The Impact of Stress on Paramedic Performance During Simulated Critical Events

AbstractObjectivesSubstantial research demonstrates that the stressors accompanying the profession of paramedicine can lead to mental health concerns. In contrast, little is known about the effects of stress on paramedics’ ability to care for patients during stressful events. In this study, we examined paramedics’ acute stress responses and performance during simulated high-stress scenarios.MethodsTwenty-two advanced care paramedics participated in simulated low-stress and high-stress clinical scenarios. The paramedics provided salivary cortisol samples and completed an anxiety questionnaire at baseline and following each scenario. Clinical performance was videotaped and scored on a checklist of specific actions and a global rating of performance. The paramedics also completed patient care documentation following each scenario.ResultsThe paramedics demonstrated greater increases in anxiety (P < .05) and salivary cortisol levels (P < .05) in response to the high-stress scenario compared to the low-stress scenario. Global rating scores were significantly lower in the high-stress scenario than in the low-stress scenario (P < .05). Checklist scores were not significantly different between the two scenarios (P = .12). There were more errors of commission (reporting information not present in the scenario) in the patient care documentation following the high-stress scenario than following the low-stress scenario (P < .05). In contrast, there were no differences in omission errors (failing to recall information present in the scenario) between the two scenarios (P = .34).ConclusionClinical performance and documentation appear vulnerable to the impact of acute stress. This highlights the importance of developing systems and training interventions aimed at supporting and preparing emergency workers who face acute stressors as part of their every day work responsibilities.LeBlanc VR, Regehr C, Tavares W, Scott AK, MacDonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 2012;27(4):1-6.

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Stressful Life Events Are Related to More Negative Interpretations, but Not Under Acute Stress

Psychological Reports ◽

10.1177/00332941211014150 ◽

2021 ◽

pp. 003329412110141

Author(s):

Kathy Bélanger ◽

Isabelle Blanchette

Keyword(s):

Life Events ◽

Stressful Life Events ◽

Acute Stress ◽

Stressful Events ◽

Stressful Life ◽

Control Group ◽

Arithmetic Task ◽

Significant Difference ◽

Stressful Task ◽

The Impact

Studies have identified deleterious effects of stress on multiple cognitive processes such as memory and attention. Little is known about the impact of stress on interpretation. We investigated how an induced acute stress and more long-term stress related to life events were associated with interpretations of ambiguous stimuli. Fifty participants answered a questionnaire indexing the number of stressful life events. A median split was used to compare those reporting few or more events. Half of participants performed an arithmetic task that induced acute stress; they were compared to a control group performing a less stressful task. We measured the interpretation of ambiguous visual stimuli, which participants had to judge as “negative” or “positive”. We found a significant interaction between the number of stressful life events and the induced acute stress on the proportion of positive interpretations. In the control group, participants reporting more stressful events produced less positive interpretations than those reporting few events. In the induced stress condition, no significant difference was found. Life events tend to influence interpretation in the absence of an acute stressor, which seems to be more influent in the short term.

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Quality Improvement Initiatives to Improve Transfusion Safety and Efficiency for Patients Receiving Daratumumab

Blood ◽

10.1182/blood-2019-126958 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 2100-2100

Author(s):

Richard Curtis Godby ◽

Tammy Gray ◽

Hollie Christopher ◽

Lance A. Williams ◽

Marisa B. Marques

Keyword(s):

Patient Care ◽

B Lymphocyte ◽

Conflicts Of Interest ◽

Tracking System ◽

Surface Glycoprotein ◽

Reference Laboratory ◽

Major Step ◽

Clinical Scenarios ◽

Number Of Patients ◽

The Impact

Introduction: Daratumumab is an IgG1k monoclonal antibody directed against CD38, a surface glycoprotein expressed on several cell types including erythrocytes and B lymphocytes at various stages in development, including bone marrow precursors and plasma cells. It was initially approved by the FDA in 2015 for the treatment of multiple myeloma and has since garnered additional approvals in other settings leading to a growing number of patients receiving daratumumab. Its anti-B lymphocyte properties are therapeutic in myeloma patients; however, it also binds CD38 on erythrocytes and circulates for up to six months after a dose. This creates a long-term problem when caring for these patients regarding transfusion needs and resources. In particular, daratumumab causes antibody screens to be panreactive, potentially masking the presence of clinically relevant antibodies. Mitigation of this effect requires specialized treatment with dithiothreitol (DTT)-treated reagent erythrocytes to release CD38 from the cell membrane. This step allows for more accurate detection of clinically relevant antibodies, with the noted exception of the Kell system as these antigens are also removed. Methods: When daratumumab was placed on formulary, we started weekly communication between the laboratory and clinical teams in order to establish best institutional practices. Additionally, a list of patients on daratumumab was created in order to track them across the institution and measure the impact of interventions on their care. These have prompted multiple interventions to improve the safety and efficiency of patients on daratumumab receiving transfusions. Results: As of January 2018, our laboratory began implementing in-house DTT testing and eliminated the need to send patient samples to a reference laboratory. Beginning in January 2019, DTT-antibody screens (ABSC) were captured in the electronic medical record (EMR). Over the next six months, 173 distinct DTT-ABSC were performed on 41 patients. Of these, 13 received at least one RBC transfusion for a total of 41 units, with 12 (29%) occurring as an outpatient and 29 (71%) as an inpatient. Importantly, all of these transfusions were on the same-day of the DTT-ABSC, reducing the burden of time and cost associated with travel, as well as the morbidities of delayed transfusion. This is a major step forward in patient care as there were previously no "same-day" transfusions when DTT-ABSC was sent to a reference laboratory. The previous reference laboratory turnaround time averaged 1165 minutes compared with 186 minutes for the in-house testing. These initiatives have also resulted in educational efforts, such as the creation of a daratumumab-specific transfusion consent form to be signed by the attending hematologist at the time of starting therapy, outlining the challenges associated with identifying blood for transfusion and documenting that the benefits of transfusion outweigh the potential risks. This form is valid indefinitely and has subverted previous clinical scenarios where inpatients on daratumumab required urgent/emergent transfusion without an in-house hematologist available to consent for the transfusion. Because DTT also eliminates Kell antigens, clinically relevant antibodies may go undetected in samples treated with DTT. Thus, it is our policy to use Kell-negative products for patients who are on daratumumab, unless the patient expresses the Kell antigen. Conclusions/Future Directions: Daratumumab therapy is becoming increasingly common in hematology practice. Awareness of the laboratory and clinical challenges that accompany its use and working to mitigate them will lead to safer and more timely patient care. In particular, in-house DTT-ABSC has led to same-day results and transfusion on the same outpatient visit. Next steps include additional educational efforts at an institutional level, establishing simple algorithms within the EMR linked with the order for daratumumab (e.g., automatic ABSC prior to administration), and refining our tracking system to better assess future interventions. Disclosures No relevant conflicts of interest to declare.

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Designing meditation for doctor well-being: can ‘Om’ help obstetrics and gynaecology doctors?

Australasian Psychiatry ◽

10.1177/1039856219891589 ◽

2020 ◽

Vol 28 (3) ◽

pp. 342-347 ◽

Cited By ~ 1

Author(s):

Rosie Allen ◽

Andrew Robinson ◽

Shelley Allen ◽

Elizabeth Nathan ◽

Edwina Coghlan ◽

...

Keyword(s):

Stress Responses ◽

Salivary Cortisol ◽

Physiological Stress ◽

Brain Activity ◽

High Stress ◽

Depression Scale ◽

Well Being ◽

Brain Wave ◽

Obstetrics And Gynaecology ◽

The Impact

Objective: The study aimed to measure the impact of meditation on participants’ ability to regulate brain wave activity in high-stress situations, control physiological stress responses and improve subjective wellbeing. Methods: Twelve obstetrics and gynaecology (O&G) doctors meditated for 20 minutes daily for 21 days utilising a portable EEG (electroencephalogram) providing instantaneous audio feedback. Their brain activity levels and salivary cortisol were measured before and after performing three surgical procedures. Participants were interviewed about their experiences and completed self-ratings of distress (e.g. DASS-21, Depression, Anxiety and Depression Scale). Data were analysed statistically and thematically. Results: (a) Measures of pre- and post-operative brain activity showed no significantly higher levels of alpha waves. (b) Pre- and post-operative salivary cortisol levels did not significantly decrease. (c) DASS-21 scores showed significant decreases in levels of anxiety and stress. Conclusion: Results suggest that, with biofeedback meditation, O&G doctors can learn to reduce situational stress and improve mood overall through a focussed intervention.

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Female Volleyball Players Are More Prone to Cortisol Anticipatory Stress Response than Sedentary Women

Medicina ◽

10.3390/medicina55060258 ◽

2019 ◽

Vol 55 (6) ◽

pp. 258

Author(s):

Inga Dziembowska ◽

Małgorzata Wójcik ◽

Iga Hołyńska-Iwan ◽

Kamila Litwic-Kaminska ◽

Artur Słomka ◽

...

Keyword(s):

Heart Rate ◽

Stress Response ◽

Menstrual Cycle ◽

Salivary Cortisol ◽

State Anxiety ◽

Stressful Events ◽

Training Status ◽

Volleyball Players ◽

Anxiety Levels ◽

The Impact

Background and Objectives: Top-level sports performance places heavy physical and psychological demands on elite-level athletes, which can be a source of increased levels of stress. Therefore, high-level volleyball players may present altered cardiovascular and endocrinological stress response during stressful events. Although many previous studies have examined the response to stress on athletes, most of them regarded only males, while the impact of the female menstrual cycle has rarely been taken into account. We aimed to study psychophysiological response to anticipatory stressor through analysis of heart rate, self-reported anxiety level, and salivary cortisol in healthy young female athletes by minimalizing the effect of confounders. Materials and Methods: A total of 55 females (25 members of the best league for female volleyball players in Poland and 30 sedentary-lifestyle control subjects) in the follicular phase of their menstrual cycle were exposed to mental arithmetic tasks as an experimental imitation of the stressor. Volleyball players were significantly taller than sedentary individuals (177.1 ± 3.4 cm vs. 173.3 ± 3.4 cm, respectively, p = 0.034), but did not differ in weight (73.6 ± 5.2 kg vs. 70 ± 4.23 kg, respectively, p = 0.081), body mass index (BMI) (23.5 ± 1.13 vs. 24.1 ± 1.45, respectively, p = 0.060), and age (22 ± 1.11 vs. 23 ± 1.14 years, respectively, p = 0.2). Their stress responses were assessed through self-reported anxiety levels and physiological measurements of salivary cortisol concentrations and heart rate (HR). Results: For HR, significant effects of time (F(2,120) = 21.34, p < 0.001, η2 = 0.26) were found, but not for training status (F(1,60) = 2.69, p = 0.106, η2 = 0.04). For cortisol levels, the analysis showed the main effects of time (F(3,180) = 11.73, p < 0.001, η2 = 0.16) and training status (F(1,60) = 4.69, p = 0.034, η2 = 0.07) and a significant interaction between training status and time (F(3,180) = 3.07, p = 0.029, η2 = 0.05). Post-hoc analyses showed higher cortisol concentrations among volleyball players following the math task (all p < 0.001), as well as higher cortisol concentrations in S2, S3, and S4 compared to S1 in volleyball players (all p < 0.001). We observed also a significant increase in state anxiety in both groups (all p < 0.001), but no differences in state anxiety levels between groups. Conclusion: Female volleyball players may not differ in subjective graduation of stressors; however, exposure to training-based stressors seems to promote cortisol response to the anticipated stressor.

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Manipulating Levels of Socially Evaluative Threat and the Impact on Anticipatory Stress Reactivity

Frontiers in Psychology ◽

10.3389/fpsyg.2021.622030 ◽

2021 ◽

Vol 12 ◽

Author(s):

Olivia A. Craw ◽

Michael A. Smith ◽

Mark A. Wetherell

Keyword(s):

Stress Reactivity ◽

Acute Stress ◽

Stressful Events ◽

Social Evaluation ◽

Cardiovascular Stress ◽

Sampling Window ◽

Indirect Evaluation ◽

Stress Responding ◽

Assessment Window ◽

The Impact

Previous work suggests that relative increases in socially evaluative threat modulate the psychobiological stress response. However, few studies have compared stressors which manipulate the level of socially evaluative threat to which the participant is exposed. Here we present two studies. In the first, we assessed the integrity of an ecologically valid, laboratory stressor (direct socially evaluated multitasking) and its effects on acute psychobiological reactivity and ability to evoke an anticipatory response prior to participation. Specifically, we assessed whether the expectation and experience of direct social evaluation (multitasking while standing and facing an evaluator) evokes greater reactivity than indirect evaluation (over-the-shoulder evaluation). In the second study, we sought to replicate the findings regarding acute stress reactivity whilst extending the assessment window to assess the extent to which the stressor evokes anticipatory responses. As hypothesized, greater reactivity was observed following direct social evaluation compared with indirect observation. Increases in anxiety, heart rate and blood pressure were demonstrated across both studies and the paradigm therefore provides an ecologically valid technique for the activation of psychological and cardiovascular stress responding. Additionally, anticipation of experiencing socially evaluated multitasking led to increases in anxiety, tension, and worry prior to the event itself, supporting previous suggestions that threat anticipation may prolong the activation of stress mechanisms. In the present studies we assessed whether the expectation and experience of direct social evaluation evokes greater reactivity than indirect evaluation. The findings have demonstrated that direct social evaluation of multitasking is a more potent stressor than multitasking with indirect evaluation. Furthermore, our findings indicate that the period of anticipation of stressful events may be critical to understanding the process of stress regulation, and as such we recommend extending the sampling window to allow for the investigation of these processes.

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Measuring clinical pathway compliance using a simulated patient approach with clinical performance and value (CPV) vignettes.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.31_suppl.96 ◽

2013 ◽

Vol 31 (31_suppl) ◽

pp. 96-96 ◽

Cited By ~ 1

Author(s):

Karen K. Fields ◽

Hatem Hussein Soliman ◽

Eliot Lawrence Friedman ◽

Rachel V. Lee ◽

Maria Czarina Acelajado ◽

...

Keyword(s):

Quality Of Care ◽

Clinical Performance ◽

Clinical Pathways ◽

Cancer Center ◽

Axillary Lymph Nodes ◽

Axillary Lymph ◽

Medical Oncologists ◽

Clinical Scenarios ◽

The Impact

96 Background: Although clinical pathways have the promise to improve the quality of care, they have had limited success changing practice or standardizing care. Moffitt Cancer Center (MCC) has > 40 pathways incorporating interdisciplinary care strategies linked to evidence and decision support tools. Methods: To improve compliance with pathways we used an innovative measure to quantify quality of care, CPV vignettes. CPV vignettes are validated, simulated clinical scenarios constructed so that adherence to pathways is clear-cut. Providers care for identical cases so there is no need for case mix adjustment. After completing each case, providers are given personalized feedback. Twelve breast cancer (ca) vignettes were developed by MCC breast medical oncologists and surgeons and QURE, a healthcare measurement company. The cases were developed using MCC pathways, other evidence and core issues such as diagnostic work-up. The vignettes were randomized at the department level and given to all MCC providers who care for breast ca patients. A total of 18 providers took 34 CPVs: 7 medical oncologists, 6 advanced practitioners and 5 surgeons. QURE-trained physician abstractors blinded to the CPV-taker’s identity scored each vignette and provided confidential feedback. Results: Total scores for providers averaged 55.4%, s.d. 12.5%, a typical score for a CPV baseline study. Adherence to pathways varied by area with the highest concordance for radiation and hormonal therapy and the lowest for management of axillary lymph nodes (see Table). Conclusions: Adherence to pathways varied among providers and by clinical domain. Ongoing efforts will evaluate the impact of serial CPV measurement on pathway adherence. Simulations simplified the task of determining pathway adherence making pathway compliance at the physician level a reasonable expectation and standardization at the group level scientifically rigorous and feasible. [Table: see text]

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