Immersive virtual reality-based training improves response in a simulated operating room fire scenario

A Systematic Review of Immersive Virtual Reality for Nontechnical Skills Training in Surgery

OBJECTIVE

Immersive virtual reality (IVR) can be utilized to provide low cost and easily accessible simulation on all aspects of surgical education. In addition to technical skills training in surgery, IVR simulation has been utilized for nontechnical skills training in domains such as clinical decision-making and pre-operative planning. This systematic review examines the current literature on the effectiveness of IVR for nontechnical skill acquisition in surgical education.

DESIGN

A literature search was performed using MEDLINE, EMBASE, and Web of Science for primary studies published between January 1, 1995 and February 9, 2022. Four reviewers screened titles, abstracts, full texts, extracted data, and analyzed included studies to answer 5 key questions: How is IVR being utilized in nontechnical skills surgical education? What is the methodological quality of studies? What technologies are being utilized? What metrics are reported? What are the findings of these studies?

RESULTS

The literature search yielded 2340 citations, with 12 articles included for qualitative synthesis. Of included articles, 33% focused on clinical decision-making and 67% on anatomy/pre-operative planning. Motion sickness was a recorded metric in 25% of studies, with an aggregate incidence of 13% (11/87). An application score was reported in 33% and time to completion in 16.7%. A commercially developed application was utilized in 25%, while 75% employed a noncommercial application. The Oculus Rift was used in 41.7% of studies, HTC Vive in 25%, Samsung Gear in 16.7% of studies, Google Daydream in 8%, and 1 study did not report. The mean Medical Education Research Quality Instrument (MERSQI) score was 10.3 ± 2.3 (out of 18). In all studies researching clinical decision-making, participants preferred IVR to conventional teaching methods and in a nonrandomized control study it was found to be more effective. Averaged across all studies, mean scores were 4.33 for enjoyment, 4.16 for utility, 4.11 for usability, and 3.73 for immersion on a 5-point Likert scale.

CONCLUSIONS

The IVR nontechnical skills applications for surgical education are designed for clinical decision-making or anatomy/pre-operative planning. These applications are primarily noncommercially produced and rely upon a diverse array of HMDs for content delivery, suggesting that development is primarily coming from within academia and still without clarity on optimal utilization of the technology. Excitingly, users find these applications to be immersive, enjoyable, usable, and of utility in learning. Although a few studies suggest that IVR is additive or superior to conventional teaching or imaging methods, the data is mixed and derived from studies with weak design. Motion sickness with IVR remains a complication of IVR use needing further study to determine the cause and means of mitigation.

Airway fires in otolaryngologic surgery: A database review

PURPOSE

An estimated 34 % of reported operating room fires involve the airway. Despite the inherent risks in otolaryngologic surgery, education regarding prevention and management of airway fires is limited in graduate medical training. One contributing factor is a lack of reporting of such rare events in our literature.

METHODS

The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of adverse events related to fires occurring during surgical procedures of the airway from January 1, 2010, to March 31, 2020.

RESULTS

3687 reports were identified and 49 unique reports of airway fire were included. Sustained fires were described in 16 (32.7 %) reports and 33 (67.3 %) described transient flares. 2 fires extended beyond the airway and 9 (18.4 %) were noted to have occurred at the start of the case. Fires were reported most commonly during tonsillectomy (n = 22 [44.9 %]), vocal fold excision (n = 5 [10.2 %]), and adenoidectomy (n = 4 [8.2 %]). 46 reports attributed flare initiation to a specific element of the fire triangle. 16 patient and 2 operator injuries were reported. Saline washing was utilized in 7 (14.3 %) cases overall. Patients were extubated immediately in 2 (12.5 %) of the 16 reports of sustained fires. 0 mortalities were reported.

CONCLUSION

Airway fires were reported in a variety of upper airway procedures performed regularly by otolaryngologists. The triggering factor that led to fire was identified as a spark or char in about half of the reported cases, and only 2 reports described immediate removal of the endotracheal tube.

Virtual simulation and problem-based learning enhance perceived clinical and cultural competence of nursing students in Asia: A randomized controlled cross-over study

BACKGROUND

Both clinical and cultural competencies are of paramount importance in ensuring patients' safety and high-quality care. While problem-based learning (PBL) is a widely applied pedagogy in nursing education, an emerging technology-based pedagogy, virtual simulation provides a realistic clinical learning experience for students. It can be an effective solution for continuing clinical and cultural learning across countries in the era of the pandemic.

OBJECTIVES

This study aimed to compare the effectiveness of virtual simulation and PBL on the perceived clinical and cultural competence for nursing students.

DESIGN

A randomized controlled cross-over study design was used.

SETTINGS AND PARTICIPANTS

Sixty-one undergraduate and postgraduate nursing students from five Asian regions were selected for participation.

METHODS

Participants were randomized to receive either virtual simulation (group A) or PBL (group B) for one day, followed by another intervention on the second day. Three self-reported questionnaires were used: Clinical Competence Questionnaire (CCQ), Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals-Student Version (IAPCC-SV), and demographic questionnaire.

RESULTS

The results revealed that students in both arms had significant improvements in CCQ total score (A: d = 21.500, P < 0.001; B: d = 16.710, P = 0.001), nursing professional behavior (A: d = 8.233, P < 0.001; B: d = 6.323, P < 0.001), and advanced nursing skills (A: d = 2.533, P = 0.008; B: d = 2.129, P = 0.029) after two interventions. In addition, both arms demonstrated significant improvements in IAPCC-SV total score (A: d = 3.467, P = 0.037; B: d = 4.032, P = 0.010) and cultural skills (A: d = 0.767, P = 0.012; B: d = 1.000, P = 0.001). No significant differences were observed between the two arms.

CONCLUSIONS

The findings indicated that both virtual simulation and PBL were effective in promoting students' perceived clinical and cultural competence. As both education modes have their own uniqueness and effectiveness in both outcomes, the combination of both could enhance the variability of learning modalities. Notably, the use of virtual simulation first could engage students better in learning and achieve better educational outcomes.

Learning about Victims of Holocaust in Virtual Reality: The Main, Mediating and Moderating Effects of Technology, Instructional Method, Flow, Presence, and Prior Knowledge

The goal of the current study was to investigate the effects of a virtual reality (VR) simulation of Anne Frank’s hiding place on learning. In a 2 × 2 experiment, 132 middle school students learned about the living conditions of Anne Frank, a girl of Jewish heritage during the Second World War, through desktop VR (DVR) and head-mounted display VR (HMD-VR) (media conditions). Approximately half of each group engaged in an explorative vs. an expository learning approach (method condition). The exposition group received instructions on how to explore the hiding place stepwise, whereas the exploration group experienced it autonomously. Next to the main effects of media and methods, the mediating effects of the learning process variables of presence and flow and the moderating effects of contextual variables (e.g., prior technical knowledge) have been analyzed. The results revealed that the HMD-VR led to significantly improved evaluation, and—even if not statistically significant—perspective-taking in Anne, but less knowledge gain compared to DVR. Further results showed that adding instructions and segmentation within the exposition group led to significantly increased knowledge gain compared to the exploration group. For perspective-taking and evaluation, no differences were detected. A significant interaction between media and methods was not found. No moderating effects by contextual variables but mediating effects were observed: For example, the feeling of presence within VR can fully explain the relationships between media and learning. These results support the view that learning processes are crucial for learning in VR and that studies neglecting these learning processes may be confounded. Hence, the results pointed out that media comparison studies are limited because they do not consider the complex interaction structures of media, instructional methods, learning processes, and contextual variables.

Simulation training results in performance retention for the management of airway fires: A prospective observational study

Given the severity of the consequences of operating room fires, it is recommended that every anaesthesiologist master fire safety protocols and periodically participate in operating room fire drills. The aim of the present study was to evaluate skill retention one year after an airway fire training programme. Anaesthesiology residents were evaluated using an airway fire simulation-based scenario one year after an educational programme that included a one-h long problem-based learning session, a simulation-based airway fire drill with debriefing, and a formal group discussion. The same simulation scenario was used for both the initial training and the one-year assessment. Thirty-eight anaesthesiology residents participated as pairs in the initial training programme. Of these, 36 participated in the evaluation a year later. Performance after one year was better than performance during the initial simulation. Time to removal of tracheal tube was 7.0 (4.0-12.8) s (median (interquartile range)) at the one-year assessment compared with 22.0 (18.5-52.5) s at the time of initial training (P < 0.001). Performance improvement was also demonstrated by a higher incidence of performance of crucial action items (cessation of airway gases, removal of sponges and pouring of saline), as well as shorter duration of time necessary to perform these tasks. After controlling the fire, the time to re-establish ventilation by bag-mask ventilation or intubation was shorter at one year: 18.0 (11.0-29.0 ) s, compared with initial training 54.0 s (36.2-69.8) s (P = 0.001). We conclude that skills are effectively retained for a year after an airway fire management training session.

Virtual Reality Head-Mounted Displays in Medical Education: A Systematic Review

SUMMARY STATEMENT

Simulation-based training using virtual reality head-mounted displays (VR-HMD) is increasingly being used within the field of medical education. This article systematically reviews and appraises the quality of the literature on the use of VR-HMDs in medical education. A search in the databases PubMed/MEDLINE, Embase, ERIC, Scopus, Web of Science, Cochrane Library, and PsychINFO was carried out. Studies were screened according to predefined exclusion criteria, and quality was assessed using the Medical Education Research Study Quality Instrument. In total, 41 articles were included and thematically divided into 5 groups: anatomy, procedural skills, surgical procedures, communication skills, and clinical decision making. Participants highly appreciated using VR-HMD and rated it better than most other training methods. Virtual reality head-mounted display outperformed traditional methods of learning surgical procedures. Although VR-HMD showed promising results when learning anatomy, it was not considered better than other available study materials. No conclusive findings could be synthesized regarding the remaining 3 groups.

Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training

BACKGROUND

Operating room (OR) fires are rare but devastating events requiring immediate and effective response. Virtual Reality (VR) simulation training can provide a safe environment for practice of skills in such highly stressful situation. This study assessed interprofessional participants' ability to respond to VR-simulated OR fire scenarios, attitudes, numbers of attempt of the VR simulation do participants need to successfully respond to OR fires and does prior experience, confidence level, or professional role predict the number of attempts needed to demonstrate safety and pass the simulation.

METHODS

180 surgical team members volunteered to participate in this study at Beth Israel Deaconess Medical Center, Boston, MA. Each participant completed five VR OR simulation trials; the final two trials incorporated AI assistance. Primary outcomes were performance scores, number of attempts needed to pass, and pre- and post-survey results describing participant confidence and experiences. Differences across professional or training role were assessed using chi-square tests and analyses of variance. Differences in pass rates over time were assessed using repeated measures logistic regression.

RESULTS

One hundred eighty participants completed simulation testing; 170 (94.4%) completed surveys. Participants included surgeons (17.2%), anesthesiologists (10.0%), allied health professionals (41.7%), and medical trainees (31.1%). Prior to training, 45.4% of participants reported feeling moderately or very confident in their ability to respond to an OR fire. Eight participants (4.4%) responded safely on the first simulation attempt. Forty-three participants (23.9%) passed by the third attempt (VR only); an additional 97 participants (53.9%) passed within the 4-5th attempt (VR with AI assistance).

CONCLUSIONS

Providers are unprepared to respond to OR fires. VR-based simulation training provides a practical platform for individuals to improve their knowledge and performance in the management of OR fires with a 79% pass rate in our study. A VR AI approach to teaching this essential skill is innovative, feasible, and effective.

Advances and safe use of energy devices in lung cancer surgery

Objectives

A clear understanding of energy devices would help achieve high effectiveness and safety and guide the selection of devices. The present review aimed to elucidate the efficacy and adverse events of energy devices in lung cancer to guide the selection of appropriate devices depending on the situation.

Methods

Four major databases were searched electronically for relevant articles published until 16 April 2021. The reference lists of the identified papers were examined. We excluded (1) irrelevant studies, (2) manuscripts published in languages other than English and Japanese, (3) duplicates, and (4) studies for which the full text was not available in the databases. The results and key information obtained were summarized by means of a narrative approach.

Results

A total of 78 papers were included in the review and these were categorized according to the main topic of investigation as follows: (1) electrosurgery-related injuries, (2) fundamentals of electrosurgery, (3) monopolar devices, (4) bipolar electrosurgical devices, (5) ultrasonic energy devices, (6) energy devices in lung cancer surgery, (7) operating room fire risks, and (8) basic principles of surgery.

Conclusions

Understanding energy devices could help us use them in a more effective and safer manner. Knowledge of their selection criteria (suitability), merits, risks, and safety precautions relevant to each process of lung cancer surgery could guide appropriate selection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11748-022-01775-w.

Virtual Reality Simulation for Disaster Preparedness Training in Hospitals: Integrated Review

BACKGROUND

A critical component of disaster preparedness in hospitals is experiential education and training of health care professionals. A live drill is a well-established, effective training approach, but cost restraints and logistic constraints make clinical implementation challenging, and training opportunities with live drills may be severely limited. Virtual reality simulation (VRS) technology may offer a viable training alternative with its inherent features of reproducibility, just-in-time training, and repeatability.

OBJECTIVE

This integrated review examines the scientific evidence pertaining to the effectiveness of VRS and its practical usefulness in training health care professionals for in-hospital disaster preparedness.

METHODS

A well-known 4-stage methodology was used for the integrated review process. It consisted of problem identification, a literature search and inclusion criteria determination, 2-stage validation and analysis of searched studies, and presentation of findings. A search of diverse publication repositories was performed. They included Web of Science (WOS), PubMed (PMD), and Embase (EMB).

RESULTS

The integrated review process resulted in 12 studies being included. Principle findings identified 3 major capabilities of VRS: (1) to realistically simulate the clinical environment and medical practices related to different disaster scenarios, (2) to develop learning effects on increased confidence and enhanced knowledge acquisition, and (3) to enable cost-effective implementation of training programs.

CONCLUSIONS

The findings from the integrated review suggested that VRS could be a competitive, cost-effective adjunct to existing training approaches. Although the findings demonstrated the applicability of VRS to different training scenarios, these do not entirely cover all disaster scenarios that could happen in hospitals. This integrated review expects that the recent advances of VR technologies can be 1 of the catalysts to enable the wider adoption of VRS training on challenging clinical scenarios that require sophisticated modeling and environment depiction.

Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows

Background: Invasive procedures are a core aspect of pulmonary and critical care practice. Procedures performed in the intensive care unit can be divided into high-risk, low-volume (HRLV) procedures and low-risk, high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy, pericardiocentesis, Blakemore tube placement, and bronchial blocker placement. LRHV procedures include arterial line placement, central venous catheter placement, thoracentesis, and flexible bronchoscopy. Despite the frequency and importance of procedures in critical care medicine, little is known about the similarities and differences in procedural training between different Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) training programs. Furthermore, differences in procedural training practices for HRLV and LRHV procedures have not previously been described.

Objective: To assess procedural training practices in PCCM and CCM fellowship programs in the United States, and compare differences in training between HRLV and LRHV procedures.

Methods: A novel survey instrument was developed and disseminated to PCCM and CCM program directors and associate program directors at PCCM and CCM fellowship programs in the United States to assess procedural teaching practices for HRLV and LRHV procedures.

Results: The survey was sent to 221 fellowship programs, 168 PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the procedural educational strategies assessed, each strategy was used significantly more frequently for LRHV versus HRLV procedures. The majority of respondents (51.1%) report having no dedicated training for HRLV procedures versus 6.9% reporting no dedicated training for any LRHV procedure (P < 0.001). For HRLV procedures, 76.9% of respondents indicated that there was no set number of procedures required to determine competency, versus 25.3% for LRHV procedures (P < 0.001). For LRHV procedures, fellows were allowed to perform procedures independently without supervision 21.7% of the time versus 3.9% for HRLV procedures (P = 0.004). Program directors’ confidence in their ability to determine fellows’ competence in performing procedures was significantly lower for HRLV versus LRHV versus HRLV procedures (P < 0.001).

Conclusion: Significant differences exist in procedural training education for PCCM and CCM fellows for LRHV versus HRLV procedures, and awareness of this discrepancy presents an opportunity to address this educational gap in PCCM and CCM fellowship training.

Team training and surgical crisis management

Team training and crisis management derive their roots from fundamental learning theory and the culture of safety that burgeoned forth from the industrial revolution through the rise of nuclear energy and aviation. The integral nature of telemedicine to many simulation-based activities, whether to bridge distances out of convenience or necessity, continues to be a common theme moving into the next era of surgical safety as newer, more robust technologies become available.

Virtual reality operating room with AI guidance: design and validation of a fire scenario

BACKGROUND

Operating room (OR) fires are uncommon but disastrous events. Inappropriate handling of OR fires can result in injuries, even death. Aiming to simulate OR fire emergencies and effectively train clinicians to react appropriately, we have developed an artificial intelligence (AI)-based OR fire virtual trainer based on the principle of the "fire triangle" and SAGES FUSE curriculum. The simulator can predict the user's actions in the virtual OR and provide them with timely feedback to assist with training. We conducted a study investigating the validity of the AI-assisted OR fire trainer at the 2019 SAGES Learning Center.

METHODS

Fifty-three participants with varying medical experience were voluntarily recruited to participate in our Institutional Review Board approved study. All participants were asked to contain a fire within the virtual OR. Participants were then asked to fill out a 7-point Likert questionnaire consisting of ten questions regarding the face validation of the AI-assisted OR fire simulator. Shapiro-Wilk tests were conducted to test normality of the scores for each trial. A Friedman's ANOVA with post hoc tests was used to evaluate the effect of multiple trials on performance.

RESULTS

On a 7-point scale, eight of the ten questions were rated a mean of 6 or greater (72.73%), especially those relating to the usefulness of the simulator for OR fire-containing training. 79.25% of the participants rated the degree of usefulness of AI guidance over 6 out of 7. The performance of individuals improved significantly over the five trials, χ2(4) = 119.89, p < .001, and there was a significant linear trend of performance r = .97, p = 0.006. A pairwise analysis showed that only after the introduction of AI did performance improve significantly.

CONCLUSIONS

The AI-guided OR fire trainer offers the potential to assess OR personnel and teach the proper response to an iatrogenic fire scenario in a safe, repeatable, immersive environment.

The Cognitive Affective Model of Immersive Learning (CAMIL): a Theoretical Research-Based Model of Learning in Immersive Virtual Reality

There has been a surge in interest and implementation of immersive virtual reality (IVR)-based lessons in education and training recently, which has resulted in many studies on the topic. There are recent reviews which summarize this research, but little work has been done that synthesizes the existing findings into a theoretical framework. The Cognitive Affective Model of Immersive Learning (CAMIL) synthesizes existing immersive educational research to describe the process of learning in IVR. The general theoretical framework of the model suggests that instructional methods which are based on evidence from research with less immersive media generalize to learning in IVR. However, the CAMIL builds on evidence that media interacts with method. That is, certain methods which facilitate the affordances of IVR are specifically relevant in this medium. The CAMIL identifies presence and agency as the general psychological affordances of learning in IVR, and describes how immersion, control factors, and representational fidelity facilitate these affordances. The model describes six affective and cognitive factors that can lead to IVR-based learning outcomes including interest, motivation, self-efficacy, embodiment, cognitive load, and self-regulation. The model also describes how these factors lead to factual, conceptual, and procedural knowledge acquisition and knowledge transfer. Implications for future research and instructional design are proposed.

A review of virtual-simulation for assessing healthcare students' clinical competency

OBJECTIVES

Health professional education is transitioning to online platforms to meet students' need for flexibility and international access. However, there is a necessity for authentic presentation of educational material particularly in regard to clinical skills development. There has been major growth in the delivery of virtual simulated-based learning and assessment to provide clinical skill acquisition in an online platform. The aim of this review was to explore the use of virtual simulation to assess clinical competence in health education.

DESIGN

Integrative review.

DATA SOURCES

Peer reviewed studies published between 2008 to March 2020 were searched across PubMed, Embase, Cochrane Library, CINAHL Medline, Scopus, and PsycINFO.

REVIEW METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses was followed. Twenty-three studies, which met the inclusion criteria, were downloaded, and a quality appraisal and analysis was completed by the research team.

RESULTS

A thematic analysis identified four themes; pedagogy differences across disciplines, debriefing to enhance learning, preparing healthcare professionals in a safe and cost-effective environment, and managing challenges of virtual simulation. Debriefing with students within the online environment enabled students to share experience and reflect on choices for a deeper learning experience.

CONCLUSIONS

Virtual simulation can prepare students for the clinical environment by providing safe practice within complex clinical situations. Challenges related to managing and debriefing students must be overcome to ensure best student learning outcomes. Virtual simulation is a feasible strategy to assess students' clinical competency and support their learning in both medical and nursing programs, however simulation should be authentic and incorporate reflection.

Virtual Reality and Its Applications in Education: Survey

In the education process, students face problems with understanding due to the complexity, necessity of abstract thinking and concepts. More and more educational centres around the world have started to introduce powerful new technology-based tools that help meet the needs of the diverse student population. Over the last several years, virtual reality (VR) has moved from being the purview of gaming to professional development. It plays an important role in teaching process, providing an interesting and engaging way of acquiring information. What follows is an overview of the big trend, opportunities and concerns associated with VR in education. We present new opportunities in VR and put together the most interesting, recent virtual reality applications used in education in relation to several education areas such as general, engineering and health-related education. Additionally, this survey contributes by presenting methods for creating scenarios and different approaches for testing and validation. Lastly, we conclude and discuss future directions of VR and its potential to improve the learning experience.

Surgical Fires and Burns: A 5-Year Analysis of Medico-legal Cases

Surgical fires and unintended intraoperative burns cause serious patient harm, yet surveillance data are lacking in Canada. Medico-legal data provide unique descriptions of these events which can inform burn prevention strategies. We extracted 5 years of data on closed (2012-2016) medico-legal cases involving surgical fires and burns from the database of our organization which, in 2016, provided medico-legal support to >93,000 Canadian physicians. We performed a retrospective descriptive analysis of contributing factors using an in-house coding system and case reviews. We identified 53 eligible burn cases: 26 from thermal sources (49.1%), 16 from fires (30.2%), 5 from chemical sources (9.4%), and 6 from undetermined sources (11.3%). Common burn sources were electrosurgical equipment, lasers, lighting, and improper temperatures (causing thermal burns), cautery or lasers combined with supplemental oxygen and/or a flammable fuel source (causing fire), and improperly applied solutions including antiseptics (causing chemical burns). Nontechnical factors also contributed to patient outcomes, such as nonadherence to protocols (15 cases, 28.3%), failures in surgical team communication (3 cases, 5.7%), and lost situational awareness leading to delays in recognizing and treating burns (7 cases, 13.2%). This retrospective study highlights a need for improved surgical safety interventions to address surgical fires and burns. These interventions could include: effectively implemented surgical safety protocols, surgical team communication strategies, and raising awareness about preventing, diagnosing, and managing surgical burns.

Simulation in endoscopy: Practical educational strategies to improve learning

In gastrointestinal endoscopy, simulation-based training can help endoscopists acquire new skills and accelerate the learning curve. Simulation creates an ideal environment for trainees, where they can practice specific skills, perform cases at their own pace, and make mistakes with no risk to patients. Educators also benefit from the use of simulators, as they can structure training according to learner needs and focus solely on the trainee. Not all simulation-based training, however, is effective. To maximize benefits from this instructional modality, educators must be conscious of learners' needs, the potential benefits of training, and associated costs. Simulation should be integrated into training in a manner that is grounded in educational theory and empirical data. In this review, we focus on four best practices in simulation-based education: deliberate practice with mastery learning, feedback and debriefing, contextual learning, and innovative educational strategies. For each topic, we provide definitions, supporting evidence, and practical tips for implementation.

Process of medical simulator development: An approach based on personal experience

With increasing demand for simulators from the healthcare community and increasingly sophisticated technology being used in the manufacture of medical simulators, the manufacture of healthcare simulators has become a multifaceted undertaking. Based on our experience in the field and our diverse backgrounds, we explore the processes and issues related to the development of these simulators and suggest ways for the developing teams to collaborate and coordinate with each other to achieve a successful outcome.