Asheen Rama

All Publications

• Pro-Con Debate: Virtual Reality Compared to Augmented Reality for Medical Simulation. Anesthesia and analgesia Caruso, T. J., Rama, A., Uribe-Marquez, S., Mitchell, J. D. 2024

  View details for DOI 10.1213/ANE.0000000000007057

  View details for PubMedID 39424614

• A Quality Improvement Project to Improve the Utilization of an Intraoperative Rapid Response System. Pediatric quality & safety Rama, A., Qian, D., Forbes, T., Wang, E., Knight, L., Berg, M., Caruso, T. J. 2023; 8 (6): e686

  Abstract

  Rapid response teams (RRTs) improve morbidity by reducing the incidence of cardiac arrests. Although providers commonly activate RRTs on acute care wards, they are infrequently used perioperatively. At our institution, two intraoperative calls for help exist: staff assists (SAs) and code blues (CBs). The SA functions analogously to an RRT, and the CB indicates cardiopulmonary arrest. Given the success of RRTs, this project aimed to increase the use of the SA system. Our primary goal was to increase the ratio of SA to CB alerts by 50% within 6 months.A quality improvement team led this project at an academic pediatric hospital in Northern California. The team analyzed the current state and identified an achievable goal. After developing key drivers, they implemented monthly simulations to teach providers the signs of clinical deterioration and to practice activating the SA system. In addition to measuring the ratio of SA to CB alerts, the team surveyed the etiologies of SA and measured process satisfaction.Before the introduction of this initiative, the ratio of SA to CB alerts were 1:13.3. These improvements efforts led to an increase of SA to CB alerts to 1.5:1 (P = 0.0003). Twenty-three anesthesiologists provided etiologies for SA, reporting laryngospasm as the most common reason (30.4%). Nineteen nurses completed the SA survey and reported high satisfaction.This project successfully increased the utilization of a rapid response protocol in a pediatric perioperative setting using improvement methodologies and a simulation-based educational program.

  View details for DOI 10.1097/pq9.0000000000000686

  View details for PubMedID 38089833

  View details for PubMedCentralID PMC10715782

• Enhancing Telemedicine Perioperative Simulations Using Augmented Reality. The journal of education in perioperative medicine : JEPM Rama, A., Tsai, A. H., Caruso, T. J. 2023; 25 (3): E711

  View details for DOI 10.46374/volxxv_issue3_Rama

  View details for PubMedID 37720372

• Virtual Immersion into a Poorly-Managed Medical Crisis Worsens Subsequent Performance: A Randomized, Controlled Trial CLINICAL SIMULATION IN NURSING Rama, A., Neiman, N., Burdsall, K., Fonseca, A., Lee, C., Domingue, B., Jackson, C., Caruso, T. J. 2022; 70: 47-55

  View details for DOI 10.1016/j.ecns.2022.06.008

  View details for Web of Science ID 000834629800001

• Assessing Pediatric Life Support Skills Using Augmented Reality Medical Simulation With Eye Tracking: A Pilot Study. The journal of education in perioperative medicine : JEPM Qian, J., Rama, A., Wang, E., Wang, T., Hess, O., Khoury, M., Jackson, C., Caruso, T. J. 2022; 24 (3): E691

  Abstract

  Background: Augmented reality (AR) and eye tracking are promising adjuncts for medical simulation, but they have remained distinct tools. The recently developed Chariot Augmented Reality Medical (CHARM) Simulator combines AR medical simulation with eye tracking. We present a novel approach to applying eye tracking within an AR simulation to assess anesthesiologists during an AR pediatric life support simulation. The primary aim was to explore clinician performance in the simulation. Secondary outcomes explored eye tracking as a measure of shockable rhythm recognition and participant satisfaction.Methods: Anesthesiology residents, pediatric anesthesiology fellows, and attending pediatric anesthesiologists were recruited. Using CHARM, they participated in a pediatric crisis simulation. Performance was scored using the Anesthesia-centric Pediatric Advanced Life Support (A-PALS) scoring instrument, and eye tracking data were analyzed. The Simulation Design Scale measured participant satisfaction.Results: Nine each of residents, fellows, and attendings participated for a total of 27. We were able to successfully progress participants through the AR simulation as demonstrated by typical A-PALS performance scores. We observed no differences in performance across training levels. Eye tracking data successfully allowed comparisons of time to rhythm recognition across training levels, revealing no differences. Finally, simulation satisfaction was high across all participants.Conclusions: While the agreement between A-PALS score and gaze patterns is promising, further research is needed to fully demonstrate the use of AR eye tracking for medical training and assessment. Physicians of multiple training levels were satisfied with the technology.

  View details for DOI 10.46374/volxxiv_issue3_qian

  View details for PubMedID 36274998

• A Pilot Quality Improvement Project to Reduce Intraoperative MRI Hypothermia in Neurosurgical Patients. Pediatric quality & safety Wong, B. J., Rama, A., Caruso, T. J., Lee, C. K., Wang, E., Chen, M. 2022; 7 (2): e531

  Abstract

  Intraoperative hypothermia increases patient morbidity, including bleeding and infection risk. Neurosurgical intraoperative magnetic resonance imaging (iMRI) can lead to hypothermia from patient exposure and low ambient temperature in the MRI suite. This quality improvement project aimed to reduce the risk of hypothermia during pediatric neurosurgery laser ablation procedures with iMRI. The primary aim was to increase the mean lowest core temperature in pediatric patients with epilepsy during iMRI procedures by 1 °C from a baseline mean lowest core temperature of 34.2 ± 1.2 °C within 10 months and sustain for 10 months.Methods: This report is a single-institution quality improvement project from March 2019 to June 2021, with 21 patients treated at a pediatric hospital. After identifying key drivers, temperature-warming interventions were instituted to decrease hypothermia among patients undergoing iMRI during neurosurgery procedures. A multidisciplinary team of physicians, nurses, and MRI technologists convened for huddles before each case. Interventions included prewarmed operating rooms (ORs), blanket coverings, MRI table and room; forced-air blanket warming, temperature monitoring in the OR and iMRI environments; and the MRI fan turned off.Results: Data were analyzed for five patients before and nine patients after the institution of the temperature-warming elements. The sustainment period included 15 patients. The mean lowest intraoperative temperature rose from 34.2 ± 1.3 °C in the preintervention period to 35.5 ± 0.6 °C in sustainment (P = 0.004).Conclusion: Hybrid OR and MRI procedures increase hypothermia risk, which increases patient morbidity. Implementation of a multidisciplinary, multi-item strategy for patient warming mitigates the risk.

  View details for DOI 10.1097/pq9.0000000000000531

  View details for PubMedID 35369418

• The Physiologic and Emotional Effects of 360-Degree Video Simulation on Head-Mounted Display Versus In-Person Simulation: A Noninferiority, Randomized Controlled Trial. Simulation in healthcare : journal of the Society for Simulation in Healthcare Caruso, T. J., Armstrong-Carter, E., Rama, A., Neiman, N., Taylor, K., Madill, M., Lawrence, K., Hemphill, S. F., Guo, N., Domingue, B. W. 2021

  Abstract

  INTRODUCTION: A key simulation component is its capability to elicit physiological changes, improving recall. The primary aim was to determine whether parasympathetic responses to head-mounted display simulations (HMDs) were noninferior to in-person simulations. The secondary aims explored sympathetic and affective responses and learning effectiveness.METHODS: The authors conducted a noninferiority trial. Hospital providers who did not use chronotropic medications, have motion sickness, or have seizures were included. The authors randomized participants to in-person or HMD simulation. Biometric sensors collected respiratory sinus arrhythmia and skin conductance levels to measure parasympathetic and sympathetic states at baseline, during, and after the simulation. Affect was measured using a schedule. The authors measured 3-month recall of learning points and used split-plot analysis of variance and Mann-Whitney U tests to analyze.RESULTS: One hundred fifteen participants qualified, and the authors analyzed 56 in each group. Both groups experienced a significant change in mean respiratory sinus arrhythmia from baseline to during and from during to afterward. The difference of change between the groups from baseline to during was 0.134 (95% confidence interval = 0.142 to 0.410, P = 0.339). The difference of change from during the simulation to after was -0.060 (95% confidence interval = -0.337 to 0.217, P = 0.670). Noninferiority was not established for either period. Sympathetic arousal did not occur in either group. Noninferiority was not established for the changes in affect that were demonstrated. The mean scores of teaching effectiveness and achievement scores were not different.CONCLUSIONS: Although a parasympathetic and affective response to the video simulation on an HMD did occur, it was not discernibly noninferior to in-person in this study.

  View details for DOI 10.1097/SIH.0000000000000587

  View details for PubMedID 34120135

• Individualized simulations in a time of social distancing: Learning on donning and doffing of an COVID-19 airway response team. Journal of clinical anesthesia Rama, A. n., Murray, A. n., Fehr, J. n., Tsui, B. n. 2020; 67: 110019

  View details for DOI 10.1016/j.jclinane.2020.110019

  View details for PubMedID 32862074

• Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation. Pediatric quality & safety Rama, A., Knight, L. J., Berg, M., Chen, M., Gonzales, R., Delhagen, T., Copperman, L., Caruso, T. J. 2019; 4 (6): e222

  Abstract

  Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

  View details for DOI 10.1097/pq9.0000000000000222

  View details for PubMedID 32010849

• Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team. Pediatric quality & safety Caruso, T. J., Rama, A. n., Knight, L. J., Gonzales, R. n., Munshey, F. n., Darling, C. n., Chen, M. n., Sharek, P. J. 2019; 4 (3): e172

  Abstract

  Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

  View details for DOI 10.1097/pq9.0000000000000172

  View details for PubMedID 31579871

  View details for PubMedCentralID PMC6594783