Managing a surgical exsanguination emergency in the operating room through simulation: an interdisciplinary approach

Creation of a Virtual Reality Telesimulation Program in Response to Mandatory COVID-19 Social Distancing During the Pandemic: A Primer for Those considering VR Simulation and Application to a Group of Physicians Naive to Virtual Reality

The COVID-19 pandemic necessitated the closure of traditional simulation centers, prompting innovative solutions for medical education. Drawing from prior studies, which advocated for telesimulation and virtual reality (VR) as alternatives, this article explores the development and implementation of VR simulation in medical training. Leveraging the Acadicus® VR platform, a VR simulation solution was created, enabling interactive scenarios simulating pediatric critical care situations. Thirty-one diverse scenarios were designed and executed over an 8-month period, involving pediatric and emergency medicine residents and fellows. The development process involved creating lifelike mannequins and dynamic cardiac waveforms, enhancing realism and spontaneity. Using VR headsets and streaming technology, participants engaged in immersive scenarios remotely. Performance evaluation used a modified version of the Tool for Resuscitation Assessment Using Computer Simulation, revealing comparable outcomes across different training levels and specialties. Participant feedback underscored the immersive nature of VR simulation, offering enhanced realism and in-depth debriefing opportunities compared with traditional mannequin-based simulation. However, limitations such as the lack of haptic feedback and the need for better integration with existing simulation center infrastructure were noted. Cost-effectiveness emerged as a significant advantage of VR simulation, with lower upfront costs compared with traditional simulation centers. VR simulation also demonstrated versatility in staging training across various hospital settings, offering a more comprehensive learning experience. Although acknowledging the need for further research to measure skill acquisition and retention, this study highlights the potential of VR simulation as an adjunctive modality in medical education.

Technology-enhanced trauma training in low-resource settings: A scoping review and feasibility analysis of educational technologies

BACKGROUND

Lack of training contributes to the burden of trauma-related mortality and morbidity in low- and lower-middle-income countries (LMICs). Educational technologies present a unique opportunity to enhance the quality of trauma training. Therefore, this study reviews current technologies used in trauma courses and evaluates their feasibility for LMICs.

METHODS

We conducted a scoping review evaluating the learning outcomes of technology-enhanced training in general trauma assessment, team skills or any procedures covered in the 2020 Advanced Trauma Life Support® program. Based on the Technology-Enhanced Learning criteria, we created and applied a feasibility analysis tool to evaluate the technologies for use in LMICs.

RESULTS

We screened 6471 articles and included 64. Thirty-four (45%) articles explored training in general trauma assessment, 28 (37%) in team skills, and 24 (32%) in procedures. The most common technologies were high-fidelity mannequins (60%), video-assisted debriefing (19%), and low-fidelity mannequins (13%). Despite their effectiveness, high-fidelity mannequins ranked poorly in production, maintenance, cost, and reusability categories, therefore being poorly suited for LMICs. Virtual simulation and digital courses had the best feasibility scores, but still represented a minority of articles in our review.

CONCLUSION

To our knowledge, this is the first study to perform a feasibility analysis of trauma training technologies in the LMIC context. We identified that the majority of trauma courses in the literature use technologies which are less suitable for LMICs. Given the urgent need for pediatric trauma training, educators must use technologies that optimize learning outcomes and remain feasible for low-resource settings.

LEVEL OF EVIDENCE

IV.

Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review

OBJECTIVE

Simulation-based training as an educational intervention for healthcare providers has increased in use over the past 2 decades. The simulation community has called for standardized reporting of methodologies and outcomes. The purpose of this review was to (1) summarize existing data on the use of simulation-based team training for acute trauma resuscitation, and (2) describe differences in training methodologies, outcomes reporting, and gaps in the literature to inform research priorities.

DESIGN

We performed a scoping review of Ovid Medline, Embase, Cochrane Library, CINAHL, Web of Science, ERIC, and Google Scholar for studies evaluating simulation-based team training for acute trauma resuscitation. Full-text review was performed by 2 reviewers and variables related to study design, training methodology, outcomes reported, and impact of training were abstracted.

RESULTS

Forty-seven out of 3,911 screened studies met criteria for inclusion. Only 2 studies were randomized. The most frequent design was a pre-post study (64%). Eleven studies did not report their simulated scenario design. Interventions occurred most frequently in a laboratory-based setting (45%). Simulation-based training was associated with greater knowledge (n = 5/6), higher nontechnical skills (n = 12/13), greater number of resuscitation tasks completed (n = 10/13), and faster time to resuscitation task completion (n = 11/11). No differences in patient outcomes were found (n = 3/3).

CONCLUSIONS

Simulation-based training for trauma resuscitation is associated with improved measures of teamwork, task performance and speed, knowledge, and provider satisfaction. Type of reported outcomes and training methodologies are variable. Standardized reporting of training methodology and outcomes is needed to address the impact of this intervention.

Interprofessional Simulations Promote Knowledge Retention and Enhance Perceptions of Teamwork Skills in a Surgical-Trauma-Burn Intensive Care Unit Setting

BACKGROUND

The current state of health care encompasses highly acute, complex patients, managed with ever-changing technology. The ability to function proficiently in critical care relies on knowledge, technical skills, and interprofessional teamwork. Integration of these factors can improve patient outcomes. Simulation provides "hands-on" practice and allows for the integration of teamwork into knowledge/skill training. However, simulation can require a significant investment of time, effort, and financial resources. The Institute of Medicine recommendations from 2015 include "strengthening the evidence base for interprofessional education (IPE)" and "linking IPE with changes in collaborative behavior." In one surgical-trauma-burn intensive care unit (STBICU), no IPE existed. The highly acute and diverse nature of the patients served by the unit highlights the importance of appropriate training. This is heightened during critical event situations where patients deteriorate rapidly and the team intervenes swiftly.

PURPOSE

The aims of this study were to (1) evaluate knowledge retention and analyze changes in perceptions of teamwork among nurses and resident physicians in a STBICU setting after completion of an interprofessional critical event simulation and (2) provide insight for future interprofessional simulations (IPSs), including the ideal frequency of such training, associated cost, and potential effect on nursing turnover.

DESIGN

A comparison-cohort pilot study was developed to evaluate knowledge retention and analyze changes in perceptions of teamwork.

METHODS

A 1-hour critical event IPS was held for nurses and resident physicians in a STBICU setting. A traumatic brain injury patient with elevated intracranial pressure, rapid deterioration, and cardiac arrest was utilized for the simulation scenario. The simulation required the team to use interventions to reduce elevated intracranial pressure and then perform cardiac resuscitation according to Advanced Cardiac Life Support guidelines. A semistructured debriefing guided by the TENTS tool highlighted important aspects of teamwork. Participants took knowledge and Teamwork Skills Scale (TSS) pretests, posttests, and 1-month posttests. Mean scores were calculated for each time point (pre, post, and 1-month post), and paired t tests were used to evaluate changes.

RESULTS

Mean knowledge test and TSS scores both significantly increased after the simulation and remained significantly elevated at 1-month follow-up. Participants recommended retraining intervals of 3 to 6 months. Cost of each simulation was estimated to be $324.44. Analysis of nursing turnover rates did not demonstrate a statistically significant reduction in turnover; however, confounding factors were not controlled for.

CONCLUSION

Significant improvements on both knowledge test and TSS scores demonstrate the effectiveness of the intervention, and retention of the information gained and teamwork skills learned. Participants valued the intervention and recommended to increase the frequency of training. Future studies should develop a framework for "best practice" IPS, analyze the relationship with nursing turnover, and ultimately seek correlations between IPS and improved patient outcomes.

The Role of High-Fidelity Team-Based Simulation in Acute Care Settings: A Systematic Review

Introduction  High-fidelity team-based simulation has been identified as an effective way of teaching and evaluating both technical and nontechnical skills. Several studies have described the benefits of this modality in a variety of acute care settings, but a lack of standardized methodologies has resulted in heterogeneous findings. Few studies have characterized high fidelity simulation across a broad range of acute care settings and integrated the latest evidence on its educational and patient impact.

Methods  The MEDLINE, EMBASE, Cochrane Library, and PsycINFO databases were searched for empirical studies from the last 10 years, investigating high fidelity team-based simulation in surgical, trauma, and critical care training curricula.

Results  Seventeen studies were included. Interventions and evaluations were comprehensively characterized for each study and were discussed in the context of four overarching acute care settings: the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams.

Conclusions  The use of high-fidelity team-based simulation has expanded in acute care and is feasible and effective in a wide variety of specialized acute settings, including the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams. Training programs have evolved to emphasize team-based, multidisciplinary education models and are often conducted in situ to maximize authenticity. In situ simulations have also provided the opportunity for system-level improvement and discussions of complex topics such as social hierarchy. There is limited evidence supporting the impact of simulation on patient outcomes, sustainability of simulation efforts, or cost-effectiveness of training programs. These areas warrant further research now that the scope of utilization across acute care settings has been characterized.

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

Simulation in the operating room

Simulation has become a significant training tool in the operating room (OR). It can be used in both simple task training and complex scenarios. The challenge for simulation in the OR is how to translate that which is learned, and perceived to beneficial, into behavioral change and improved patient outcomes. Simulation in the developing world is progressing, but is still hampered by a shortage of material, personnel funding.

Multidisciplinary team simulation for the operating theatre: a review of the literature

INTRODUCTION

Analyses of adverse events inside the operating theatre has demonstrated that many errors are caused by failure in non-technical skills and teamwork. While simulation has been used successfully for teaching and improving technical skills, more recently, multidisciplinary simulation has been used for training team skills. We hypothesized that this type of training is feasible and improves team skills in the operating theatre.

METHODS

A systematic search of the literature for studies describing true multidisciplinary operating theatre team simulation was conducted in November and December 2012. We looked at the characteristics and outcomes of the team simulation programmes.

RESULTS

1636 articles were initially retrieved. Utilizing a stepwise evaluation process, 26 articles were included in the review. The studies reveal that multidisciplinary operating theatre simulation has been used to provide training in technical and non-technical skills, to help implement new techniques and technologies, and to identify latent weaknesses within a health system. Most of the studies included are descriptions of training programmes with a low level of evidence. No randomized control trial was identified. Participants' reactions to the training programme were positive in all studies; however, none of them could objectively demonstrate that skills acquired from simulation are transferred to the operating theatre or show a demonstrable benefit in patient outcomes.

CONCLUSION

Multidisciplinary operating room team simulation is feasible and widely accepted by participants. More studies are required to assess the impact of this type of training on operative performance and patient safety.