition. Elsevier; 2021. Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223 Landsman, I. (2004). Cricoid pressure: Indications and complications. Pediatric Anesthesia, 14(1), 4347. https://doi.org/10.1046/j.1460-9592.2003.01202.x Lee, D., Czech, A. J., Elriedy, M., Nair, A., ElBoghdadly, K., & Ahmad, I. (2018). A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning. Anaesthesia, 73(10), 12291234. https://doi.org/10.1111/anae.14399 Lim, S. M., Ng, B. K., Wilson, A., Cheong, C. C., Ng, T. Y., & Wang, C. Y. (2021). Ultrasound guided paralaryngeal pressure versus cricoid pressure on the occlusion of esophagus: A crossover study. Journal of Clinical Monitoring and Computing, 36(1), 8792. https://doi.org/10.1007/s10877-020-00623-7 Nagelhout, J. J., Elisha, S., Heiner, J. S., eds. Nurse Anesthesia. 7th edition. Elsevier; 2018. 34 Noll, E., Shodhan, S., Varshney, A., Gallagher, C., Diemunsch, P., Florence, F. B., Romeiser, J., & Bennett-Guerrero, E. (2019). Trainability of cricoid pressure force application. Anesthesia & Analgesia, 128(1), 109116. https://doi.org/10.1213/ane.0000000000003385 Pellrud, R., & Ahlstrand, R. (2018). Pressure measurement in the upper esophagus during cricoid pressure: A high-resolution solid-state manometry study. Acta Anaesthesiologica Scandinavica, 62(10), 13961402. https://doi.org/10.1111/aas.13209 Qasem, F., Khalaf, R., Sebbag, I., Lavi, R., Jones, P. M., & Singh, S. I. (2019). Efficacy of surface landmark palpation for identification of the cricoid cartilage in obstetric patients: A prospective observational study. Journal of Anaesthesiology Clinical Pharmacology, 35(3), 335. https://doi.org/10.4103/joacp.joacp_222_17 Trethewy, C. E., Doherty, S. R., Burrows, J. M., & Clausen, D. (2017). Ideal cricoid pressure is biomechanically impossible during laryngoscopy. Academic Emergency Medicine, 25(1), 9498. https://doi.org/10.1111/acem.13326 White, L., Thang, C., Hodsdon, A., Melhuish, T., & Vlok, R. (2020). Cricoid pressure during intubation: A systematic review and meta-analysis of Randomised Controlled Trials. Heart & Lung: The Journal of Cardiopulmonary and Acute Care, 49(2), 175180. https://doi.org/10.1016/j.hrtlng.2019.10.001 Williams, P., & Umranikar, A. (2017). A comparative prospective cohort study comparing physical exam to ultrasound for identifying the cricoid cartilage. Journal of Perioperative Practice, 27(9), 186191. https://doi.org/10.1177/175045891702700902 You-Ten, K. E., Wong, D. T., Ye, X. Y., Arzola, C., Zand, A., & Siddiqui, N. (2018). Practice of ultrasound-guided palpation of neck landmarks improves accuracy of external palpation of 35 the cricothyroid membrane. Anesthesia & Analgesia, 127(6), 13771382. https://doi.org/10.1213/ane.0000000000003604 Zdravkovic, M., Rice, M. J., & Brull, S. J. (2021). The clinical use of cricoid pressure: First, do no harm. Anesthesia & Analgesia, 132(1), 261267. https://doi.org/10.1213/ane.0000000000004360 Zeidan, A. M., Salem, M. R., Bamadhaj, M., Mazoit, J.-X., Sadek, H., Houjairy, H., Abdulkhaleq, K., & Bamadhaj, N. (2017). The cricoid force necessary to occlude the esophageal entrance. Anesthesia & Analgesia, 124(4), 11681173. https://doi.org/10.1213/ane.0000000000001631 36 Appendix A Included Screening Identification Identification of studies via databases Records identified from: PubMed (n = 103) Medline Ovid (n = 95) Hand searches (n = 2) Records removed before screening: Duplicate records removed (n = 95) Records screened (n = 105) Records excluded (n = 80) Reports sought for retrieval (n = 25) Reports not retrieved (n = 2) Full articles assessed for eligibility (n = 23) Articles excluded: Research objective is unrelated (n = 2) Study setting is not universally applicable (n = 2) Article is narrative with limited original data (n = 3) Studies included in review (n = 16) 37 Appendix B Reference Research Design & Level of Evidence Non-experimental prospective observational study; level 4 Population/Sample n=x Variables Instruments/Data Collection Results n=206; anesthetists and anesthetic nurses Occupation, identification of cricoid cartilage, amount of force applied; prior knowledge of cricoid pressure Laerdal airway model; electronic weight scale; 2attempts at pressure placement Beckford et al., 2018 Systematic review & meta-analysis; level 1 n=8; studies included from database searches Designs and results of individual studies; selection criteria for analysis; accurate application of cricoid pressure; educational intervention 7 databases searched; Fishers combined probability testing; R-statistical software Birenbaum et al., 2019 Randomized clinical trial; level 2 n=3472; patients over 18 years age, requiring RSI Training session with occluded 50mL syringe; randomized assignment software; pulmonary aspiration as determined by visualized gastric contents at glottic level or diagnosed tracheal aspiration Bohman et al., 2018 Randomized clinical trial; level 2 n=95; surgical patients at-risk for microaspiration Application of pressure or sham procedure; incidence of pulmonary aspiration; incidence of secondary morbidities; intubation time; Cormack & Lehane laryngeal view grade Application of cricoid pressure; presence of pepsin A in gastric contents; ventilation difficulty; laryngoscopy difficulty, incidence of potssurgical pulmonary disease 49% correct identification of cricoid cartilage; 16.5% correct pressure first attempt; 20.4% correct pressure second attempt; 18% knowledge of correct amount of pressure (p<.001) Data compiled and tested against each other to determine that simulated and/or educational training has a statistically significant correlation to improved application of cricoid pressure (p<.001) Longer intubation times and poorer laryngoscopy views were seen with cricoid group (p<.001). No significance was found for difference in any morbidity (all p.28) or positive case of aspiration (p=.14) No reduction in pepsin A in the lower airway with cricoid pressure (p=.529). 19% patients developed microaspiration, 8.5% from each group, and 2% that received intermittent treatment (p=.748). Andruszkiewicz et al., 2017 Sampled secretions from the lower airway; pepsin A presence in lower airway secretions; measured pepsin A concentration > 0.1 ng/mL 38 Fischer et al., 2018 Randomized controlled trial; level 2 n=118; fourth to sixth year medical students Format of training provided; numeric examination scores; exam topic; rated satisfaction with training method PowerPoint video training; Mentice VIST-Lab coronary angiography simulator training; 40 question multiple-choice exam including varying topics; student satisfaction questionnaire Simulation group scored higher overall: 59.8 points versus 43.8 points (p<.001), and in each exam topic: (all p<.001). Satisfaction scores higher in the simulation group at 98% compared to 75% (p<.001). 81.1% and 88.3% of attempts achieved target force with real-time feedback whereas the non-feedback group achieved the target 26.5% and 33.3% of the time (p<.001). Hee et al., 2020 Quasi-experimental cross-sectional study; level 3 n=22; anesthetic nurses Presence of real-time feedback during pressure application, force of application, reproducibility of cricoid pressure technique Laerdal Airway Management Trainer manikin placed; electronic weight scale; biofeedback sensor system; computerized visual display Lee et al., 2018 Quasi-experimental prospective study; level 3 n=100; elective surgical patients undergoing general anesthesia Use of palpation and landmarks; location of finger placement; distance from actual cartilage; BMI; age; sex Distance from cricoid cartilage greater than 5mm in 41% of patients. No significant relation between this and BMI (p=.539), age (p=.843), or sex (p=.138). Lim et al., 2021 Quasi-experimental cross-sectional study; level 3 n=51; elective surgical patients undergoing general anesthesia Anatomical alignment of esophagus; use of cricoid pressure vs paralaryngeal pressure (PLP) with ultrasound; esophageal occlusion S-NerveTM Ultrasound; craniocaudal midpoint of the cricoid cartilage; skin marker with measuring scale; recorded demographic information including height, weight, age, and gender SonoSite M-Turbo Ultrasound with HFL38x probe; visualized compression of esophagus under both pressures Noll et al., 2019 Quasi-experimental pretest-posttest; level 3 n=100; clinicians who have to perform cricoid pressure routinely Practice with a force measurement or not; number of attempts at pressure; amount of force applied Model trachea and larynx; Vernier Software & Technology Model FP-BTA force plate, force recording computer interface After four attempts with a force measurement, success rate increased by 16% (p<.001). Each successive attempt in simulation environment had a larger success rate (p<.001) through all 30 cycles performed. Cricoid pressure occluded 27% of laterally displaced esophagi to PLPs 30% (p=1.0). 100% of midline esophagi achieved occlusion with cricoid pressure 39 Pellrud & Ahlstrand, 2018 Randomized controlled trial; level 2 n=17; healthy student volunteers Placement of cricoid pressure; upper esophageal sphincter (UES) pressure; proximal esophagus pressure; alfentanil vs placebo administration High-resolution solid-state manometry nasal catheter; medications to administer: IV alfentanil, IV saline (placebo), IV propolipid Qasem et al., 2019 Non-experimental prospective observational study; level 4 n=53; caregivers involved in patient airway management Occupation of clinician; accuracy of locating cricoid cartilage; speed of locating cricoid cartilage; patient BMI SonoSite MicroMaxx linear array ultrasound; Invisible Ink Spy Pen with Built in UV Light Magic Marker; 30 random volunteer subjects and their airway surface landmarks Trethewy et al., 2017 Randomized controlled trial; level 2 n=54; patients presenting to ED requiring RSI to intubate Measured force of cricoid pressure before & during intubation; presence of real-time feedback; incidence of aspiration Cricoid pressure instructional video; Model PT270 platform scale with mounted liquid crystal display; Photologic serial data logger White et al., 2020 Systematic review & meta-analysis; level 1 n=12; studies included from database searches Designs and results of individual studies; selection criteria for analysis; incidence of aspiration; time to intubation; use of cricoid pressure 5 databases searched; RevMan 5.3 data analysis software; Mantel-Haenszel random effects model No significant differences in pressures relative to medication administered (all p.>.05). Average UES pressures increased from 4446mmHg to 167-173mmHg with determined 30N of pressure. Overall success of locating the cricoid was 42%. 60% of respiratory therapists (RTs), 53% of anesthesia residents, 40% of anesthesia consultants, and 13% of nurses were successful. No significant noted across professions (all p>.05). RTs were significantly faster than: consultants (p<.001), residents (p=.002), and nurses (p=.071). Both groups able to achieve adequate pressure; no significant difference between feedback group and blind group (p=.416). Both groups fell outside recommended pressure during intubation; no significance between groups (p=.742). About 13% of patients had aspiration after. Data compiled and tested against each other to determine that cricoid pressure application had no significant reduction in incidence of aspiration (p=.51) Time to intubation significantly increased with cricoid pressure (p<.001). 40 Williams & Umranikar, 2017 Quasi-experimental comparative prospective cohort study; level 3 n=30; anesthetic and non-anesthetic surgical nurses You-Ten et al., 2018 Randomized controlled trial; level 2 n=15; anesthesia residents, fellows, and assistants Zeidan et al., 2017 Quasi-experimental prospective study; level 3 n=60; surgical patients undergoing general anesthesia Ultrasound guidance for locating the cricoid cartilage or surface landmarks; distance to target, patient body mass index, age, sex, neck circumference, and cricoid depth Practice with or without ultrasound; distance from cricothyroid midpoint; use of surface landmarks GE LOGIQ Ultrasound probe; InvisibleWriter invisible ink marker; red dot stickers; 10 volunteer elective surgery patients Patient gender; ability to insert a gastric tube; amount of cricoid pressure force 20F gastric tube; Glidescope video laryngoscope; cricometer force measurement Zonare Medical System, Inc, portable ultrasound; invisible ink; 10 human volunteers and their surface airway landmarks Median distance away from target was 10mm. Large neck circumference was found to have greater distance from target as was larger body mass index, although associations were not significant (p=.243) and (p=.285). Median accuracy rate of ultrasound group was 65% to the non-ultrasound groups 30% (p=.025) and its mean distance from the target was 3.6mm to the non-ultrasound groups 6.8mm (p=.001). Mean force required to occlude the esophagus and prevent gastic tube insertion was 18.7N for women and 30.8 for men (p<.001) 41 Appendix C (Iowa Model Collaborative, 2017) 42 Appendix D Easily reproducible Small size Cost effective with few resources required Decreased generalizability Relevant to current practice Short-term follow-up only Potential to improve anesthesia practice Limited data/results Efficient/Timely Program specific Few to no risks for participants Examine a multifaceted educational approach (simulation, education, specific measured parameters) Benefit future providers and their patients Promote standardized approach for future studies on cricoid pressure Increased awareness of present cricoid pressure controversy Adjunct education for rapid sequence inductions Decreased participation would hinder results Potential for skewed results secondary to sample size Limited time available for training sessions Schedule conflicts or other unavoidable absences could further limit results 43 Appendix E Please create a four-character unique test code using the last 4 numbers of your Marian student ID. ____ 1. How confident do you feel that you can correctly place cricoid pressure during rapid sequence induction? Very confident Somewhat confident Neutral or Unsure Somewhat doubtful Very doubtful 2. Place the indicator mark on the location where cricoid pressure should be applied (Nagelhout & Elisha, 2018) 3. Place the indicator mark on the location where cricoid pressure should be applied (Nagelhout & Elisha, 2018) 44 4. How much force in Newtons should you apply after the patient is unconscious for proper cricoid pressure placement? (Nagelhout & Elisha, 2018) __________ 5. Which of the following surgical patients receiving general anesthesia would require rapid sequence induction with cricoid pressure placement? (Nagelhout & Elisha, 2018) Morbidly obese patient with history of obstructive sleep apnea and hypothyroidism Elderly patient with paroxysmal atrial fibrillation not on blood thinners presenting with hip fracture 24-week gestation parturient with biliary obstruction who is actively vomiting Patient with uncontrolled diabetes presenting with neuropathic gangrenous foot for amputation 6. Which of the following precludes the use of cricoid pressure during rapid sequence induction? (Landsman, 2004) Esophageal stricture Difficult mask ventilation Cervical spine instability All of the above 7. Rank these events in chronological order: (Landsman, 2004) Cricoid pressure placed on the cricoid cartilage Force of 30-40N applied to the cricoid cartilage Cricoid pressure released from the cricoid cartilage Anesthesia induction and loss of consciousness Endotracheal tube insertion Confirmation of endotracheal tube placement 8. True or False: When encountering difficulty intubating while performing RSI with cricoid pressure, pressure should not be released until intubation is confirmed. (Hines & Jones, 2021) True False 9. True or false: Placement of cricoid pressure 20N or more on an awake patient can cause gagging or pain (Landsman, 2004) True False 10. Cricoid pressure placed in which manner can result in increased difficulty attaining laryngeal view and longer time to achieve intubation? (Select all that apply) (Nagelhout & Elisha, 2018) 45 Not directly on the cricoid cartilage Force of pressure greater than 40N Force of pressure less than 30N 11. Which of the following is NOT a surgical scenario in which cricoid pressure is merited? (Nagelhout & Elisha, 2018) Exploratory laparotomy following a motor vehicle accident Emergency surgery without time to abide by NPO guidelines Laparoscopic gallbladder removal with intraoperative cholangiogram C-section requiring general anesthesia 12. What is another term for cricoid pressure? (Nagelhout & Elisha, 2018) Mullers maneuver Larsons maneuver Valsalvas maneuver Sellicks maneuver Survey Powered By Qualtrics 46  ...

... Laryngospasm Versus Bronchospasm High Fidelity Simulation Laryngospasm Versus Bronchospasm High-Fidelity Simulation David Gray and Creighton Smith Leighton School of Nursing, Marian University 1 Laryngospasm Versus Bronchospasm High Fidelity Simulation 2 (Abstract) Laryngospasm and bronchospasm are anesthesia complications that occur commonly in the operating room. Laryngospam and bronchospasm can both lead to hypoxia, hypercarbia, and hemodynamic instability. Our goal was to determine if first year SRNAs would have a better understanding of identifying and treating each complication through a simulation and debrief scenario. We used a pretest to gather baseline knowledge and confidence level followed by a simulation where the subjects were to identify and treat either bronchospasm or laryngospasm. Following the simulation, a debrief was conducted to educate and discuss the simulation using an interactive powerpoint presentation. After the debrief, the same simulation was conducted again. Afterwards, a posttest was administered to determine if an increase in knowledge and confidence was gained. As a result, there was an increase in knowledge and confidence following the simulation and debrief. Laryngospasm Versus Bronchospasm High Fidelity Simulation 3 Table of Contents Abstract2 Introduction..4 Background..5 Problem Statement...7 Needs Assessment7 Aims & Objectives...8 Theoretical Framework....9 Review of Literature..10 Project Design....12 Population & Setting..13 Measurement Instruments..13 Data Collection Procedures....13 Ethical Considerations / Protection of Human Subjects14 Project Evaluation Plan..14 Data Analysis and Results 15 Conclusion.16 References..18 Appendix A22 Appendix B23 Appendix C....25 Appendix D26 Appendix E29 Laryngospasm Versus Bronchospasm High Fidelity Simulation 4 Laryngospasm Versus Bronchospasm High Fidelity Simulation Introduction Laryngospasm and bronchospasm are known complications of anesthesia. Laryngospasm and bronchospasm can present as persistent coughing and stridor leading to improper oxygenation (Juang et al., 2020). One study showed that airway complications such as laryngospasm and bronchospasm occurred in 40 out of 300 (13%) patients that underwent anesthesia (Juang et al., 2020). While these two complications present similarly clinically, they are physiologically different and are treated differently. Providers must know how to distinctly tell the difference between these two and how they are going to treat them promptly. If the provider is not efficient in treating these emergency situations, the provider is putting the patients wellbeing at risk. Preparing for these situations starts in training as a Student Registered Nurse Anesthetist (SRNA). While SRNAs are required to meet a certain number of cases before graduating, the Council of Accreditation (COA) recommends further training with the use of simulation (COA, 2020). Historically, high fidelity simulation training has been utilized by aviation training and the military in order to address skills, communication, and safety in critical situations (Green et al., 2016). Over the years, simulation has made its way into the world of anesthesia. Simulation in anesthesia can be utilized to mimic human responses in a realistic manner such as breathing patterns, heart rate, blood pressure, and even different levels of airway obstruction (Green et al., 2016). This study aims to identify if a high fidelity simulation scenario followed by a debrief will assist SRNAs in feeling more confident and able to identify and treat laryngospasm and bronchospasm. Laryngospasm Versus Bronchospasm High Fidelity Simulation 5 Background Laryngospasm is a dangerous situation during anesthesia that causes the vocal cords to spasm in the closed position, thus cutting off the ability to ventilate (Holley et al., 2019). Eventually, this may lead to hypoxia, hypercarbia, and death (Holley et al., 2019). Signs and symptoms of a laryngospasm can occur throughout anesthesia but most often occur during extubation when the airway is not secure and the patient is unable to speak or breathe (Holley et al., 2019). These symptoms include inspiratory stridor, suprasternal and supraclavicular retraction during inspiration, or an absent or altered EtCO2 waveform (Holley et al., 2019). As the vocal cords slowly relax and open, you may hear a high-pitched stridor (Holley et al., 2019). Treatment for laryngospasm is a combination of jaw thrust at the angle of the mandible (Larsons maneuver) while applying positive pressure ventilation with 100% oxygen (Holley et al., 2019). If the Larsons maneuver & positive pressure fail, administering succinylcholine can break the spasm (Holley et al., 2019). The recommended dose of succinylcholine varys from 0.25 to 1 mg/kg intravenously or 4 mg/kg intramuscularly (Holley et al., 2019). In addition, some texts recommend suctioning foreign material from the oropharynx, administering lidocaine, 1-1.5 mg/kg, and removing or avoiding any painful stimulus (Holley et al., 2019). Bronchospasm is a reversible reflex spasm of the smooth muscle in the bronchi. Bronchospasm is vagally mediated and caused by histamine, or one of many noxious stimuli including cold air, inhaled irritants, and instrumentation such as tracheal intubation (Gautam & Sharkya, 2019). Signs and symptoms of bronchospasm are high peak inspiratory pressures (PIP) and airway resistance (Gautam & Sharkya, 2019). Manual ventilation will often feel like the air isnt moving, or that youre hitting a wall (Gautam & Sharkya, 2019). As a result, bronchospasm leads to wheezing, reduced tidal volumes, reduced dynamic compliance, and Laryngospasm Versus Bronchospasm High Fidelity Simulation 6 hypoxemia (Gautam & Sharkya, 2019). During anesthesia, this can occur during induction or at any stage throughout the use of anesthesia during surgery (Gautam & Sharkya, 2019). Treatment for bronchospasm includes 100% oxygen, manual ventilation (to assess pulmonary compliance and to assess any other possible reasons for high circuit pressure), and deepening of sedation (Hines & Marschall, 2018). Deepening of sedation can be accomplished through volatile anesthetics, propofol, ketamine, or a combination of agents (Hines & Marschall, 2018). Short acting beta 2 agonists such as albuterol can also be utilized to treat bronchospasm. If the patient is still spasming, epinephrine can be given (Hines & Marschall, 2018). For epinephrine, best practice is to give judiciously in small increments and wait for reaction (this can sometimes take up to 5 minutes) (Hines & Marschall, 2018). Corticosteroids should be considered for the long-term effects, as these drugs will help very little in acute/emergent situations (Hines & Marschall, 2018). Desflurane and isoflurane can be irritating on the airway, thus sevoflurane is the superior volatile in regards to limiting bronchospasm (Hines & Marschall, 2018). While signs and symptoms of laryngospasm and bronchospasm are very similar, they are not treated the same (Xiong & Sun, 2019). Both disease processes can have devastating effects on a patient during anesthesia (Xiong & Sun, 2019). For instance, if laryngospasm is not treated efficiently, the patient may develop negative pressure pulmonary edema leading to severe hypoxemia and pulmonary edema (Xiong & Sun, 2019). On the other hand, bronchospasm can increase the patient's pulmonary vascular resistance and lead to hypoxemia and right-sided heart failure (Woods & Sladen, 2009). Anesthesia providers must be ready to recognize the difference between the two and treat promptly for safe anesthetic care (Xiong & Sun, 2019). Building a strong anesthesia foundation starts while in school as an SRNA. By preparing SRNAs with Laryngospasm Versus Bronchospasm High Fidelity Simulation 7 high-fidelity simulation, the anesthesia trainee can have better confidence in recognizing and providing prompt treatment for either laryngospasm or bronchospasm. Problem Statement While SRNAs are taught how to identify and treat laryngospasm and bronchospasm accordingly, experiencing it in real time and knowing what to do in the moment is what makes this concept difficult. When taking a written exam, the SRNA has time to think about the question, gather their thoughts, and choose from given options. In the real world, this is not the case, and the provider must critically think in a timely manner in order to protect the patient. Thus, simulation experiences while in school may lead to increased knowledge and confidence for SRNAs when it comes to facing these issues in the clinical setting. This project seeks to discover if first year SRNAs will grow in knowledge and confidence through a high-fidelity simulation experience coupled with a debrief of the simulation. The simulation will immerse the subjects into a real life scenario requiring knowledge and critical thinking in order to overcome the task at hand. In order to test for statistical significance, the subjects will be asked to complete a pretest before the simulation and a post test after the simulation is complete. Needs Assessment The Nurse anesthesia program at a University in the Midwest would benefit from an immersive simulation experience involving laryngospasm and bronchospasm and how to treat accordingly. Currently, first year SRNA students at this university are learning about laryngospasm & bronchospasm in class, but they are not exposed to these scenarios in a simulation activity. However, studies have shown that students who receive simulation experience in addition to didactic learning acquire significantly higher skill levels of knowledge and confidence compared to those with didactic alone (Bowling & Underwood, 2016). Laryngospasm Versus Bronchospasm High Fidelity Simulation 8 Laryngospasm and bronchospasm are not uncommon, with laryngospasm occurring in every 2.5% of cases with emergence (Chambers, 2020). On the other hand, the incidence of bronchospasm is 2% in asthmatic patients and an overall incidence of 0.2% (Vojdani, 2018). It is imperative that nurse anesthetists are equipped with the knowledge and skills to identify and manage life-threatening situations. Therefore, it is important to prepare future anesthesia providers for when these life threatening situations arise. Aims and Objectives The aim of this project is to identify if the first year SRNAs feel knowledgeable and confident in identifying and treating laryngospasm and bronchospasm following a simulation experience with a debrief of the simulation. The confidence and knowledge levels will be accessed with a posttest after a high fidelity simulation to gauge whether or not the simulation experience increases knowledge and confidence. The high fidelity simulation scenario will be designed and presented to the first year SRNAs by two junior SRNAs. The simulation and evaluation will be carried out from January 15, 2023 to May 5, 2023. The objectives of this project are: Gauge first year SRNA confidence in identifying laryngospasm and bronchospasm. Gauge first year SRNA knowledge on how to properly identify and treat both laryngospasm and bronchospasm. If statistically significant, discuss implementing the simulation experience to future cohorts. Identify whether a debrief increases knowledge of identification and treatment of laryngospasm and bronchospasm. Laryngospasm Versus Bronchospasm High Fidelity Simulation 9 Theoretical Framework Achieving optimal evidence-based practice is imperative in the realm of healthcare. With healthcare constantly changing and the creation of new technology/ methods, discovering best practice through research will continue to be pertinent. In the early 1990s, a team of nurses from the University of Iowa developed a framework called the Iowa Model of Research (Buckwalter et al., 2017). The Iowa Model (see APPENDIX A) provides a pathway or method to evidence-based practice (Buckwalter et al., 2017). Essentially, it is a guide laid out in steps that allows the researchers to carry out evidence based practice in the appropriate manner in order to improve the quality of care. It involves identifying a trigger, determining if the problem is a priority, forming a team, and gathering and analyzing research (Buckwalter et al., 2017). Next, the researchers critique and synthesize the research and decide whether or not there is sufficient research in order to implement the change (Buckwalter et al., 2017). Next the model includes implementing change within a chosen sample size followed by evaluating the results and deciding whether or not the change is statistically warranted (Buckwalter et al., 2017). For this project, we identified an issue after we felt underprepared as first year SRNAs on how to identify and treat bronchospasm and laryngospasm. Then, we decided that this issue is a priority due to the prevalence of bronchospasm and laryngospasm and the repercussions that can ensue. The team we gathered involves the two of us junior SRNA students, a chair, and a board member who has access to the high-fidelity simulation lab. Next, we gathered and analyzed research and decided that there was sufficient enough data on the prevalence of bronchospasm and laryngospasm as well as the lack of treatment confidence. In addition, we found data supporting the use of simulation in order to increase confidence and knowledge. Going forward, we will choose a sample size including first year SRNA students at a University in the midwest Laryngospasm Versus Bronchospasm High Fidelity Simulation 10 and gauge whether or not a high fidelity simulation experience will statistically improve knowledge and confidence. After gathering the results, it will be decided as to whether or not this should be integrated into the curriculum of current first year SRNAs at this institution. GANTT Chart The GANTT chart (see Appendix B) provides a timeline for how we plan to carry out and complete the study. SWOT Analysis The key stakeholders of the project are first year SRNA students as well as future patients who will benefit from stronger anesthesia providers. The strengths of the project are the use of a high fidelity simulation lab and cooperation by the SRNA students. Potential barriers include time restraints for both the subjects and research conductors due to full time course loads and clinical obligations . Opportunities for this project include increased knowledge and confidence, thus stronger anesthesia providers. Potential threats to this project include skewed data from the first year SRNA students rushing to fill out the pre and post tests. Table of full SWOT analysis is presented in APPENDIX C. Literature Review Results The literature review was conducted throughout October and November 2022 using Pubmed and Medline EBSCO databases to assess various articles in regards to the effectiveness of simulation as a learning tool. The key words used in the search include effects, outcomes, simulation, high-fidelity, manifestations, SRNA, medical, nursing, anesthetists, students, knowledge, and confidence. The BOOLEAN phrases used in the search include simulation OR Laryngospasm Versus Bronchospasm High Fidelity Simulation 11 high-fidelity simulation OR role-playing OR knowledge OR confidence . As a result of the database searches, 203 articles were provided as seen in the PRISMA flowchart (appendix E). After reducing the search to the last five years and randomized controlled trials, 53 articles remained. Next, the articles were examined for the inclusion criteria of only pertaining to simulation rather than videos or virtual reality. Then, several articles unrelated to healthcare were thrown out. From that, the 11 remaining randomized control articles were selected that display the effects or lack thereof of simulation experience on boosting knowledge and confidence. The matrix containing basic information on the 11 selected articles can be found in appendix D. Anesthesia-related articles Of the 11 articles selected, five of them tested for significance with simulation-based training among anesthesia-related skills. One of the articles had 104 subjects and utilized a questionnaire to see if there was statistical significance in crisis management for those partaking in the simulation versus just observing. As a result, both groups improved while those partaking in simulation had improved scores versus those just observing. Another article studied the effects of simulation on performance using transesophageal echocardiography versus those doing an online module. Posttest scores were significantly higher for those in the simulation group (P<0.01). Two of the articles studied whether or not simulation would improve CPR performance and adequacy and both displayed statistical significance in improvement scores from pretest to posttest. In one of these, 51.9% of the subjects from the experimental group met the criteria for adequate CPR whereas only 12.5% from the control group met criteria. In another study, the researchers were able to find that simulation improved ultrasound skills in anesthesia students. This study examined the performance scores using the Objective Structured Laryngospasm Versus Bronchospasm High Fidelity Simulation 12 Assessment of Ultrasound Skills (OSAUS) and showed that the performance scores for the simulation group were significantly higher than the non-simulation group. Non-anesthesia Related Articles Of the selected 11 articles, six of them are unrelated to anesthesia but still pertain to healthcare in genreal. One of the articles tested for significance in whether or not simulation would improve knowledge and critical thinking with the management of preeclampsia. From this study, knowledge (p<0.001), critical thinking (p<0.05), and decision making (p <0.05) were all increased for those in the experimental group. Another article studied nursing students to see if a simulation would improve their knowledge on nursing ethics principles. In this study, the control group still received education on ethics but it was in more of a traditional lecture setting. As a result, nursing knowledge improved for both groups, however the simulation was no more statistically significant. Another study testing the significance in a simulated cerebral spinal drainage catheter insertion showed no significance (P=0.48) compared to the control group. One study involving nursing students tested for significance in a simulation to improve skill and anxiety levels when it comes to cardiac auscultation. The results show that simulation compared to traditional teaching was more effective (P<0.001). An article involving medical residents illuminated whether simulation is superior to lecture-style teaching in regards to hospital orientation. This study did not show that one method is superior to the other. Finally, the last article we found involved extracorporeal membrane oxygenation (ECMO) and supported the idea of simulation being a more effective teaching method versus traditional teaching. Project Design The research design for this project is going to be an educational project design. This design was chosen due to the need for further education on the identification and treatment of Laryngospasm Versus Bronchospasm High Fidelity Simulation 13 laryngospasm and bronchospasm by the first year SRNA students. The project is being conducted with first year SRNA students in a high-fidelity simulation lab. The measurement tools planned on being used are a pretest, a high-fidelity simulation lab, debrief, final simulation, and a posttest. Data collection procedures will be based on the pretest and posttest results. Ethical considerations and protection of humans in the study will make sure the simulation environment is a safe, non threatening environment for them to attempt to identify and treat laryngospasm and bronchospasm accordingly. The pre and post test will be done with no identifiers except the last four digits of their student ID number (provided by their campus identification card) for comparison of the results. The pre and post test number will be made known to the participants so they are fully aware that the results will be compared. Population and Setting The population selected to participate in this educational project is 20 first year SRNA students. The setting will be located in a high-fidelity simulation lab at a small Catholic university in the midwest United States. This study will take place between February and March 2023. Measurement Instruments A pre and post test will be used to measure applicability of the project. The pre and post test consists of select multiple, select one, true and false, and likert scale style questions (see Appendix F). There are 14 questions on the pretest and 16 questions on the posttest. Two additional questions are on the posttest to gauge a better understanding of the subject's feelings of the simulation as a whole. Data Collection Procedures The first year SRNA students will be given a pre test that they will be asked to fill out. Laryngospasm Versus Bronchospasm High Fidelity Simulation 14 The pre and post tests will be given without any outside factors for assistance, no open book, and will be answered individually. After the high-fidelity simulation has occurred, they will be asked to fill out a post test. The pre and post test will be compared to each other to identify if the project design was effective or not. Ethical considerations Ethical considerations that will be implemented to ensure anonymity will include refraining from putting their name on the pre and post test. Instead they will be asked to provide their last four digits of their student identification number so the pre and post test can be compared and analyzed. IRB approval will also be gained to ensure the project design to protect the human subjects.The participants of the study will be instructed they can leave the study at any point without any repercussions. The pre and post test will be stored together with the authors at all times on a password-protected computer that only the authors have access to. The data collected will be kept for two years. Project Evaluation Plan The effectiveness of the project will be determined based on answers from our post simulation test. It will be determined if the students feel more knowledgeable and confident about identifying and treating laryngospasm and bronchospasm. Additionally, the post simulation test will identify if they are able to answer questions correctly concerning laryngospasm and bronchospasm recognition and treatment. The test will be compared to the results from the pretest given before the simulation for statistical significance. To maintain validity, the tests will be taken before and after the simulation with the proctors present to ensure sharing of information is prohibited. After the pre and post test and simulation have been conducted, Laryngospasm Versus Bronchospasm High Fidelity Simulation 15 analysis will be performed to identify if the P-value is equal to or less than 0.05 to be considered statistically significant. Quantitative Results A statistical hypothesis test using a one sample T-Test was used to determine if there was statistical significance when comparing the pretest and posttest results in regards to knowledge improvement. Fourteen SRNAs completed the pre test, participated in the simulation and debrief, then completed the post test. The P-value of the quantitative questions was <0.001, showing that the study was significant. The following table provides the associated mean presented as the t-values for the pre and post test followed by the significant p values. One Sample T-Test Statistic df p Pre Test Quantitative Student's t 28.8 13. 0 < .001 Post Test Quantitative Student's t 53.9 13. 0 < .001 Note. H 0 Qualitative Results A statistical hypothesis test using a one sample T-Test was used to determine if there was statistical significance when comparing the pretest and posttest results in regards to confidence improvement. 14 SRNAs answered the pretest, underwent the simulation and debrief, then completed the post test. The P-value of the qualitative questions was <0.001, showing that the study was significant. The table below provides the associated mean represented by the t-values for the pre and post test followed by the significant p values. Laryngospasm Versus Bronchospasm High Fidelity Simulation 16 One Sample T-Test Statistic df p Pre Test Qualitative Student's t 7.81 13. 0 < .001 Post Test Qualitative Student's t 32.27 13. 0 < .001 Note. H 0 Discussion The results from the post test compared to the pretest display significant improvement in knowledge and confidence following the simulation experience. Each question on the pre and post test was evaluated in order to reach this conclusion. This project strengthens the idea that SRNAs can improve knowledge and confidence through simulation & debrief when dealing with stressful situations during anesthesia. The idea of a simulation and debrief can be applied to endless scenarios for educational purposes. Strengths and Limitations The projects strengths include participation and knowledge base from the freshmen SRNAs. In addition, strengths included access to a high fidelity simulation lab to carry out the simulation. Limitations were having a different number of participants that did the pre test and the post test. Another limitation was changing of faculty in the middle of the project. Conclusion The projects aims was to determine if a simulation with debrief would increase first year SRNAs comfort and ability to identify and treat laryngospasm and bronchospasm. A simulation that required the SRNAs to identify and treat both laryngospasm and bronchospasm was Laryngospasm Versus Bronchospasm High Fidelity Simulation 17 implemented. Following the simulation, a debrief was conducted to discuss the differences and identification as well as treatment for both. The debrief included a powerpoint presentation explaining bronchospasm and laryngospasm. After the debrief, the SRNAs were asked to perform the simulation again. There was a pre test and post test to see if the SRNAs knowledge and confidence improved. The results were significant with a P-value of <.001. To further benefit SRNAs moving forward, this training can be added into the simulation curriculum for first year SRNAs at this institution. In addition, the same simulation design can be used for various situations anesthetists may encounter in the operating room. Further educational projects should be completed with larger sample sizes for comparison. Laryngospasm Versus Bronchospasm High Fidelity Simulation 18 References Akalin, A., & Sahin, S. (2020). The impact of high-fidelity simulation on knowledge, critical thinking, and clinical decision-making for the management of pre-eclampsia. International Journal of Gynecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics, 150(3), 354360. https://doi.org/10.1002/ijgo.13243 Argalious, M., Trombetta, C., Makarova, N., Saasouh, W., & Rajan, S. (2019). Simulation versus problem based learning for cerebrospinal drainage catheter insertion and management: A randomized trial in a large academic anesthesiology residency program. Journal of Cardiothoracic and Vascular Anesthesia, 33(4), 9931000. https://doi.org/10.1053/j.jvca.2018.07.033 Berger, C., Brinkrolf, P., Ertmer, C., Becker, J., Friederichs, H., Wenk, M., Van Aken, H., & Hahnenkamp, K. (2019). Combination of problem-based learning with high-fidelity simulation in CPR training improves short and long-term CPR skills: a randomized single blinded trial. BMC Medical Education, 19(1), 180. https://doi.org/10.1186/s12909-019-1626-7 Blani, A., Gorse, S., Roulleau, P., Figueiredo, S., & Benhamou, D. (2018). Impact of learners' role (active participant-observer or observer only) on learning outcomes during high-fidelity simulation sessions in anesthesia: A single center, prospective and randomized study. Anesthesia, Critical Care & Pain Medicine, 37(5), 417422. https://doi.org/10.1016/j.accpm.2017.11.016 Laryngospasm Versus Bronchospasm High Fidelity Simulation 19 Bowling A. & Underwood, P. (2016). Effect of simulation on knowledge, self confidence, and skill performance in the USA: A quasi-experimental study. Nurs Health Sci. 18(3): 292-298. doi:10.111/nhs.12267 Buckwalter, K., Cullen, L., Hanrahan, K., Klieber, C., McCarthy, A., Rakel, B., Steelman, V., Reimer, T. & Tucker, S. (2017). Iowa model of evidence-based practice: Revisions and validations. Worldviews on Evidence-Based Nursing (14)3, 175-182. https://doi.org/10.1111/wvn.12223 Council on Accreditation of Nurse Anesthesia Educational Programs. The value of simulation in nurse anesthesia education [position statement]. https://www.coacrna.org/wp-content/ uploads/2020/01/COA-Response-Regarding-the-Use-of-Simulation.pdf. Updated January 2020. Accessed September 2022 Chambers, P. (2020). Repeated postanesthetic laryngospasm in male adults. American Association of Nurse Anestesia (88)2. Donnelly, M. B., Horsley, T. L., Adams, W. H., Gallagher, P., & Zibricky, C. D. (2017). Effect of simulation on undergraduate nursing students' knowledge of nursing ethics principles. The Canadian Journal of Nursing Research, 49(4), 153159. https://doi.org/10.1177/0844562117731975 Gannon, W. D., Stokes, J. W., Pugh, M. E., Bacchetta, M., Benson, C., Casey, J. D., Craig, L., Semler, M. W., Shah, A. S., Troutt, A., & Rice, T. W. (2022). Simulation versus interactive mobile learning for teaching extracorporeal membrane oxygenation to clinicians: A randomized trial. Critical Care Medicine, 50(5), e415e425. https://doi.org/10.1097/CCM.0000000000005376 Laryngospasm Versus Bronchospasm High Fidelity Simulation 20 Green M, Tariq R, Green P. (2016). Improving patient safety through simulation training in anesthesiology: where are we? Anesthesiol Res Pract. 2016;2016:4237523. Doi:10.115 Gautam B, Shakya R. (2019). Anaphylactic Bronchospasm during Induction of General Anesthesia: A Case Report. JNMA J Nepal Med Assoc. 2019 Aug;57(218):2635. doi: 10.31729/jnma.4304. Epub 2019 Aug 31. PMCID: PMC8827528. Hines, R. L., & Marschall, K. E. (Eds.). (2018). Stoelting's anesthesia and co-existing disease (Seventh). Elsevier. Holley, D., Mendez, A., & Donald, C. (2019). Paroxysmal laryngospasm: Episodic closure of the upper airway. JAAPA: Official Journal of the American Academy of Physician Assistants, 32(2), 3134. https://doi.org/10.1097/01.JAA.0000552724.72939.4c 5/2016/4237523 Juang, J., Cordoba, M., Ciaramella, A., Xiao, M., Goldfarb, J., Bayter, J. E., & Macias, A. A. (2020). Incidence of airway complications associated with deep extubation in adults. BMC anesthesiology, 20(1), 274. https://doi.org/10.1186/s12871-020-01191-8 McCoy, C. E., Rahman, A., Rendon, J. C., Anderson, C. L., Langdorf, M. I., Lotfipour, S., & Chakravarthy, B. (2019). Randomized controlled trial of simulation vs. standard training for teaching medical students high-quality cardiopulmonary resuscitation. The Western Journal of Emergency Medicine, 20(1), 1522. https://doi.org/10.5811/westjem.2018.11.39040 stergaard, M. L., Rue Nielsen, K., Albrecht-Beste, E., Kjr Ersbll, A., Konge, L., & Bachmann Nielsen, M. (2019). Simulator training improves ultrasound scanning performance on patients: a randomized controlled trial. European Radiology, 29(6), 32103218. https://doi.org/10.1007/s00330-018-5923-z Laryngospasm Versus Bronchospasm High Fidelity Simulation 21 Shields, J. A., & Gentry, R. (2020). Effect of simulation training on cognitive performance using transesophageal echocardiography. AANA journal, 88(1), 5965 Vojdani S. (2018). Bronchospasm During Induction of Anesthesia: A Case Report and Literature Review. Galen Medical Journal, 7, e846. https://doi.org/10.22086/gmj.v0i0.846 Vural Doru, B., & Zengin Aydn, L. (2020). The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study. Nurse Education Today, 84 (3). 104216. https://doi.org/10.1016/j.nedt.2019.104216 Woods, B., & Sladen, R. (2009). Perioperative considerations for the patient with asthma and bronchospasm. British Journal of Anesthesia, 103 Suppl 1, i57i65. https://doi.org/10.1093/bja/aep271 Xiong, J., Sun, Y. (2019). Negative pressure pulmonary edema: a case report. BMC Anesthesiol (19)63 https://doi.org/10.1186/s12871-019-0730Yamamoto, A., Obika, M., Mandai, Y., Murakami, T., Miyoshi, T., Ino, H., Kataoka, H., & Otsuka, F. (2019). Effects on postgraduate-year-I residents of simulation-based learning compared to traditional lecture-style education led by postgraduate-year-II residents: a pilot study. BMC Medical Education, 19(1), 87. https://doi.org/10.1186/s12909-019-1509-y Laryngospasm Versus Bronchospasm High Fidelity Simulation Appendix A 22 Laryngospasm Versus Bronchospasm High Fidelity Simulation Appendix B August 1, 2022 Identified a need for education about Laryngospasm and Bronchospasm August 1-15, 2022 Literature Review Conducted August 15, 2022 Identified who needed education and how to present the Information September 20, 2022 Project Chair selected and confirmed October 1, 2022 Project Approved by Chair and Program Director October 24, 2022 Introduction, Background, Problem statement, and Needs assessment written November 14, 2022 Aims and Objectives, Theoretical concepts, Gantt Chart, and SWOT Analysis written December 5, 2022 Project Design/ Methods December 5, 2022 Evaluation Plan January 9, 2023 Revised Project Proposal January 13, 2023 IRB Submission 23 Laryngospasm Versus Bronchospasm High Fidelity Simulation March 12, 2023 Data Collection March 20, 2023 Data Analysis March 27, 2023 Complete Academic Paper Draft March 31, 2023 Complete Executive Summary April 10, 2023 Poster Presentation April 17, 2023 Final Project Report 24 Laryngospasm Versus Bronchospasm High Fidelity Simulation 25 Appendix C Strengths Access to high Fidelity Simulation Lab First year SRNA cooperation & willingness to learn First-hand access and assistance from the simulation instructor Opportunities Increased knowledge and confidence to first year SRNA students in regards to laryngospasm and bronchospasm Potential curriculum change for future cohorts Increased patient outcomes due to higher knowledge and confidence Weakness Junior SRNA time Constraints First year SRNA time Constraints Potentially small sample size Threats Skewed Data from hurried participation Limited simulation time Lack of participation in general Laryngospasm Versus Bronchospasm High Fidelity Simulation 26 Appendix D Citation Research Design & Level of Evidence Akalin, A., & Sahin, S. (2020). The impact of high-fidelity simulation on knowledge, critical thinking, and clinical decision-making for the management of pre-eclampsia. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 150(3), 354360. https://doi.org/10.1002/ijgo. 13243 Randomized control trial; level 2 Donnelly, M. B., Horsley, T. L., Adams, W. H., Gallagher, P., & Zibricky, C. D. (2017). Effect of Simulation on Undergraduate Nursing Students' Knowledge of Nursing Ethics Principles. The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres, 49(4), 153159. https://doi.org/10.1177/0844 562117731975 Randomized control trial; level 2 Vural Doru, B., & Zengin Aydn, L. (2020). The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study. Nurse education today, 84, 104216. https://doi.org/10.1016/j.ned t.2019.104216 Blani, A., Gorse, S., Roulleau, P., Figueiredo, S., & Benhamou, D. (2018). Impact of learners' role Popula tion / Sampl e size n=x Major Variables Instruments / Data collection Results n=107 The students in the experimental group attended the simulation training using a high-fidelity simulator, while the students in the control group attended only the classical training on the management of pre-eclampsia Pretest vs. posttest after intervention Knowledge (P<0.001), critical thinking (P<0.05), and clinical decision-making (P<0.05) scores of students in the experimental group increased after the simulation. n=154 Those in the experimental group participated in a 1 hour ethics consultation simulation whereas the control group watched a video. Pretest vs posttest after intervention Nursing students knowledge of nursing ethics principles significantly improved from pre-test to post-test (p = .002); however, there was no significant difference between the experimental and control groups knowledge scores (p = .13). n=72 The students in the simulation group received a cardiac auscultation training by using a high-fidelity simulator while the students in the control group received training with the traditional teaching method Knowledge Assessment Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation and State Anxiety Inventory.. It was found that the high-fidelity simulator method was more effective than the traditional teaching method to increase the students' knowledge (p = 0.001) and skill (p < 0.001) levels. n=104 The subjects were divided into Questionnaire This study suggests an immediate improvement of Randomized control trial; level 2 Randomized Laryngospasm Versus Bronchospasm High Fidelity Simulation (active participant-observer or observer only) on learning outcomes during high-fidelity simulation sessions in anesthesia: A single center, prospective and randomized study. Anesthesia, critical care & pain medicine, 37(5), 417422. https://doi.org/10.1016/j.acc pm.2017.11.016 Argalious, M., Trombetta, C., Makarova, N., Saasouh, W., & Rajan, S. (2019). Simulation Versus Problem Based Learning for Cerebrospinal Drainage Catheter Insertion and Management: A Randomized Trial in a Large Academic Anesthesiology Residency Program. Journal of cardiothoracic and vascular anesthesia, 33(4), 9931000. https://doi.org/10.1053/j.jvc a.2018.07.033 Shields, J. A., & Gentry, R. (2020). Effect of Simulation Training on Cognitive Performance Using Transesophageal Echocardiography. AANA journal, 88(1), 5965. McCoy, C. E., Rahman, A., Rendon, J. C., Anderson, C. L., Langdorf, M. I., Lotfipour, S., & Chakravarthy, B. (2019). Randomized Controlled Trial of Simulation vs. Standard Training for Teaching Medical Students High-quality Cardiopulmonary Resuscitation. The western journal of emergency medicine, 20(1), 1522. https://doi.org/10.5811/west jem.2018.11.39040 control trial; level 2 Out of 28 residents who completed the study, 13 were randomized to simulation-based learning and N = 15 residents to the traditional approach. Anesthetists non-technical skills (ANTS) global rating score. Compared to traditional learning, simulation-based learning does not result in a statistically significant improvement in anesthesia resident performance during insertion and management of cerebrospinal fluid drainage catheters. n=71 71 student registered nurse anesthetists were randomly assigned to either web-based or simulator-based TEE training Pretest/ posttest comparison post intervention Posttest scores were significantly higher in all 3 cognitive categories in the simulator group compared with the online group (P < .01. n=70 70 fourth-year medical students to either simulation or standard training. Randomized control trial; level 2 Randomized control trial; level 2 n=76 Randomized control trial; level 2 learning outcomes for both roles after immersive simulation. n=28 Randomized control trial; level 2 Yamamoto, A., Obika, M., Mandai, Y., Murakami, T., Miyoshi, T., Ino, H., Kataoka, H., & Otsuka, F. (2019). Effects on postgraduate-year-I residents of simulation-based learning compared to traditional lecture-style education led by postgraduate-year-II residents: a pilot study. BMC medical education, 19(1), 87. either an active participation role or an observer. 27 The study enrolled 76 residents, who were randomized into two groups: simulation and lecture groups. Kruskal-Walli s rank sum test pretest / posttest after intervention. Students in the SIM group performed CPR that more closely adhered to the AHA guidelines of compression depth and compression fraction There was no statistical significance in regards to improved test scores between the simulation and lecture groups. Laryngospasm Versus Bronchospasm High Fidelity Simulation 28 https://doi.org/10.1186/s129 09-019-1509-y Gannon, W. D., Stokes, J. W., Pugh, M. E., Bacchetta, M., Benson, C., Casey, J. D., Craig, L., Semler, M. W., Shah, A. S., Troutt, A., & Rice, T. W. (2022). Simulation Versus Interactive Mobile Learning for Teaching Extracorporeal Membrane Oxygenation to Clinicians: A Randomized Trial. Critical care medicine, 50(5), e415e425. https://doi.org/10.1097/CC M.0000000000005376 stergaard, M. L., Rue Nielsen, K., Albrecht-Beste, E., Kjr Ersbll, A., Konge, L., & Bachmann Nielsen, M. (2019). Simulator training improves ultrasound scanning performance on patients: a randomized controlled trial. European radiology, 29(6), 32103218. https://doi.org/10.1007/s003 30-018-5923-z Berger, C., Brinkrolf, P., Ertmer, C., Becker, J., Friederichs, H., Wenk, M., Van Aken, H., & Hahnenkamp, K. (2019). Combination of problem-based learning with high-fidelity simulation in CPR training improves short and long-term CPR skills: a randomised single blinded trial. BMC medical education, 19(1), 180. https://doi.org/10.1186/s129 09-019-1626-7 n=44 Participants were randomized to receive either simulation training, training with quizzes, or no training. The primary outcome was knowledge about extracorporeal membrane oxygenation assessed by score on the immediate post intervention written examination Simulation was superior to quiz training and no training in regards to extracorporeal membrane oxygenation knowledge acquisition. n=20 Students were randomly assigned to either the simulation-based group or no intervention. Performance scores assessed using Objective Structured Assessment of Ultrasound Skills (OSAUS) The study showed improved performance in diagnostic ultrasound scanning on patients after simulation-based mastery learning for radiology residents. n=112 The experimental group partook in a 45 minute high-fidelity CPR simulated training. Pre and post intervention questionnaire comparison of results. 51.9% of the intervention group met the criteria of sufficiently performed CPR as compared to only 12.5% in the control group on the day of the intervention (p = 0.007). Randomized control trial; level 2 Randomized control trial; level 2 Randomized control trial; level 2 Laryngospasm Versus Bronchospasm High Fidelity Simulation Appendix E PRISMA 2009 Flow Diagram 29 Laryngospasm Versus Bronchospasm High Fidelity Simulation 30 Appendix F Last 4 Digits of Badge Number: Pretest 1. On a scale 1-5, 1 being the lowest and 5 being the highest, how confident are you in identifying the difference between laryngospasm and bronchospasm? 1 2 3 4 5 2. What commonly occurs because of sensory stimulation of the vagus nerve via the internal branch of the superior laryngeal nerve? A. Laryngospasm B. Bronchospasm 3. When a bronchospasm occurs, the afferent response causes spasm and closing of the vocal cords from the external branch of both the superior laryngeal nerve and the recurrent laryngeal nerve. True or False. A. True B. False Laryngospasm Versus Bronchospasm High Fidelity Simulation 31 4. Which muscles are responsible for closing of the vocal cords during a laryngospasm? (Select 2) 5. 6. 7. A. Lateral Cricoarytenoid Muscle B. Interarytenoid C. Cricothyroid D. Thyroarytenoid Treatment for Laryngospasm include all of the following except? A. Administer 80% FIO2 B. Remove stimulus C. Larson Maneuver D. Positive pressure ventilation 10-30 cm H2O E. Succinylcholine .2-2 mg/ kg IV or 4-5 mg/ kg IM F. Deepen Anesthetic If left untreated, Laryngospasm can result in? Select 2 A. Hypoxia B. Negative- pressure pulmonary edema C. Coagulopathy D. Hypothermia What Guedel stage should a patient be extubated to prevent a laryngospasm from occurring A. Guedel Stage 1 B. Guedel Stage 2 C. Guedel Stage 3 Laryngospasm Versus Bronchospasm High Fidelity Simulation D. 8. 9. Either Guedel Stage 1 or 3 Causes of intraoperative Bronchospasm include all of the following except: A. Airway manipulation B. Chronic exposure to allergies C. Stress of surgery D. Asthmatic episode Identify signs and symptoms of Bronchospasm. (Select 2) A. Wheezing B. Low inspiratory pressures C. Decreased EtCO2 D. Decreased PACO2 10. Identify the treatment for Bronchospasm A. Administer 100% FIO2 B. Deepen Anesthetic C. Short acting B2 agonist D. Epinephrine 1 mcg/ kg E. Aminophylline F. All the Above 11. Why is use of a paralytic not a viable option for Bronchospasm treatment? 32 Laryngospasm Versus Bronchospasm High Fidelity Simulation A. They often make the bronchospasm worse B. Administration may be difficult C. Paralytics do not work on smooth muscle D. Only nebulized paralytics will be effective 12. What reversal agent is preferred in a patient with a reactive airway A. Neostigmine/ Glycopyrrolate B. Edrophonium/ Atropine C. Sugammadex 13. What Electrolyte imbalance can cause laryngospasm? Select 2 A. Hypernatremia B. Hypocalcemia C. Hypomagnesemia D. Hypercalcemia E. Hyperkalemia 14. Signs of laryngospasm include all of the following except: A. Suprasternal & supraclavicular retraction during expiration B. Rocking horse appearance of the chest wall C. Lower rib flailing D. Inspiratory stridor E. Absent or altered EtCO2 waveform 33 Laryngospasm Versus Bronchospasm High Fidelity Simulation 34 Last 4 Digits of Badge Number: Post Test 1. On a scale 1-5, 1 being the lowest and 5 being the highest, how confident are you in identifying the difference between laryngospasm and bronchospasm? 1 2 3 4 5 2. What commonly occurs because of sensory stimulation of the vagus nerve via the internal branch of the superior laryngeal nerve? A. Laryngospasm B. Bronchospasm 3. When a bronchospasm occurs the afferent response causes spasm and closing of the vocal cords to occur from the external branch of both the superior laryngeal nerve and the recurrent laryngeal nerve? True or False. A. True B. False 4. Which muscles are responsible for closing of the vocal cords during a laryngospasm? (Select 2) A. Lateral cricoarytenoid Muscle Laryngospasm Versus Bronchospasm High Fidelity Simulation B. Interarytenoid C. Cricothyroid D. Thyroarytenoid 5. 6. Treatment for Laryngospasm includes all of the following except? A. Administer 80% FIO2 B. Remove stimulus C. Larson Maneuver D. Positive pressure ventilation 10-30 cm H2O E. Succinylcholine .2-2 mg/ kg IV or 4-5 mg/ kg IM F. Deepen Anesthetic If left untreated, laryngospasm can result in? Select 2 A. Hypoxia B. Negative- pressure pulmonary edema C. Coagulopathy D. Hypothermia 7. What Guedel stage should a patient be extubated to prevent a laryngospasm from occurring? A. Guedel Stage 1 B. Guedel Stage 2 C. Guedel Stage 3 D. Either Guedel Stage 1 or 3 35 Laryngospasm Versus Bronchospasm High Fidelity Simulation 8. Causes of intraoperative Bronchospasm include all of the following except. A. Airway manipulation B. Chronic exposure to allergies C. Stress of surgery D. Asthmatic episode 9. What are the signs and symptoms of Bronchospasm? (Select 2) A. Wheezing B. Low inspiratory pressures C. Decreased EtCO2 D. Decreased PACO2 10. What is the appropriate treatment for Bronchospasm? A. Administer 100% FIO2 B. Deepen Anesthetic C. Short acting B2 agonist D. Epinephrine 1 mcg/ kg E. Aminophylline F. All the Above 11. Why is use of a paralytic not a viable option for Bronchospasm treatment A. They often make the bronchospasm worse B. Administration may be difficult 36 Laryngospasm Versus Bronchospasm High Fidelity Simulation C. Paralytics do not work on smooth muscle D. Only nebulized paralytics will be effective 12. What reversal agent is preferred in a patient with a reactive airway A. Neostigmine/ Glycopyrrolate B. Edrophonium/ Atropine C. Sugammadex 13. What Electrolyte imbalance can cause laryngospasm? Select 2 A. Hypernatremia B. Hypocalcemia C. Hypomagnesemia D. Hypercalcemia E. Hyperkalemia 14. Signs of laryngospasm include all of the following except: F. Suprasternal & supraclavicular retraction during expiration G. Rocking horse appearance of the chest wall H. Lower rib flailing I. Inspiratory stridor J. Absent or altered EtCO2 waveform 37 Laryngospasm Versus Bronchospasm High Fidelity Simulation 38 15. On a scale 1-5, 1 being the least confident and 5 being the most confident, after a high-fidelity simulation, how do you feel about identifying and treating laryngospasm and bronchospasm? 1 2 3 4 5 16. On a scale of 1-5, 1 being the least confident and 5 being the most confident, did the use of a High-Fidelity Simulation advance your understanding of Bronchospasm and Laryngospasm? 1 2 3 4 5  ...

... Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetists Tyler A Rex and Vincent S Scheuher Marian University Leighton School of Nursing ________________________________________ Date of Submission: October 28, 2023 1 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Abstract Background and Review of Literature: Operating room (OR) fires can inflict devastating harm to healthcare organizations, staff, patients, and caretakers. All perioperative staff members need specific education on preventing and managing OR fires. Student registered nurse anesthetists (SRNAs) should receive thorough fire prevention and management training during their didactic training before entering clinical rotations to increase patient and staff safety. Purpose: This is a project aimed to determine if implementing an electronic OR fire training module would increase the knowledge and confidence of first-year SRNAs attending a small private Catholic university in the mid-west before heading into their clinical rotations. Methods:81 research articles concerning current knowledge and education in OR fires were analyzed. Implementation Plan/Procedure: A pre-education intervention assessment questionnaire was completed to establish a knowledge baseline. A module was developed to provide critical education on OR fire safety, in which 34 SRNAs participated in the project. A post-education assessment questionnaire revealed increased knowledge and confidence in OR fire prevention and management. The SRNA participants also completed a modified Educational Practices QuestionnaireCurriculum Likert-scale tool that allowed them to give feedback to the course presenters regarding whether their educational needs were met. The sample population size of only 34 participants limits the interpretation of the results. Further 2 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist investigation into using electronic training modules to increase knowledge and confidence should be explored. Keywords: operating room, surgical, safety, and fire 3 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Table of Contents Abstract 2 Section I. Introduction .5 Background .5 Problem Statement ..7 Organizational "Gap" Analysis of Project Site7 Purpose Statement ..8 Section II. Theoretical Framework .8 Evidence .10 Literature Review ..10 Section III. Project Design 13 Project Site and Population ...14 Project Team .14 Goals/Objectives/Expected Outcomes ..14 Measurement Instrument ..15 Data Collection Procedure 15 Ethical Considerations/Protection of Human Subjects .....16 Section IV. Data Analysis and Results .18 Results ...18 Section V. Interpretation and Limitations .21 Interpretation of Findings ..21 Limitations.21 Section VI. Conclusion .....22 References .....24 4 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Appendices Appendix A. Iowa Model .27 Appendix B. GANTT Chart/ Timeline .28 Appendix C. SWOT Analysis .29 Appendix D. Prisma Diagram .30 Appendix E. Literature Review Matrix ...31 Appendix F. Pre-test Questionnaire 36 Appendix G. Post-test Questionnaire .38 Appendix H. Educational Practices Questionnaire-Curriculum (EPQ-C) .41 Appendix I. Modified (EPQ-C) Utilized 42 5 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Section I. Introduction Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetists Operating room (OR) fires can result in devastating outcomes for staff and patients. Approximately 550 to 650 OR fires occur yearly in the United States, but occurrences may be significantly higher because only 50% of states have mandatory reporting requirements (Clarke & Bruley, 2012). Although OR fires are infrequent, knowledge of the proper management and prevention techniques is critical. Certified registered nurse anesthetists (CRNAs) are best positioned to prevent and manage OR fires because they administer more than 50 million anesthetics per year, and most fires occur in the airway, the anesthetists' area of expertise (American Association of Nurse Anesthesiology [AANA], n.d.). As future CRNAs, student registered nurse anesthetists (SRNAs) represent the ideal population to improve patient safety regarding OR fire knowledge. Additionally, a solid understanding of the prevention and management of OR fires will decrease the response time to extinguish the fire when every second matters. Background OR fires can lead to adverse outcomes such as burns, infection, inhalational injuries, disfigurement, and death. Other complications associated with OR fires include prolonged hospital courses, psychological trauma, cancellation of surgery, and increased hospital resource use. (Apfelbaum et al., 2013). In addition, OR fires are an increasing source of liability for anesthetists, with fire-related surgical anesthesia claims increasing from less than 1% in 1985 to 4.4% by 2009 (Mehta et al., 2013). Of note, 83% of fires occurred during monitored anesthesia care (MAC) for procedures of the head, neck, and upper chest, while 17% occurred during 6 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 7 general anesthesia, usually due to an endotracheal tube cuff leak (Mehta et al., 2013). The perception of the possibility of an OR fire decreased in the late 1970s with new volatile anesthetics that were less explosive and flammable (Nagelhout, 2018). However, despite these new adjuncts of anesthesia, surgical fires remain a real danger in today's OR (Nagelhout, 2018). Therefore, the attitudes of OR staff towards OR fires remain an important consideration in the preparedness to manage a surgical fire (Cho et al., 2022). Case studies and prospective experimental design studies have been utilized to help guide the movement toward OR fire prevention. However, much of this exploratory research investigating oxygen delivery devices has demonstrated a very real cause for concern regarding OR fire risks. For example, even laser-resistant endotracheal tubes can be prone to ignite and cause an airway fire at temperatures produced by lasers and electrocautery in the presence of supplemental oxygen. In addition, these studies have shown a significant issue regarding significant oxygen leaks to closed airway systems when laryngeal mask airway devices are used in children. Finally, even though studies have experimented with different surgical draping techniques and the use of scavenging devices to reduce the oxygen concentration in the OR, the surgical drapes and sterile gowns tested by the Consumer Product Safety Commission do not meet requirements for flammability in oxygen-enriched environments (Tola et al., 2018). In 2008, the Joint Commission established OR fire reduction as the 11th National Patient Safety Goal and identified knowledge deficit as a contributing factor to OR fires (The Joint Commission, n.d.). Despite increased emphasis by the Anesthesia Patient Safety Foundation, many CRNAs are still unaware of the risks of an OR fire (Mehta et al., 2013). CRNAs and SRNAs have self-reported knowledge deficits in fire risk assessment and management, exacerbated by a lack of interest in this important topic that requires urgent intervention (Coletto Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 8 et al., 2018). To confront this shortcoming, effective communication regarding OR fire risk acknowledgment among all surgical team members is necessary (Tola et al., 2018). Coletto et al. (2018) suggest education should be the first step toward addressing this deficit. Furthermore, the Association of Perioperative Registered Nurses has taken a stand against OR fires and is playing a leading role in patient safety and education for preventing surgical fires. Their guidelines depict fire safety practices, including all possible components to the fire triangle, and focus on clear communication among staff and using a fire risk assessment tool during the surgical timeout (Tola et al., 2018). Problem Statement OR fires are a preventable problem that impacts patient safety, and CRNAs are in the most influential position to prevent and manage them. Unfortunately, SRNAs have a knowledge deficit in OR fire risk and management. Thus, they are the ideal population to target to influence the future of effective OR fire prevention and management. This knowledge deficit led to the following PICOT question: In Marian University SRNAs graduating in 2025, does the institution of an E-learning module on OR fires increase knowledge? To investigate this question, premodule test results will be compared to post-module results to determine if knowledge was significantly increased. Expanding the knowledge of SRNAs regarding OR fire prevention and management can address the increasing incidence of OR fires and knowledge deficits among SRNAs surrounding OR fires. Needs Assessment & Gap Analysis Marian University currently addresses OR fires during NSG 611: Anesthesia Principals II using PowerPoint lecture to cover chapter 47: Anesthesia and Laser Surgery in Nurse Anesthesia by Nagelhout. However, current evidence reflects that CRNAs and SRNAs report a knowledge Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 9 deficit in this area (Coletto et al., 2018). While the best practice to increase knowledge in SRNAs has not been determined, traditional textbook and lecture strategies have not successfully addressed this issue. Therefore, Marian University's nurse anesthesia program represents an opportunity for an OR fire E-learning module to improve SRNA knowledge. Project Aims and Objectives This project aimed to determine if electronic learning modules increase OR fire management and prevention knowledge amongst first-year SRNAs in a nurse anesthesia program in the mid-west. While OR fires may be considered a rare occurrence in the field of anesthesia, the outcomes can be devastating to the patient and providers both physically and mentally. The purpose of this project was to determine if a change from the current OR fire prevention and management education improves the knowledge and skill sets of first-year SRNAs and increases their overall confidence heading into clinical. An electronic learning module was completed following an anonymous pre-test survey questionnaire, and the results were compared to a posttest questionnaire. The survey questionnaire consisted of quantitative questions regarding OR fire management and prevention and six Likert scale ranking questions. The expected outcome was that most SRNAs from the nurse anesthesia program in the mid-west would demonstrate increased survey scores between the pre-test and the post-test and exhibit an increase in confidence ranking after the online education modules. Section II. Theoretical Framework Theoretical Framework The Iowa Model developed at the University of Iowa Hospitals and Clinics in the 1990s to guide research and improve patient care will be the theoretical framework for this research project (Iowa Model Collaborative, 2017). (See APPENDIX A). This model guided the process Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 10 of identifying the current knowledge gap issues surrounding OR fires, research solutions, and implementing changes. The model is a step-by-step guide that starts with identifying a trigger or issue. This step is followed by examining the priority level of the problem, forming a research team, and assembling, appraising, and synthesizing research (Iowa Model Collaborative, 2017). Once sufficient evidence has been acquired, an implementation plan will be developed with baseline data collected and compared to post-pilot data to determine if the change is appropriate for adoption into practice (Iowa Model Collaborative, 2017). The Iowa Model was used to guide this project by determining the issue of first-year SRNAs feeling underprepared regarding the management and prevention of OR fires as they transition into clinical as junior students with the current OR fire education in the curriculum. After many discussions with classmates regarding their confidence regarding OR fire knowledge, feeling underprepared was deemed an issue. Despite the rarity of OR fire occurrence, the devastation that ensues due to a lack of fire management and prevention knowledge makes it a high-level priority. As a result, a project team was developed comprised of two junior-level SRNAs, a chair, and a board member. The implementation portion of this project will include an E-learning module subjected to a small sample population consisting of first-year SRNAs at a private Catholic University in the Midwest. This project aimed to determine if the intervention would statistically improve knowledge and confidence among the sample population. Based on the study's results, it will be decided if the E-learning module should be integrated into the university's curriculum during the first year of didactic before transitioning into clinical. GANTT Chart See APPENDIX B Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 11 SWOT Analysis Key stakeholders in this project include first-year SRNAs and the patients who will benefit from safer, more knowledgeable anesthesia providers. This project's strengths include using electronic educational and survey material to increase the ease and convenience of completion and academic support from the program director. Additional strengths include the project chair being an anesthesia principles professor from the university who is well-versed in academic question design and development to assist in the survey questionnaire development. Weaknesses of this project proposal include a small sample population that may not represent the larger population. Additional barriers include limited responses from first-year participants who receive no rewards for participation. Opportunities for this project include increased knowledge and confidence for first-year SRNAs as they begin clinical rotations. Threats to this project include the willingness of students to participate in the E-learning course and the potential for students to miss key their anonymous ID numbers between the pre-test and post-test, making it difficult to compare data using paired t-tests. A table outline of the SWOT analysis can be seen in APPENDIX C. Methods This literature review was conducted to examine articles concerning operating fire safety. The review was performed using the keywords operating, room, surgical, safety, and fire. This review was conducted in November 2022 using the databases Medline-Ebsco and PubMed. The database searches were performed using the BOOLEAN phrases operating room, AND fire, AND safety, OR surgical fire. The 81 database search results were reduced to exclude duplicates, articles not written in English, and articles published greater than five years ago, resulting in 24 research articles as shown in a PRISMA flow chart (Appendix D). Inclusion criteria was used to Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 12 reduce the remaining articles further. The inclusion criteria consisted of articles reporting on operating room or surgical fire and safety and articles published over the past five years, excluding class studies. Articles that did not primarily investigate operating room or surgical fires and safety were excluded. After consideration, 11 articles and other sources were included in the literature review. Results 81 articles were initially retrieved from the literature review. After applying inclusion and exclusion criteria, the literature review yielded 11 articles. A PRISMA flow chart in Appendix E shows the inclusion and exclusion criteria. The 11 articles included two expert opinion articles and guidelines, two cross-sectional studies, six experimental studies, and one prospective cohort study. None of the studies reported theoretical frameworks to guide research. Of the final articles that included sample sizes, there were 11 articles comprising a total sample size of 589 with a range of 7 to 170 participants. These studies were conducted in the United States and Korea. The literature review matrix includes specific information about each study, shown in Appendix E. Current Knowledge The OR fire triad is a major area of focus among current literature on OR fire knowledge (Apfelbaum et al., 2013; Chavis et al., 2016; Cho & Hwang, 2022; Coletto et al., 2018; Culp & Muse, 2021; Davis et al., 2018; Fischer, 2015; Flowers, 2004; Samuels et al., 2020; Tola & Graling, 2018; & Troung, et al., 2022). The triad that enables an OR fire to occur includes an ignition source, fuel, and an oxidizer (Chavis et al., 2016). The most common ignition source is electrocautery and lasers (Chavis et al., 2016; Coletto et al., 2018; Culp & Muse, 2021). The most common oxidizer is supplemental oxygen, but nitrous oxide can also serve as a source, and the most common fuel is the surgical drapes and dressings, but it can also include hair (Coletto et Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 13 al., 2018). Team members all have a role in controlling the fire triad, where generally, the surgeon is in control of the ignition source, the anesthesia provider handles the oxidizer, and the OR nurse controls the fuel (Chavis et al., 2016; Coletto et al., 2018) Most surgical fires occur during MAC sedation because there is frequently an unprotected oxygen source, such as a nasal cannula (Samuels et al., 2020; Tola & Graling, 2018). Most fires occur during outpatient procedures, where MAC anesthetics are more common (Samuels et al., 2020; Tola & Graling, 2018). Procedures above the xiphoid process are considered a higher risk for a fire (Tola & Graling, 2018). Effective communication and the fire risk being addressed during a surgical time-out have been identified as guidelines that help reduce fire risk (Davis et al., 2018; Samuels et al., 2020). Education Due to the rarity of OR fires, educational programs tend not to emphasize fire safety and prevention (Culp & Muse, 2021). Four of the 11 articles selected for review employed an educational intervention or a pre-intervention knowledge assessment compared to a postintervention assessment (Chavis et al., 2016; Fischer, 2015; Tola & Graling, 2018; & Troung et al., 2022). Education has been identified as a useful means to increase knowledge regarding OR fires, prevention, and management (Chavis et al., 2016; Fischer, 2015; & Troung et al., 2022). Chavis et al. (2016) specifically utilized an e-learning module to implement education and found an increase in knowledge from 12.2% to 26.8%, a 14.6% increase. Knowledge retention was also measured over time, and 90 days later, knowledge was found to be 31% (Chavis et al., 2016). Another study employed a 50-question pre-test and post-test to measure fire prevention knowledge in ten anesthesia providers after implementing an educational course (Fischer, 2015). A satisfactory score on this test was 85%, and none of the participants achieved Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 14 this, with an average score of 66.60. The average post-test score was 92.80 and showed a statistically significant increase in knowledge with a p-value of 0.001 (Fischer, 2015). Troung et al. (2022) measured the confidence of OR staff in managing an OR fire before and after education and simulation-based intervention. 180 OR staff participated, and 86% reported feeling more confident if an OR fire did occur (Troung et al., 2022). One of the four studies that examined the effectiveness of an educational intervention on OR fire knowledge found that gains in knowledge from the intervention were insignificant (Tola & Graling, 2018). Tola and Graling (2018) utilized a 27-question pre-test and post-test to assess fire safety knowledge, fire prevention, and surgical fire management. The average percent correct on the pre-test was 48.82% compared to 71.88% post-test, which was insignificant, with a p-value of 0.22 (Tola & Graling, 2018). Section III. Project Design Development of a Curriculum This project aims to improve the educational practices pertaining to OR fire prevention and management to prepare SRNAs better as they transition into clinical practice to promote patient and staff safety. An E-learning module was developed using the university's current learning management system to improve SRNA knowledge and confidence in OR fires. A quantitative methods design using pre/post-tests was developed. This method design will allow for the direct comparison of data results to determine if the educational intervention successfully increased OR fire knowledge. The assessment and evaluation of the outcomes will be used to determine if a change to the current curriculum is warranted. Project Site and Population Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 15 This project was implemented at a private liberal arts university in the Midwest United States. On average, the DNP nurse anesthesia program admits 32 students per cohort every year. The structure of the DNP nurse anesthesia program is heavily frontloaded with a didactic course load during the first four semesters and backloaded with more clinical focus during the remaining five semesters of the program. Additionally, the course structure is split between hybrid online and in-person classes. Several academic faculty are remote, out of state, and teach online courses via a video chat streaming service. Simulation training begins in semester three and runs through the end of semester five. Currently, the only mention of OR fires in this program's course structure is confined to one PowerPoint presentation slide regarding ears, nose, and throat surgery in an anesthesia principles course. Furthermore, the current structure of the simulation training does not include any OR fire prevention and management scenarios to challenge and prepare the SRNAs as they transition from didactic to clinical practice. The target population for this capstone project included all first-year SRNAs from a private liberal arts university's spring class of 2025. These SRNAs were currently in their anesthesia principles courses and had not yet learned about OR fire prevention and management. Those SRNA students from the program who are not part of the 2025 class were excluded. The researchers have witnessed a lack of clinical preparedness regarding OR fire safety in the previous cohorts and aimed to improve educational processes at the university. Project Team In the spring of 2023, two SRNA students collaborated to develop an E-learning module on OR fire prevention and management. The team consisted of two SRNAs and a clinical CRNA faculty member who served as the project chair and provided validation for the knowledge Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 16 assessment questionnaire tool that was utilized. The two SRNAs developed the knowledge assessment tool using anesthesia textbooks from the National Certification Examination bibliography, administered pre and post-test surveys and interpreted the results. Methods and Measurement Instruments A pre/post-test survey questionnaire addressing the knowledge and confidence rating of OR fire prevention and management was utilized for this project. Using Qualtrics software, two questionnaires were created for the SRNAs to complete, consisting of entry-level to advancedlevel questions. Two program faculty members reviewed the questions for face validity and content validity. Both questionnaires consisted of 11 questions, including multiple-choice, select all that apply, true and false, and one Likert scale confidence ranking question. The post-test includes teaching effectiveness questions developed using the Educational Practices Questionnaire-Curriculum (EPQ-C) retrieved from https://www.nln.org/education/teachingresources/tools-and-instruments. Please see appendix (F) for the pre-test and appendix (G) for the post-test intervention questionnaire. Please see appendix (H) for the complete tool Educational Practices Questionnaire-Curriulum (EPQ-C). See appendix (I) for the modified (EPQ-C) tool utilized for this project. Data Collection Procedures In March of 2023, an email was sent out to SRNAs from the class of 2025 containing a link to the pre-test knowledge questionnaire, E-learning module, and post-test knowledge questionnaire. The knowledge assessment questionnaires were developed using Qualtrics survey software. Students were asked to complete the pre-test questionnaire prior to viewing the Elearning module and then complete the post-test questionnaire after the learning module was completed. Survey questions remained the same from the pre-test to the post-test, with five EPQ- Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 17 C Likert scale questions added to the post-test. Students were granted seven days to complete all components of the project, at which time they received an email thanking them for their participation. No student information was collected during this project. Students were asked to use the last four digits of their student ID to maintain anonymity while allowing researchers the ability to match and compare each student's pre/post-test results. Ethical Considerations Internal Review Board (IRB) approval was obtained before initiating this DNP project. This project contained no participant identifiers. Data was stored in an encrypted file on the researcher's personal laptop. Only direct members of the DNP project, including the researchers, chair, and project mentor, had access to the data. Data collection results were stored for 24 months when all project data was destroyed. Participants were all SRNAs from the private liberal arts university who were engaged in their didactic workload. All participants voluntarily participated in the project, and no financial incentives, risks, or punitive actions were taken against those who did not participate. Minimal risk to participants was expected and identified as risks related to the stress of using an E-learning module for educational purposes. The identifiable risk fell within the expected risk for all other educational structures of the university. Participants maintained confidentiality by using the last four digits of their student ID instead of their names. In addition, the Qualtrics software assisted in preserving data results' anonymity. An informed consent document was dispersed to the participants, explaining the key elements of the research project and what their participation in that project resembles, including the potential risks and benefits to participants. Furthermore, all researchers satisfactorily completed the Collaborative Institutional Training Initiative Modules pertaining to the conduction of responsible research. Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 18 Project Evaluation Plan Data results were collected utilizing Qualtrics software. The statistical measurement test employed in this project was a paired t-test. Pre-test and post-test were compared to determine if the two questionnaires had significantly higher score averages. The same pre-test and post-test surveys were used, with the exception of the five additional EPQ-C questions on the post-test questionnaire, to maintain consistent measurements. Descriptive statistics were gathered and compared between both samples. Inferential statistics using a paired t-test were analyzed and reported on. In this project, the test score was the dependent variable, and the E-learning module was the independent variable. The level of measurement for the results was interval. The data analysis program utilized for result testing was Excel. Section IV. Data Analysis and Results Results Prior Student Training on OR Fires 32 SRNAs participated in this DNP project from start to finish. All SRNAs reported having no prior training in preventing or managing OR fires. All of the participating SRNAs were currently first-year students before entering into clinical rotations. Student Participation 32 SRNAs (100%) of the first-year cohort participated in this quality improvement project, which included completing a pre-test knowledge survey, an E-learning module, a posttest knowledge survey, and the modified EPQ-C assessment tool. Demographic data, including gender, age, and race, were not collected as they were deemed irrelevant to the project. Student Self-Confidence Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 19 A comparison between the pre-test and post-test confidence ranking questions revealed a shift from 87.5% of participants feeling extremely and moderately unconfident to 83.1% feeling confident to moderately confident. The scale was as follows: 1= Extremely Confident, 2= Moderately Confident, 3= Confident, 4= Moderately Unconfident, 5= Extremely Unconfident. The median Likert scale value for the pre-test was five (extremely unconfident). The median value for the post-test was three (confident). A paired t-test revealed a statistically significant difference (p<0.001) between SRNAs pre-test confidence and their post-test confidence. See Table 1 for results on self-confidence between the pre-test and post-test. Table 1 t-Test: Paired Two Sample for Means Pretest Mean 4.5 Variance 0.516129032 Observations 32 Pearson Correlation 0.750958467 Hypothesized Mean Difference 0 df 31 t Stat 19.415596 P(T<=t) one-tail <0.001 t Critical one-tail 1.695518783 P(T<=t) two-tail <0.001 t Critical two-tail 2.039513446 Post test 2.84375 0.394153226 32 Student Knowledge All 32 participating SRNAs reported having no prior OR fire prevention and management training. A pre-test was administered before any education intervention. A systematic analysis of each question revealed a low of 3.13% (question 7) and a high of 75% (question 5) in correctness from respondents. The post-test analysis displayed a low of 25% (question 9) and a high of 100% (questions 3,4,11,12). See Appendix F for pre and post-test questions. A paired t-test was Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 20 also conducted, determining a statistical significance between the two samples (p< 0.001). See Table 2 for results on SRNA knowledge from the pre-test to the post-test. Table 2 t-Test: Paired Two Sample for Means Mean Variance Observations Pearson Correlation Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail Pretest Post-test 36.88% 79.38% 0.05984813 0.09574833 10 10 0.60461899 0 9 -5.3097115 <0.001 1.83311293 <0.001 2.26215716 Educational Practices Questionnaire-Curriculum (EPQ-C) Analysis The Educational Practices Questionnaire-Curriculum tool was modified with permission from the National League for Nursing to allow participants to evaluate aspects of the E-learning in regards to meeting their educational needs. This tool consisted of five Likert-style questions. The scale was as follows: 1=strongly disagree with the statement, 2= disagree with the statement, 3= neither agree or disagree, 4= agree with the statement, 5= strongly agree with the statement. The results range was as follows: 1-1.8=Strongly Disagree, 1.9-2.6= Disagree, 2.7-3.4= Neither agree or disagree, 3.5-4.2= Agree, 4.3-5= Strongly Agree. See Table 3 for the analysis of the EPQ-C tool. Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 21 Table 3 Educational Practices Questionnaire-Curriculum (EPQ-C) Q1 - I had an opportunity to learn how to apply course concepts to future real-life experiences. Q2 - Using learning experience activities made my learning more productive. Q3 - I could complete the coursework in a reasonable amount of time. Q4 - The objectives for the learning experience were clear and easy to understand. Q5 - The learning experience offered a variety of ways in which to learn the material. Average 3.55 3.95 4.16 4.39 4.18 Interpretation Agree Agree Agree Strongly Agree Agree Section V. Interpretations and Limitations Interpretations of Findings In this education interventional study, an OR fire e-learning module resulted in significantly higher test scores than baseline ones. The learning module also resulted in a significant change in student self-confidence in OR fire prevention and management. In addition, a curriculum analysis tool was used, which revealed the module was, on average, able to meet the learning needs of the 32 participants. Further investigations would be valuable in determining how OR fire education is addressed in the remaining 123 nurse anesthesia programs in the U.S. and comparing knowledge assessments to broaden the analysis of the effectiveness of our e-learning module. The significant results of our study suggest that future research should focus on the generalizability of our findings. Another area for future research to explore is the effectiveness of an e-learning module versus simulation education or the effect of combining both modalities. The results of our study could have implications for practice in anesthesia and in the OR. For example, our intervention was effective in students, but e-learning modules may be able to be used in hospitals to educate employees to increase knowledge, confidence, and preparedness. Limitations Some limitations of this study should be considered. First, it was relatively underpowered to conclude generalizability, with only 32 participants. A larger study would help with the Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 22 relevance of our findings. Second, follow up with participants to determine the retention of knowledge confidence and examine if a lasting impact was not feasible. Finally, the knowledge test included 11 questions that could be underpowered to extrapolate a true knowledge change. However, including a self-confidence assessment component aimed to negate this issue, and the study can serve as the basis for further investigations appropriately designed to assess lasting knowledge change. Section VI. Conclusions Conclusion OR fire safety and training is an essential piece of education that needs to be emphasized early in the SRNA's didactic workload. Incompetence related to OR fire prevention and management can have deadly consequences for our patients. Despite the relatively low reported occurrence of fires in the OR nationally, all perioperative staff members must do their part to reduce fire risks. This project was designed to determine the implications of implementing an electronic learning course to increase SRNA knowledge and confidence as they head into their clinical rotations. Prior OR fire education at this particular university was deemed insufficient amongst previous cohorts. An in-depth module was created and included a descriptive PowerPoint, ASA fire safety algorithm, videos, and case studies to allow the learners multiple ways to receive the information. An analysis of the data revealed a statistically significant improvement between pre-test knowledge and pre-test confidence ratings compared to the post-test knowledge and post-test confidence ratings. These findings reiterate the need for the university to implement a more Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist advanced OR fire education module to the current didactic regimen. Moving forward, the university could add this OR fire educational module to their anesthesia principals' materials to better prepare their students for clinical practice. 23 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 24 References American Association of Nurse Anesthesiology (AANA). (n.d.). Certified registered nurse anesthetists fact sheet. Retrieved October 8th, 2022, from https://www.aana.com/membership/become-a-crna/crna-fact-sheet Apfelbaum, J. L., Caplan, R. A., Barker, S. J., Connis, R. T., Cowles, C., Ehrenwerth, J., Nickinovich, D. G., Pritchard, D., Roberson, D. W., Caplan, R. A., Barker, S. J., Connis, R. T., Cowles, C., de Richemond, A. L., Ehrenwerth, J., Nickinovich, D. G., Pritchard, D., Roberson, D. W., & Wolf, G. L. (2013). Practice advisory for the prevention and management of operating room fires: An updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology, 118(2), 271290. https://doi.org/10.1097/ALN.0b013e31827773d2 Chavis, S., Wagner, V., Becker, M., Bowerman, M. I., & Jamias, M. S. (2016). Clearing the Air About Surgical Smoke: An Education Program. AORN Journal, 103(3), 289296. https://doi.org/10.1016/j.aorn.2016.01.007 Cho, O.-H., Lee, D., & Hwang, K.-H. (2022). Patient safety awareness, knowledge and attitude about fire risk assessment during time-out among perioperative nurses in Korea. NursingOpen, 9, 1353 1361. https://doi.org/10.1002/nop2.1180 Clarke J, Bruley M. (2012). Surgical fires: trends associated with prevention efforts. Pennsylvania Patient Safety Advisory, 9(2), 130135. Coletto, K., Tariman, J. D., Lee, Y.-M., & Kapanke, K. (2018). Perceived knowledge and attitudes of certified registered nurse anesthetists and student registered nurse anesthetists on fire risk assessment during time-out in the operating room. AANA Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 25 Journal, 86(2), 99108. Culp, W. & Muse, K. (2021). Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field. Journal of Patient Safety, 17 (8), e1846-e1850. doi: 10.1097/PTS.0000000000000665. Davis, L. B., Saxen, M. A., Jones, J. E., McGlothlin, J. D., Yepes, J. F., & Sanders, B. J. (2018). The Effects of Different Levels of Ambient Oxygen in an Oxygen-Enriched Surgical Environment and Production of Surgical Fires. Anesthesia Progress, 65(1), 38. https://doi.org/10.2344/anpr-64-04-12 Do, W., Kang, D., Hong, P., Kim, H.-J., Baik, J., & Lee, D. (2021). Incidental operating room fire from a breathing circuit warmer system: a case report. BMC Anesthesiology, 21(1), 17. https://doi.org/10.1186/s12871-021-01488-2 Fisher, M. (2015). Prevention of Surgical Fires: A Certification Course for Healthcare Providers. AANA Journal, 83(4), 271274. Flowers J. (2004). Code red in the OR -- implementing an OR fire drill. AORN Journal, 79(4), 797805. https://doi.org/10.1016/S0001-2092(06)60820-X Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223 Mehta, S. P. , Bhananker, S. M. , Posner, K. L. & Domino, K. B. (2013). Operating room fires. Anesthesiology, 118 (5), 1133-1139. doi: 10.1097/ALN.0b013e31828afa7b. Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Nagelhout, J. J. (2018). Nurse anesthesia. Elsevier. The Joint Commission. (n.d.). Hospital national patient safety goals. Joint Commission. Retrieved March 9th, 2023 from https://www.jointcommission.org/standards_information/npsgs.aspx Samuels, J. M., Carmichael, H., Wikiel, K. J., Robinson, T. N., Barnett, C. C., Jones, T. S., Jones, E. L., & Barnett, C. C., Jr. (2020). Carbon dioxide can eliminate operating room fires from alcohol-based surgical skin preps. Surgical Endoscopy, 34(4), 18631867. https://doi.org/10.1007/s00464-019-06939-z Tola, D. H., Jillson, I. A., & Graling, P. (2018). Surgical fire safety: An ambulatory surgical center quality improvement project. AORN journal, 107(3), 335344. https://doi.org/10.1002/aorn.12081 Truong, H., Qi, D., Ryason, A., Sullivan, A. M., Cudmore, J., Alfred, S., Jones, S. B., Parra, J. M., De, S., & Jones, D. B. (2022). Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training. Surgical Endoscopy, 36(5), 30593067. https://doi.org/10.1007/s00464-021-08602-y 26 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Appendix A Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223 Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 2015. For permission to use or reproduce, please contact the University of Iowa Hospitals and Clinics at 319-3849098. 27 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Appendix B 28 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 29 Appendix C Strengths Weaknesses Electronic education accessibility Small sample population size Program director reiterates project importance to first year SRNAs University anesthesia principals professor to assist with the questionnaire Opportunities Increased knowledge and confidence Improved patient outcomes related to increased knowledge and confidence Curriculum change Limited response of participants who receive no rewards for participation Threats Willingness of students to participate in the E-learning course Miss keyed anonymous ID numbers between pre and post-tests Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Appendix D From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ 30 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 31 Appendix E Citation Apfelbaum, J. L., Caplan, R. A., Barker, S. J., Connis, R. T., Cowles, C., Ehrenwerth, J., Nickinovich, D. G., Pritchard, D., Roberson, D. W., Caplan, R. A., Barker, S. J., Connis, R. T., Cowles, C., de Richemond, A. L., Ehrenwerth, J., Nickinovich, D. G., Pritchard, D., Roberson, D. W., & Wolf, G. L. (2013). Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology, 118(2), 271 290. https://doi.org/10.1097/ALN.0b0 13e31827773d2 Chavis, S., Wagner, V., Becker, M., Bowerman, M. I., & Jamias, M. S. (2016). Clearing the Air About Surgical Smoke: An Education Program. AORN Journal, 103(3), 289296. https://doi.org/10.1016/j.aorn.20 16.01.007 Research Populati Design on / & Level Sample of size Evidenc n=x e Expert Opinion Major Variables Instrume nts / Data collectio n Results 38 NA ASA Member Survey Practice advisory was created to identify situations conducive to fire, prevent OR fire occurrence s, reduce adverse outcomes, and identify the key elements of a fire response protocol. OR personn el NA Preeducatio n and posteducatio n tool A threepart elearning module was developed. LevelVII Expert Opinion LevelVII 82.9% particip ation A 14.6% increase in the usage Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 32 of smoke manageme nt systems resulted from training. Cho, O.-H., Lee, D., & Hwang, CrossK.-H. (2022). Patient safety Sectiona awareness, knowledge and l attitude about fire risk assessment during time-out Level-IV among perioperative nurses in Korea. Nursing Open, 9(2), 13531361. https://doi.org/10.1002/nop2.118 0 Coletto, K., Tariman, J. D., Lee, CrossY.-M., & Kapanke, K. (2018). Sectiona Perceived Knowledge and l Attitudes of Certified Registered Nurse Anesthetists and Student Registered Nurse Anesthetists on Level-IV Fire Risk Assessment During Time-out in the Operating Room. AANA Journal, 86(2), 99108. Culp, W. & Muse, Experim K. (2021). Preventing ental Operating Room Fires: Impact of Level-III Surgical Drapes on Oxygen Contamination of the Operative Field. Journal of Patient Safety, 17 (8), e1846- 158 Independen t- riskknowledge Dependentriskattitude 139 Attitudes, Knowledge , Years of experience, Education level, Age, Gender 30 Cotton or towel, utility, procedural, and steridrape Hospital survey on patient safety culture survey tool Knowledge had a significant effect on risk attitude (p=0.003 Fire risk assessme nt tool There was no significanc e found between the mean scores of perceived knowledge and age, gender, years of experience, and education level Fire risk knowled ge tool Cardinal oxygen Health permeabilit Guardian y varied Three significantl Liter y between Suction drapes Canister) tested. The Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist e1850. doi: 10.1097/PTS.000000000000066 5. Davis, L. B., Saxen, M. A., Jones, J. E., McGlothlin, J. D., Yepes, J. F., & Sanders, B. J. (2018). The Effects of Different Levels of Ambient Oxygen in an Oxygen-Enriched Surgical Environment and Production of Surgical Fires. Anesthesia Progress, 65(1), 38. https://doi.org/10.2344/anpr-6404-12 surgical site oxygen concentrati on ranged from 20% to 58% (P = 0.0001). 16 Temperatur e. Humidity, oxygen flow rate Fire event data collectio n The number of combustio n events with 60% oxygen was significantl y lower than with both 80% (p= .0168) and 100% (p= .002) 10 CRNAs 50question Anesthesiol knowled ogists ge assessme nt tool Paired ttest revealed a significanc e in increased knowledge (p=0.001 7 Six fire drill scenarios were developed Debriefin Staff g reported an question increase in naire confidence for handling OR fires in the future Experim ental Level-III . Fisher, M. (2015). Prevention of Surgical Fires: A Certification Course for Healthcare Providers. AANA Journal, 83(4), 271274. 33 Prospect ive Cohort Study and survey Level-II Flowers J. (2004). Code red in the OR -- implementing an OR fire drill. AORN Journal, 79(4), 797805. https://doi.org/10.1016/S00012092(06)60820-X Simulati on Study LevelIII Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Samuels, J. M., Carmichael, H., Experim Wikiel, K. J., Robinson, T. N., ental Barnett, C. C., Jones, T. S., Jones, E. L., & Barnett, C. C., Jr. Level-III (2020). Carbon dioxide can eliminate operating room fires from alcohol-based surgical skin preps. Surgical Endoscopy, 34(4), 18631867. https://doi.org/10.1007/s00464019-06939-z Tola, D. H., Jillson, I. A., & Graling, P. (2018). Surgical Fire Safety: An Ambulatory Surgical Center Quality Improvement Project. AORN Journal, 107(3), 335344. QuasiExperim ental LevelIII NA CO2 flow rate 16 NA CO2 insufflato r and smoke evacuatio n pencil 34 Carbon dioxide eliminated fire formation at a flow rate of 1 L/min with CHG-IPA skin prep (0% vs. 60% with no CO2, p < 0.0001). Carbon dioxide reduced fire formation at 1 L/min (25% vs. 47% with no CO2, p = 0.1) with Iodine-IPA skin prep and fires were eliminated at 2 L/min of flow with Iodine-IPA skin prep (p < 0.0001). 27 positive question practice knowled changes in ge participant assessme s according nt tool to surveys. Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist https://doi.org/10.1002/aorn.120 81 Truong, H., Qi, D., Ryason, A., Sullivan, A. M., Cudmore, J., Alfred, S., Jones, S. B., Parra, J. M., De, S., & Jones, D. B. (2022). Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training. Surgical Endoscopy, 36(5), 30593067. https://doi.org/10.1007/s00464021-08602-y 35 Gains in knowledge from the education program were nonsignific ant. QuasiExperim ental LevelIII 170 Surgical team members Survey, 170 simulatio (94.4%) n, and completed Presurveys. educatio Participant n and s included postsurgeons educatio (17.2%), n tool anesthesiol ogists (10.0%), allied health professiona ls (41.7%), and medical trainees (31.1%). Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 36 Appendix F Operating Room Fire Prevention and Management 1. Please list the last 4 digits of your student ID number ____ 2. Have you had prior OR fire prevention and management training? (Only on the pre-test) a. Yes b. No 3. 4. 5. 6. 7. 8. 9. Which of the following is not a component of the fire triad? a. Fuel b. Combustor c. Ignition source d. Oxidizer All of the following are potential ignition sources except? a. Desiccated soda lime b. Fiberoptic lights c. Sevoflurane at less than 2 L/min fresh gas flow d. 3-lead ECG monitor True or False: Lasers do not require direct contact with a fuel source for fire to occur a. True b. False Which of the following are correct statements on surgical fire prevention (select 2). a. Limit O2 concentration to less than 40% FiO2 when possible b. Have sterile irrigation fluid ready on the anesthesia machine c. Coat facial hair with a water-soluble lubricant during head and neck surgeries d. Administer O2 through a facemask versus a nasal cannula whenever possible Which of the following statements are true (select 2). a. Only 50% of states are required to report OR fires b. Lasers are responsible for the majority of OR fires c. Head and face are the most common site of OR fires d. Draping can occur while the alcohol-based solution is wet as long as the incision is not made until the solution has dried. e. Bowel gas is a fuel that should be considered during intraabdominal laser procedures True or False: Volatile anesthetics are nonflammable? a. True b. False Which of the following statements are correct? (Select 2) a. CO2 should be flushed over the site of the laser to separate the oxidizer from the source of ignition during airway and facial procedures b. Helium is more resistant to ignition than oxygen due to its high thermal conductivity Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 10. fire? 37 c. The presence of blood on a PVC endotracheal tube makes it susceptible to damage from the Nd: YAG laser d. The addition of methylene blue to the ETT cuff alerts the anesthetist of cuff rupture Which of the following is the first action taken by the anesthetist after a recognized airway a. Pour saline into the airway b. Remove ETT or LMA c. Turn off gas flows d. Alert the surgical team and sound the fire alarm 11. Which of the following is the most appropriate to extinguish an OR fire a. Class A-rated extinguisher b. Class B-rated extinguisher c. Class AC-rated extinguisher d. Class D-rated extinguisher 12. Which of the following is not a part of the American Society of Anesthesiologists Operating Room Fires Algorithm? a. Allow sufficient drying time for flammable skin-prepping solutions b. Avoid using ignition sources in proximity to an oxidizer-enriched atmosphere c. Moisten sponges and gauze when used in proximity to ignition sources d. Place an ETT or LMA for all high-risk cases requiring greater than 30% FiO2 13. Rate your confidence in the prevention and management of OR fires heading into clinical a. Extremely confident b. Moderately confident c. Confident d. Slightly unconfident e. Extremely unconfident Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 38 Appendix G Operating Room Fire Prevention and Management 1. Please list the last 4 digits of your student ID number ____ 2. Have you had prior OR fire prevention and management training? (Only on the pre-test) a. Yes b. No 3. 4. 5. 6. 7. 8. 9. Which of the following is not a component of the fire triad? a. Fuel b. Combustor c. Ignition source d. Oxidizer All of the following are potential ignition sources except? a. Desiccated soda lime b. Fiberoptic lights c. Sevoflurane at less than 2 L/min fresh gas flow d. 3-lead ECG monitor True or False: Lasers do not require direct contact with a fuel source for fire to occur a. True b. False Which of the following are correct statements on surgical fire prevention (select 2). a. Limit O2 concentration to less than 40% FiO2 when possible b. Have sterile irrigation fluid ready on the anesthesia machine c. Coat facial hair with a water-soluble lubricant during head and neck surgeries d. Administer O2 through a facemask versus a nasal cannula whenever possible Which of the following statements are true (select 2). a. Only 50% of states are required to report OR fires b. Lasers are responsible for the majority of OR fires c. Head and face are the most common site of OR fires d. Draping can occur while the alcohol-based solution is wet as long as the incision is not made until the solution has dried. e. Bowel gas is a fuel that should be considered during intraabdominal laser procedures True or False: Volatile anesthetics are nonflammable? a. True b. False Which of the following statements are correct? (Select 2) Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 10. fire? 39 a. CO2 should be flushed over the site of the laser to separate the oxidizer from the source of ignition during airway and facial procedures b. Helium is more resistant to ignition than oxygen due to its high thermal conductivity c. The presence of blood on a PVC endotracheal tube makes it susceptible to damage from the Nd: YAG laser d. The addition of methylene blue to the ETT cuff alerts the anesthetist of cuff rupture Which of the following is the first action taken by the anesthetist after a recognized airway a. Pour saline into the airway b. Remove ETT or LMA c. Turn off gas flows d. Alert the surgical team and sound the fire alarm 11. Which of the following is the most appropriate to extinguish an OR fire a. Class A-rated extinguisher b. Class B-rated extinguisher c. Class AC-rated extinguisher d. Class D-rated extinguisher 12. Which of the following is not a part of the American Society of Anesthesiologists Operating Room Fires Algorithm? a. Allow sufficient drying time for flammable skin-prepping solutions b. Avoid using ignition sources in proximity to an oxidizer-enriched atmosphere c. Moisten sponges and gauze when used in proximity to ignition sources d. Place an ETT or LMA for all high-risk cases requiring greater than 30% FiO2 13. Rate your confidence in the prevention and management of OR fires heading into clinical a. Extremely confident b. Moderately confident c. Confident d. Slightly unconfident e. Extremely unconfident 14. I had an opportunity to learn how to apply course concepts to future real-life experiences. 1= strongly disagree with the statement 2= disagree with the statement 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 15. Using learning experience activities made my learning more productive. 1= strongly disagree with the statement 2= disagree with the statement Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 16. I could complete the coursework in a reasonable amount of time. 1= strongly disagree with the statement 2= disagree with the statement 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 17. The objectives for the learning experience were clear and easy to understand 1= strongly disagree with the statement 2= disagree with the statement 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 18. The learning experience offered a variety of ways in which to learn the material. 1= strongly disagree with the statement 2= disagree with the statement 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 40 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist Appendix H 41 Effectiveness of Educational Modules to Increase Knowledge of Operating Room Fires in Student Registered Nurse Anesthetist 42 Appendix I Items to Rate 10. I had an opportunity to learn how to apply course concepts to future real-life experiences 14. Using learning experience activities made my learning more productive 15. I could complete the coursework in a reasonable amount of time 18. The objectives for the learning experience were clear and easy to understand 21. The learning experience offered a variety of ways in which to learn the material Use the following scoring system when rating the educational practices for your perceived agreement or disagreement of each item: 1= strongly disagree with the statement 2= disagree with the statement 3= undecided (neither agree or disagree) 4= agree with the statement 5= strongly agree with the statement NA= does not apply to learning encounter 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA 1 2 3 4 5 NA  ...