The Impact of Stress and Distraction on Bag-Valve-Mask Ventilation Performance

Stress and distraction are intrinsic to the emergency department (ED). These factors can invoke a physiologic response, potentially leading to performance decrements in life-saving procedures like bag-valve-mask (BVM) ventilation. The aim of this study is to use a simulation scenario for two reasons: (1) to evaluate how stress and distraction impact emergency medicine (EM) residents' physiology; (2) to evaluate how these factors impact BVM ventilation performance. Our hypothesis is that both factors will cause performance decrements, with stress causing increased ventilations and distraction causing disengagement and reduced ventilations.

Four EM residents were subjected to a simulation scenario comprised of three phases: (1) baseline (no stress or distraction); (2) stress (increased alarm/alerts); and (3) distraction (multiple disruptions caused by simulation center staff). Throughout the simulation each subject wore a physiologic monitor that recorded their heart rate (HR) and electrodermal activity (EDA). A high-fidelity manikin was utilized to record the BVM ventilation performance. The manikin recorded the number of ventilations delivered, duration of the ventilation and the peak inspiratory pressure (PIP) of each ventilation. To standardize physiological measures deviations of each data source relative to an algorithm-derived baseline/resting state was calculated.

The average number of ventilations per minute during phase (1) was 12.5, (2) was 16, and (3) was 11.9. The average PIP (cmH₂O/mL) delivered during phase (1) was 15.5, (2) was 24.4, and (3) was 22.3. Percent deviation from baseline for HR ranged from 16.9% to 38.4%, with three out of four EM residents having greater change during distraction. EDA data showed a 25-190.3% deviation from base line, with three out of four EM residents having the greatest deviation during the distraction phase.

Stress and distraction both had an impact on subject's physiologic stress response and BVM performance. While the stress phase caused the highest performance decrements, the distraction phase was associated with the more significant physiologic response and self-reported impact.