Journal of Emergency Medicine, Trauma and Acute Care - 3 - Qatar Health 2020 Conference abstracts, January 2020

Welcome to this special issue of the Journal of Emergency Medicine, Trauma and Acute Care (JEMTAC) dedicated primarily to Qatar Health 2020 Conference and presenting a selection of abstracts on various topics in response to a late call for free paper oral or poster presentation submissions (Table 1). Qatar Health 2020 was a collaborative event between Hamad Medical Corporation and the Qatar Ministry of Public Health, chaired by Dr. Abdul Wahab Al Musleh and organized as a multidisciplinary academic meeting open to healthcare professionals and experts from different backgrounds and countries. The theme of the congress was “Mass gatherings Healthcare Services: Emergency and Disaster Management” in preparation for the FIFA World Cup 2022 and also concentrates on presenting best practices and evidence of a trauma system approach to mass casualty events.

Hosting one of the most popular sporting events in the world is a significant undertaking that requires a lot of preparation at a national level to ensure the well-being of athletes, supporters, and various professional groups and volunteers supporting such activity, whilst also still providing the required services to the rest of the population. Mass gathering medicine is defined as “the public health challenges to hosting events attended by a large enough number of people, at a specific site, for a defined period of time, likely to strain both the planning and response to the mass gathering of a community, state, or nation.”¹ Whether it is in relation to the potential spread of infectious diseases, terrorist attacks, or accidents, medical preparedness and emergency response are key^2,3. The range of submissions received for Qatar Health 2020 in connection with the known and potential impact of mass gatherings in terms of healthcare response is a testimony of the importance of good preparation which involves a significant ramp up in healthcare manpower and physical resources, public health campaigns, interagency collaboration, considerations for the environmental and cultural context, and exercises to test and rehearse plans (Table 2).

This special issue also includes two abstracts from the first Qatar Trauma Nurse Symposium which took place at the end of 2019 and was jointly organized by the Trauma Nursing Department and the Nursing and Midwifery Education and Research Department of Hamad Medical Corporation under the leadership of Ms. Asmaa Mosa Al-Atey.

Finally, we would like to close this editorial by wishing success to the resurging JEMTAC journal and congratulating all participants that made Qatar Health 2020 Conference and the Qatar Trauma Nurse Symposium such successful events. We look forward to featuring the work presented at future events held in Qatar as well as full articles directly submitted to the journal for Open Access publication. The Editorial Board will endeavor within the next couple of years to make it a regular publication with good quality and informative contents for everyone interested in emergency medicine, trauma, acute and pre-hospital care.

Background: A major incident is defined as any incident or event which due to its size, nature, and/or complexity, is likely to cause serious disruption to services and would potentially overwhelm the Hamad Medical Corporation Ambulance Service (HMCAS) or one or more of HMC's hospitals as a result. Such an incident requires a coordinated response from multiple agencies including HMC (as well as corporate departments), other healthcare services and hospitals (Qatar Red Crescent), various police forces, and the Qatar Civil Defense (1).

Identified issues: HMCAS defines three primary goals of managing a major incident¹

1. the greatest good for the greatest number

2. scarce resources

3. not relocate the disaster by transporting all victims to one hospital.

Some common challenges faced by pre-hospital care providers in major incident management are summarized in Table 1. If these challenges are not overcome, this will cause the possibility of increasing the numbers of victims, delaying their first aid, and impact on their rapid transportation at the most appropriate healthcare facility. Results: Qatar, as the organizer of a major event such as the 2022 FIFA World Cup, expects approximately 1.3 million visitors³, which leads to the formation of mass gatherings in many areas such as stadiums, fan zones, hotels, malls, metro stations, and the airport. One of the duties of HMCAS is planning and preparing for any major incident and address the potential challenges which are listed in Table 1. Some of the proposed solutions and procedures to confront them are presented Table 2. Conclusion: Major incidents are generally overwhelming for any healthcare system. Regular staff training, good planning, and ensuring effective communication within the entire Service is necessary to ensure the provision of care to the greatest number of victims and transfer them to hospitals appropriate to their condition. HMCAS is already implementing the suggested solutions in preparation for the 2022 FIFA World Cup.

Background: Triage of victims in mass casualty incidents (MCI) is crucial in prioritizing care and allocating resources¹. Triage skills are important to be evaluated for training and better preparedness. Using clinical vignettes is a well-known approach to evaluate clinicians’ knowledge and decision-making². This study aims to evaluate preparedness of emergency residents and fellows to triage victims of MCI. Methods: Emergency Medicine (EM) residents and fellows at Hamad General Hospital, Emergency Department (HGH-ED) were invited to the study. Each participant filled a questionnaire followed by triaging of 15 vignette-based victims of MCI. Descriptive statistics elaborated on participants’ training and relevant exposures (Table 1). It also showed the degree of agreement in their triage results and rates of under-triage and over-triage. Cohen's kappa coefficient showed inter-rater agreement and internal consistency in triage results. Results: Participants included 63 emergency trainees, 27 residents, and 36 fellows. Only 28.3% (n = 17) of them participated in an MCI drill over the past two years. 51.7% (n = 31) attended training on triage in MCI. 73.3% (n = 44) indicated that they have rarely or never triaged victims in a real MCI or a drill. Only 3.3% (n = 2) perceived themselves as highly confident in triaging victims of MCI. A total of 904 triage outcomes resulted from this exercise (Table 2). The overall rate of agreement among the triage outcomes is 73% (660 times in 904 triage outcomes). The rate of over-triage was 36.8% and 23% under-triage. Conclusion: Better triage results was associated with previous triage training. The rate of over-triage was as the literature recommends. However, the rate of under triage was alarmingly higher than the literature recommendation as < 5%³. The higher rate of under-triage imposes a risk of missing seriously injured victims, which may lead to higher mortality or poor patients’ outcomes. Further training and exercises may be the key to saving more lives and resources.

Background: A mass gathering (MG) is defined as a collection of at least 1000 people at a single location over one to several days or weeks¹. Potential sites for a disaster include festivals, sporting events, conventions, refugee camps, globalization by travel, and might involve a wide range of age groups. The potential number of patients and illnesses or injuries is affected by environmental, biochemical, and psychological factors. Identified issues: Children are vulnerable to higher rates of illnesses or injuries due to multiple factors such as their anatomical and physiological differences in comparison to adults², lower motor and cognitive skills, and inability to know how and when to escape from danger. Children emergency cases are challenging and difficult to handle for healthcare providers in MG incidents due to some factors such as lack of pediatric cases, lack of training and experience in dealing with children, unfamiliarity with using the special equipment for treating children, communication barriers, the absence of a caregiver or personal identification card, inability to provide medical and allergic histories. The use of personal protective equipment can also complicate the assessment and treatment process as it may frighten children. In preparation for the FIFA World Cup 2022 in Qatar the figures to take into consideration are presented in Table 1. We aim to propose strategies to enhance the safety and care of children involved in MGs. Results: Although they represent a very small proportion of the population in Qatar, children need special strategies from an emergency management viewpoint³ which we are proposing in Table 2. Adequate preparation is the responsibility of pre-hospital and emergency department healthcare providers, children healthcare agencies, and emergency managers. Conclusion: Several factors make children more vulnerable in mass gatherings incidents and this needs to be considered in emergency preparedness. A multi-disciplinary management team approach should be emphasized, developed, and disseminated through continuing professional development courses.

Background: Mass gathering is a risk factor for infectious diseases transmission. Therefore, rapid detection of infections is highly desirable. The current gold standard approach to detect bacterial infections in clinical samples (biological fluids) requires three days of bacterial culture to obtain the diagnosis and antibiotic sensitivity results¹. This approach, although very accurate results in considerable delay in initiating proper treatment which increases the transmission of infection, mainly hospital-acquired infections. Therefore, rapid detection of infection would lead to rapid clinical interventions, which mitigate the spread of infection and support antibiotic stewardship consequently reducing the burden of hospital-acquired infections. The goal of this research is to develop a highly innovative sensor (point-of-care device) for rapid detection of bacterial infections in biological fluids. This project will also focus on identifying unique SERS spectra of bacterial infections commonly associated with mass gathering and early detection of antibiotic resistant bacteria. Methods: The proposed biosensor is a culture-free diagnostic method utilizing nanotechnology-based fabricated silver nanorod arrays (AgNR) as a substrate for the Surface Enhanced Raman Spectroscopy. Results: We reported the proof-of-concept study using this novel SERS-based diagnostic where we showed that rapid detection of bacterial biomarkers in sputum and exhaled breath condensates (EBC) from patients with cystic fibrosis^2,3. We further identified unique SERS spectra of various bacterial siderophores and small molecule metabolites. Conclusion: This method is highly sensitive, fast, cheap, and can be implemented at the bedside using a portable (hand-held) Raman spectroscope.

Background: Point-of-care testing (POCT) facilitates rapid decisions by performing tests near or at the patient side. POCT integration accelerates clinical decisions and enhances patients’ standard of care in emergency settings. POCT positively influences patient care especially during life-threatening situations or in the operating rooms and critical care areas as it enables the rapid provision of information related to blood gases and electrolytes. Such a process reduces Therapeutic Turnaround Time (TTAT) and pre-analytic and post-analytic testing errors ¹. Methods: POCT has been implemented across Hamad Medical Corporation (HMC) Emergency Departments and Critical Care Units in line with applicable hospital regulations and accreditation requirements. The aim of this project was to standardize blood gas analyzer methods and processes over all HMC facilities. The POCT team worked according to the College of American Pathologists (CAP) standards and regulations and selected the most advanced technologies available on the market for integration of the equipment on the HMC network while enabling for remote-access. This has been achieved by ensuring full connectivity integration to the hospitals Laboratory Information System (LIS). Training programs have been conducted to ensure that only competent and certified staff are authorized to perform patient testing in the Emergency Departments and Critical Care Units ². Results: A total of 80 blood gas analyzers have been installed including 47 analyzers in Emergency Departments and Critical Care Units. During the period from August 2018 up to August 2019, 179,659 tests were performed by 3123 different operators including nurses, respiratory therapists, and perfusionists. The POCT system detects, troubleshoots, and minimizes errors by continuous monitoring of Quality Key Indicators (QKI). Conclusion: Successful implementation of POCT for blood gas analysis enabled rapid, accurate, and cost-effective patient testing. Furthermore, POCT of blood gases in emergency areas has reduced process complexity and improved operational workflow and led to an enhanced lean process.¹ Effective communication through electronic documentation, quality assessment, and ongoing monitoring by the POCT team in parallel with healthcare providers who are performing bedside POCT will achieve compliance with international standards for emergency and critical care areas.

Background: Hamad Medical Corporation Ambulance Service (HMCAS) Emergency Medical Dispatch Center uses protocols and processes ensuring early recognition and early telephone CPR (T-CPR) for Sudden Cardiac Arrest (SCA) reported by the public through 999 emergency lines. An audit of random sampling cases indicated that the average time to start bystander hands-on CPR varies from 5 to 7 minutes. Consequently, a quality improvement plan was designed and launched in the Emergency Dispatch Center of HMCAS for the aim of improving the average time interval from when the call is answered by an Emergency Medical Dispatcher until the caller starts hands-on CPR. The project aimed to improve the average telephone-CPR time initiation from 5 minutes in January 2018 to 3 minutes by July 2019. Methods: We adopted the American Heart Association Telephone Cardiopulmonary Resuscitation Time standards and performance benchmarks¹. A cardiac registry was implemented, audio recordings of confirmed Out of Hospital Cardiac Arrests (OHCA) received at 999 Emergency Dispatch Center were reviewed using a standardized time-stamp methodology linked with the Ambulance Service outcome data. All call takers went through training and continuous measurement of their performance levels with timely feedback. Results: Out of 214,220 received emergency calls in 2018 a total of 697 OHCA cases were audited, 332 cases received T-CPR, 231 cases met the criteria for inclusion. By July 2019, there was a reduction in Average telephone-CPR time interval from 5:38 minutes to 3:33 minutes (Figure 1). Conclusion: The implementation of T-CPR time standards and staff training was associated with improvements in the provision and timeliness of T-CPR.

Background: Temperature, among several environment conditions like humidity, is known to impact medicine stability1,2. In emergency medical service (EMS) settings, it is often challenging to control these conditions. In the GCC region including Qatar, temperature and relative humidity values may rise over 50°C and 80%, respectively, according to climate data from the Qatar Civil Aviation Authority3. The aim of this systematic review is to collate and analyze data on the stability of EMS medicines exposed to temperature excursions beyond recommended limits (20-25°C with excursions up to 15-30°C) and provide evidence-based best practice recommendations on storage of medicines in EMS settings. Method: Literature on stability studies in EMS settings were obtained from PubMed, Embase, Web of Science and grey literature. Data from articles that met inclusion and exclusion criteria were collected using developed data collection forms then analyzed following PRISMA statement. The quality of articles were assessed using the Health Evidence Tool. Results: Thirteen studies were included (Table 1). Results were variable depending on the region and whether the study was done in an EMS setting or simulated in laboratory. Studies affirmed that medicines were exposed to temperatures beyond limits in EMS settings (Table 2). Medicines recommended to be refrigerated were not stable in a temperature-dependent manner. Although many medicines were stable, temperature-sensitive medicines degraded faster, while extreme cold produced various effects. No study has explored the biological effects of degradation and degradation products. Conclusion: EMS medicines are exposed to temperature extremes which may affect their stability and decrease their shelf-life. Therefore, routine stability testing during storage, replacement of exposed medicines and inclusion of temperature monitoring devices are paramount to validate the content of EMS medicines administered to end-users. We aim to collaborate with Hamad Medical Corporation Ambulance Service in Qatar to study the stability of EMS medicines in several settings including ambulances and paramedic bags of indoor and outdoor bike units.

Background: Currently, Tuffier's line is considered the standard level for spinal anesthesia. Incorrect determination of this line may result in iatrogenic spinal cord injury¹. The current study aims to compare the accuracy of the ultrasound versus clinical determination of the spinal level^2,3, using X-ray as the standard for comparison. Methods: This prospective, randomized and controlled study included 200 adult patients of both genders and all classes of the American Society of Anesthesiologists (ASA). After approval of the Local Ethics Committee and securing informed consent, they were randomized into two equal groups. Patients in the Clinical Group (Group C) were examined by clinical landmarks to assess the Assumed Clinical Tuffier's Line (ACTL). Midpoint of ACTL was marked with a radio-opaque marker and then the True Clinical Tuffier's Line (TCTL) was determined using Fluoroscopy (Figure 1). Patients in the Ultrasound Group (Group U) were examined using ultrasound machine to determine the Ultrasound Tuffier's Line (USTL). The results of both groups were compared with the Radiological Tuffier's line (RTL) from plain X-rays done for both groups. Results: Results are presented in Table 1. In Group C, the ACTL accurately correlated with TCTL in only 12% of the patients. It correlated one space cephalad at L3-4 space (67%), at L3 spine (13%) and two spaces cephalad at L2-3 space (7%) and at L2 spine (1%). In Group U, the UTL accurately correlated in 78% of the patients. It corresponded cephalad to L3-4 space (16%) and to L3 spine (4%) and caudad to L5 spine (2%). Conclusion: Ultrasound examination of the spine is recommended in patients planned for spinal anesthesia, as it is superior to clinical assessment in determining the lumbar interspinous level which will minimize the possibility of iatrogenic spinal cord injury.

Background: Performing a sciatic nerve block on trauma patients unable to be positioned in lateral or prone position is difficult, hence the anterior approach is better in such cases¹. Using blind nerve stimulation has more risk of nerve trauma². The aim of the current study was to compare block of the sciatic nerve with regards to the ease of performance, reliability and safety through the anterior approach by two methods; the first being the nerve stimulator guided approach and the second being ultrasound guided³. Methods: 36 adult patients were randomly allocated equally into two main groups: “Nerve Stimulator-Guided Group (NSG)” where the nerve was located by nerve stimulator only. “Ultrasound guided group (USG)” where the sciatic nerves were blocked by a stimulated needle under guidance of the ultrasound (Figure 1). Assessment of performing each technique, sensory and motor blockades, occurrence of acute systemic toxicity and hematoma formation were compared. Results: Results are shown in Table 1. Only one-third of the sciatic nerves could be visualized by ultrasound. This did not affect the block execution time but caused a statistically significant smaller number of needle passes. Sensory and motor block showed significant differences between the two groups. Criteria of acute systemic toxicity and occurrence of hematoma were not reported in both groups. Conclusion: Results of the current study showed that the addition of ultrasound to nerve stimulator in the anterior approach to the sciatic nerve block added only little to the ease of performance, reliability, and safety of the procedure. This was because only one-third of the nerves could be seen. More practice, better machines, and new blocking techniques may be needed to overcome the problem of visualizing the nerve.

Background: Pain is a leading cause of visits to any emergency department (ED) and a large percentage of it is primarily caused by musculoskeletal trauma, however there has been a lack of use of analgesia in a large proportion of these patients¹. Tramadol is a common choice among emergency residents due to the rare incidence of respiratory depression during its administration, low incidence of cardiac depression, and the incidence of dizziness and drowsiness is lower than when morphine is administered^2,3. We aim to determine whether subcutaneous tramadol administration has a lower incidence of adverse events and pain score associated with administration in comparison to intravenous tramadol. Methods: Single-center randomized parallel group trial of subcutaneous (S/C) versus intravenous (IV) tramadol as analgesia for extremities injuries with moderate pain. Both groups received a single dose of 50 mg tramadol and reassessed at 15, 30, 45, 60 minutes. Results: A total of 232 patients were studied, and divided into group A (IV tramadol) and group B (S/C) (Table 1). There was higher incidence of adverse events in the IV group at 0, 15 and 30 minutes of administration and higher mean pain score associated with administration in the IV group. These adverse effects include nausea, vomiting, giddiness, dizziness, and allergic reactions. The total number of patients developing adverse effects was 34 of 112 patients in the intravenous group as compared to 14 of 120 patients in the subcutaneous group (Figure 1). Conclusion: S/C tramadol has less adverse effects and causes less pain as compared to IV tramadol in managing moderate pain with extremities injuries and could be considered for pain relief in mass casualty incidents.

Background: Cardiovascular disease is the number one killer in Qatar¹. Cardiac rehabilitation (CR) is a secondary prevention model of care for cardiac patients. It is well-documented that CR reduces cardiovascular morbidity and mortality by 20%². However, CR is underutilized worldwide, with low enrolment and adherence rates³. This study aims to investigate factors associated with enrolment and adherence, and to examine the relationship between adherence and change in cardiac risk factors. Methods: There were 714 cardiac patients, aged ≥ 18 years, referred to a CR program in Qatar. Retrospective cohort study using data from (January 2013-September 2018) were analyzed. Logistic regression models were used to assess factors associated with enrolment, adherence, and predictors of adherence. A paired sample t-test was used to identify mean change in cardiac risk factors: body mass index, low-density lipoprotein, high-density lipoprotein and total cholesterol) pre/post-CR. An independent sample t-test was used to identify change between groups (adherents vs. non-adherents). Results: The majority of our patients were males (n = 641, 89.8%) and non-Qatari (n = 596, 83.5%), i.e., similar to the Qatar population profile of 75% males and 15% Qatari, one fourth were smokers (n = 185, 25.91%), and one fifth (n = 128, 18.8%) were diagnosed with severe depression. Significant patient factors positively associated with enrolment (p < 0.05) were nationality, percutaneous coronary intervention (PCI), coronary artery bypass grafting, and coronary artery disease (Table 1). The number of sessions attended by patients is shown in Figure 1. Patients with American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) moderate and high-risk levels were more likely to adhere compared to those with low risk. Percutaneous coronary intervention (PCI) and musculoskeletal disease were negatively associated with adherence (Table 1). We found clinically significant health improvements among adherents compared to non-adherents; reduction of 10% in cholesterol, and 15% in LDL (low-density lipoprotein). Conclusion: This study provides new insights into the factors that lead patients to enrol in and adhere to CR in the Qatar setting. These factors represent opportunities for targeted interventions to improve CR utilization.

Background: The ‘Act FAST’ campaign is a major international stroke prevention program aiming to raise knowledge and awareness of stroke signs and symptoms and encouraging calling emergency medical service (EMS) providers as soon as symptoms are recognized.¹ We aim to evaluate the impact of the campaign by analyzing EMS stroke calls in Qatar as studies on the impact of such initiative on behavioral response at onset are limited.²Methods: This is a retrospective time series evaluation utilizing monthly Hamad Medical Corporation (HMC) EMS call data for strokes in Qatar. HMC Ambulance Service (HMCAS) uses the Medical Priority Dispatch System (MPDS) and International Academies of Emergency Dispatch (IAED) protocols. Emergency calls are thoroughly analyzed for stroke diagnosis. We will evaluate pre- and post-campaign the relative change in stroke calls volume and classify them into true stroke and stroke mimic calls based on Emergency Department and Stroke Unit data, and make a comparison in total proportion of true stroke calls. We will perform multivariable regression to measure the effect of campaign exposure on the volume of stroke-related calls and also describe any significant association between specific patient characteristics with increased ambulance usage, after controlling for confounders. Anticipated results: Following the signs and symptoms of the stroke awareness campaign and suggested behavioral response at stroke onset, a relative increase in the number of stroke calls to EMS is expected as reported by Bray et al., following a similar campaign in Australia³. Conclusion: The impact of the Act FAST stroke campaign on the population of Qatar will be determined by evaluating a relative change in stroke calls post-campaign and misclassifications. The percentage change in false alarms and calls without stroke specific symptoms in a population group will help identify campaign related contributing factors thereby providing evidence to tailor future campaigns.

Background: Experiential learning is the backbone of many healthcare professional education programs¹, and the quality of experiential learning is dependent on the skills, experiences, and proficiency of the clinical preceptors who largely contribute to this experience². Preceptors should ideally possess both clinical practice and teaching skills; however, preceptors often do not possess formal training as educators³. This research was conducted at Qatar University with the aims of identifying preceptors’ educational needs and developing the skills by designing an educational professional development program called: “The Practice Educators’ Academy”. Methods: A mixed-methods triangulation study design was applied to identify preceptors’ educational needs quantitatively through a validated survey sent to preceptors (n = 325), and qualitatively by conducting 11 focus groups with preceptors (n = 20), students (n = 42), and clinical faculty members (n = 7). Quantitative and qualitative data in addition to an extensive literature review were used in designing the academy by an inter-professional healthcare and educational team. Results: Principles of learning theories, planning for experiential learning, teaching strategies, students’ assessment and feedback, and communication skills for effective preceptorship and conflict resolution were the key domains expressed as preceptors’ educational needs. A five-module program syllabus was designed to meet these needs while benchmarking it with international preceptors’ educational development programs to achieve generalizability. The designed syllabus was critically examined and validated by national and international health professional education scholars. Table 1 demonstrates the validated syllabus. Conclusion: “The Practice Educators’ Academy” syllabus is the first intervention nationally and regionally for preceptors to be better equipped with skills and knowledge required for their role as clinical educators, which will enrich the internship experiences of students. With that, preceptors can better prepare competent health profession graduates that will advance healthcare outcomes and meet the healthcare needs of Qatar society and ultimately contribute to achieving Qatar National Vision 2030.

Background: The healthcare domain is undergoing a major shift towards electronic health records (EHR) and data management as illustrated by the global trend in Figure 1 with a shift over recent times from passive technology adopters towards more investigators and explorers. There is a vital need for a universal patient record in a distributed ledger and new approaches to ensure collaborative health when we can manage our own wellness outside of the system to improve outcomes and contain healthcare costs^1,2. There are a few immediate needs to address which are patient-centric management regarding high incidence chronic diseases and identification and optimization of at-risk parameters. Methods: This is an ideation for exploring “Blockchain” implementation to match the correct individual to their health data which is critical to their medical care. It is recognized that a significant proportion of EHR are not accurately matched within the same healthcare system³ and this hinders critical success factors such as effective patient management, patient satisfaction, and continuity of quality care (Figure 2). Results: The following outcomes and advantages are expected to be delivered for patient care records management offering transparent and verifiable records which are encrypted to provide streamlined clinical data flow benefitting patients. Core benefits also include enhancing transparency to patients, reducing threats of hacking, increasing patient records safety, eliminating workarounds, and minimizing IT expenditures and downtimes. Conclusion: As a promising breakthrough, this idea should result in patients no longer needing to perform the tedious task of gathering records from various providers. Instead patients would only need to provide access to their health blockchain, hence retaining control of their data and not spending time and energy keeping their data up to date1.

Background: Over the years, the fragmented traditional risk management approach was replaced by a holistic view that is commonly identified by the literature as enterprise risk management. The comprehensive and integrative characteristic of this approach requires good communication through a reliable risk management information system to improve performance as well as provide an overall cost reduction by automating routine tasks and synchronising risk management efforts across the entire organisation. So far in healthcare, no risk analysis tool has been developed to proactively analyse and visualise risks in a comprehensive way¹. Methods: The suitability of the bowtie method in healthcare risk analysis, control, follow up, and communication was assessed using a qualitative literature review process. Results: Based on the fault tree and event tree analyses, and the Swiss cheese model, the bowtie method was developed as a proactive barrier-based risk management tool (Figure 1) to be used for visual risk assessment of critical events related to the core operations in many high-reliability industries^1,2. Bowties were used to support medication errors investigation and analysis, provide a standard for audit, improve surgical operations and intensive care unit safety, and minimise surgical instrument retention risks. Acquiring a risk management platform has the capacity to improve performance through integrated and reliable systems^1,2. Conclusion: The development and appropriate use of the bowtie method have the potential to improve process safety and achieve operational excellence, and communicate in a clear and accessible manner the best practice for a holistic risk management approach^1,3. The bowtie simplifies the complexity of daily risks to a manageable size without losing the context. A bowtie platform is a value adding advancement to create an overview of an organisation's risks and how they are managed and communicated on all levels of the operational phase to cover the whole spectrum of enterprise risk management domains².

Background: The Trauma Center of Hamad Medical Corporation (HMC), Qatar, aims to develop highly skilled specialized trauma nurses. The American Trauma Society highlights the importance of specialty courses for the professional development of trauma nurses¹. All HMC trauma nurses are mandated to attend the Advanced Trauma Care Nursing (ATCN) course. While, this course focuses on the trauma golden hours and the life threating injuries, there is no coverage on the daily and long term trauma specialty practices. HMC designed a trauma specialty programme and embedded the immersive simulation and debriefing method, a high fidelity simulation through case based teaching2,, 3,, 4. In this study we aim to evaluate the effectiveness of the programme design. Methods: A four day trauma specialty programme was designed in an active form of learning through case based high fidelity simulation. A skills assessment checklist and nine case based simulation scenarios were developed. A structured learning conversation and debriefing sessions were established after each scenario^2,3. To assess the effectiveness of the program design, a retrospective survey was conducted for trauma nurses (n = 75) who attended the programme. Results: For the trauma specialty education programmes, the learning through immersive simulation and debriefing method is an effective, dynamic, and active form of learning (Table 1). There was a significant improvement in the competency level of the trauma nurses’ specialty skills (long term and daily basis skills) (Table 1). Conclusion: Having a trauma educational specialty programme is essential for the trauma nurses’ professional development. The immersive simulation method is an effective method for the trauma specialty educational courses, as it; improves trauma nurse's knowledge and skills, and it is an active form of education.

Background: The prone ventilation technique has been newly adopted by HMC (Hamad Medical Corporation). The literature has revealed the effectiveness of the prone position technique to improve ventilation and oxygenation in traumatic and acute respiratory distress syndrome (ARDS) cases ¹. The prone ventilation technique is a step before deciding a higher medical escalation ¹. There were only a few trained and competent trauma critical care nurses on the prone ventilation technique within HMC, and the frequency of this procedure was increasing in the critical care trauma settings. The need arose to train more health professionals on prone position ventilation technique. A one-day prone position ventilation educational course was designed incorporating the immersive simulation approach (case based –high fidelity simulation). Methods: In March 2018 HMC critical care and trauma leadership decided to design a course on prone position ventilation technique. The course curriculum was designed to incorporate high fidelity immersive simulation training. A skills assessment checklist was designed. Two case based simulation scenarios were developed, and to be followed by debriefing sessions^2,, ³. A retrospective explorative survey was conducted for 100 nurses to evaluate the effectiveness of the course design. Results: Applying the immersive simulation in the prone ventilation course was effective as an interactive and dynamic learning and teaching method (Table 1). Furthermore, there was significant improvement in the skills and knowledge of HMC trauma nurses regarding the prone position ventilation technique (Table 1). Learning through reflection and debriefing was an effective approach for deep learning and knowledge retention. Discussion & conclusion: Having trained and competent healthcare practitioners on prone position ventilation is important to maintain patient safety and to improve patient outcomes. Applying case based immersive simulation is an effective method for prone position education. The high fidelity immersive simulation enhances the dynamic learner's engagement and reflective learning.