Oral Themed Presentation


Interrelation between performance scores and stress markers and its evolution during repetitive simulations

Tuesday, May 15
11:00 - 12:30
Location: Jupiter 1&2

Background: : The safety of a patient in vital distress depends on the healthcare providers’ performance under stress conditions. The relation between stress and performance has been described by different models like the Yerkes-Dodson law. However, to our knowledge, there exist no data on the evolution of this interrelation during repetitive high-fidelity simulations (HFS).

Research Question: : 1) To assess technical and non-technical performances, and stress response over one year; 2) To evaluate the evolution of the interrelation between performance scores and stress markers.

Methodology: : IRB approval by the University Hospital of Poitiers, France, and INSERM-CIC 1402 (Research Institute). RCT number: NCT02424890.19. 48 participants were randomized in 12 MDTs of French EMS (4 members: physician/PGY/nurse/ambulance driver). MDTs were randomized in 2 groups to manage infant shock in HFS. In the experimental group 6 MDTs were exposed to 9 different scenarios over 1 year. In the control group, 6 MDTs had only 3 scenarios, which were common to those of the experimental group (initial, intermediate after 6 months and final after 1 year). Technical performance was assessed by the intra-osseous (IO) access performance scale [2] and the Team Average Performance Assessment Scale (TAPAS) [3]; non-technical performance by the Behavioral Assessment Tool (BAT) for leaders and the Clinical Teamwork Scale (CTS). Stress was assessed by Holter monitoring (heart rate (HR), and heart rate variability (HRV): pNN50 and LF/HF). Parameter evolution over time was analyzed by RM-ANOVA. p <0.05 was considered significant.

Results: : Stress increased during repetitive HFS in the two groups (p<0.001 for all parameters). Performances scores significantly increased in the experimental group (p=0.04 for TAPAS, p=0.03 for IO and BAT, p=0.007 for CTS). There was no variation of performances scores in the control group.

Discussion/Conclusions: : Relationship between performance and stress is defined by an Inverted-U curve known as the Yerkes-Dodson Law [4]: stress improves performance up until a maximum point, and subsequently alters performance. In the experimental group, stress and performance increased, meaning that the repetition of the sessions every 6 weeks led to displacement on the ascending phase of the curve. In the control group, only stress increased, with a similar level of performance when simulation was repeated every 6 months, meaning that the curve was shifted to the right. These results suggest that the interrelation between performance scores and stress markers could be variable depending on the frequency of repetition of simulations over time.

Daniel Aiham Ghazali

Simulation Center, University of Paris-Diderot, Paris, France

Dr Daniel Aïham GHAZALI, MD, PhD
Emergency Department and EMS, University Hospital of Bochat, Paris, France
Simulation Center of Paris-Diderot University, Paris, France

Post Doctorate in SImulation
Reserach on teamwork and relationship between stress and performance

Teaching in the University of Poitiers (Pediatric Emergency) and in the University of Paris-Diderot (Emergency)

Publications in Education, Emergency, Critical care, and Pediatric journals


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Catherine Allan, MD

Associate Program Director - Simulator Program
Boston Children's Hospital
Boston, Massachusetts

Catherine Allan, MD is the Associate Program Director of the Simulator Program and Medical Director of the Cardiac Intensive Care Unit at Boston Children’s Hospital. Over the last 10 years she has helped to develop a robust, interdisciplinary program in ECMO Simulation at Boston Children’s Hospital. Dr. Allan has translated this model to other insitutions on both a National and International level to help these programs build new clinical ECMO Programs. She has published on the use of ECMO Simulation Skills Training and on clinical outcomes following ECMO support in the congenital heart disease population and has presented on ECMO simulation at multiple National and International Meetings.


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Interrelation between performance scores and stress markers and its evolution during repetitive simulations

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