Continuing professional development (CPD) for anesthetists: A systematic review

BACKGROUND

In accordance with the focus on patient safety and quality in healthcare, continuing professional development (CPD) has received increasing levels of attention as a means to ensure physicians maintain their clinical competencies and are fit to practice. There is some evidence of a beneficial effect of CPD, though few studies have evaluated its effect within anesthesia. The primary aim of this systematic review was to establish which CPD activities anesthetists are engaged in and their effectiveness. The secondary aim was to explore which methods are employed to evaluate anesthetists' clinical performance.

METHODS

Databases searched: Medline, Embase and Web of Science, in May 2023. Additional papers were identified through searching the references of included studies. Eligible studies included anesthetists, either exclusively or combined with other healthcare professionals, who underwent a learning activity or assessment method as part of a formalized CPD program or a stand-alone activity. Non-English language studies, non-peer reviewed studies and studies published prior to 2000 were excluded. Eligible studies were quality assessed and narratively synthesized, with results presented as descriptive summaries.

RESULTS

A total of 2112 studies were identified, of which 63 were eligible for inclusion, encompassing more than 137,518 participants. Studies were primarily of quantitative design and medium quality. Forty-one studies reported outcomes of single learning activities, whilst 12 studies investigated different roles of assessment methods in CPD and ten studies evaluated CPD programs or combined CPD activities. A 36 of the 41 studies reported positive effects of single learning activities. Investigations of assessment methods revealed evidence of inadequate performance amongst anesthetists and a mixed effect of feedback. Positive attitudes and high levels of engagement were identified for CPD programs, with some evidence of a positive impact on patient/organizational outcomes.

DISCUSSION

Anesthetists are engaged in a variety of CPD activities, with evidence of high levels of satisfaction and a positive learning effect. However, the impact on clinical practice and patient outcomes remains unclear and the role of assessment is less well-defined. There is a need for further, high-quality studies, evaluating a broader range of outcomes, in order to identify which methods are most effective to train and assess specialists in anesthesia.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

After-Action Reviews and Long-Term Performance: An Experimental Examination in the Context of an Emergency Simulation

OBJECTIVE

The present study examined the effectiveness of after-action reviews (AARs; also known as debriefing) in mitigating skill decay.

BACKGROUND

Research on the long-term effectiveness of AARs is meager. To address this gap in the literature, we conducted an experimental study that also overcomes some research design issues that characterize the limited extant research.

METHOD

Eighty-four participants were randomly assigned to an AAR or non-AAR condition and trained to operate a PC-based fire emergency simulator. During the initial acquisition phase, individuals in the AAR condition were allowed to review their performance after each practice session, whereas individuals in the non-AAR condition completed a filler task. About 12 weeks later, participants returned to the lab to complete four additional practice sessions using a similar scenario (i.e., the retention and reacquisition phase).

RESULTS

The performance of participants in the AAR condition degraded more after nonuse but also recovered faster than the performance of participants in the non-AAR condition, although these effects were fairly small and not statistically significant.

CONCLUSION

Consistent with the limited research on the long-term effectiveness of AARs, our findings failed to support their effectiveness as a decay-prevention intervention. Because the present study was conducted in a laboratory setting using a relatively small sample of undergraduate students, additional research is warranted.

APPLICATION

Based on the results of the present study, we suggest some additional strategies that trainers might consider to support long-term skill retention when using AARs.

What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness

OBJECTIVE

The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review.

METHODS

First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles.

RESULTS

The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered.

CONCLUSIONS

The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

Simulation with a colour indicator to help reduce contamination during airway management in COVID-19 times: An experience from a tertiary centre in India

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic has initiated modified protocols for aerosol-generating procedures. A simulation study using dye was conducted to highlight contamination at intubation and extubation and to encourage adherence to the new COVID-19 protocol among anaesthesia personnel in our institution.

METHODS

A video demonstrating the new COVID-19 protocols was circulated in the Department of Anaesthesiology a week prior to the study. Thirty teams, each comprising an anaesthesia resident and a staff technician, were enroled. Each team was asked to demonstrate the steps of preparation, intubation and extubation on a mannequin in a COVID-19 scenario. Checklists were used to assess points of contamination and adherence to the protocols. Following debriefing, a repeat simulation was conducted. The use of a dye highlighted the points of contamination. The study subjects provided feedback on the usefulness of the session and practical difficulties encountered in adapting to the new protocols.

RESULTS

The average contamination scores decreased by 3.4 (95% confidence interval (CI): 2.4-4.4, P < 0.001) in the post-debrief session. Adherence to the steps of the modified protocol improved by a score of 2.7 (CI: 3.6-1.83) among anaesthesiologists and by 4.3 (CI: 5.3-3.3) among technicians. Further, 93% felt that the use of the colour indicator reinforced awareness of the possible points of contamination.

CONCLUSION

Simulation with a low-fidelity mannequin by using colour indicator for secretions is an effective teaching tool to reduce health hazards during airway management in COVID-19 times.

Impact of an aging simulation workshop with different debrief methods on the development of empathy in pharmacy undergraduates

INTRODUCTION

This study aimed to investigate a workshop's impact on empathy development, compare potential differences in effects among different workshop debrief methods, and identify if any demographic factors predict empathy development.

METHODS

Participants were first randomly divided to receive either a didactic lecture, a jigsaw approach, or a fishbowl approach for the debrief method. In their respective arms, participants experienced simulation stations followed by their assigned debrief. Of 167 year-two National University of Singapore pharmacy undergraduates, 130 participated in the study and completed the Jefferson Scale of Empathy-Health Professions Student (JSE-HPS) version before and after the workshop.

RESULTS

The JSE-HPS scores were significantly increased post-workshop; however, no significant differences in pre-post workshop score changes were observed among the three approaches. Overall, no demographic factor was identified to have significantly influenced empathy development.

CONCLUSIONS

The study demonstrated that the simulation workshop developed empathy among pharmacy students regardless of the debrief method employed within the workshop. Future work would be necessary to assess if there are long-term impacts of different debrief methods on empathy development.

Individual versus collective debriefing after interprofessional training course simulation: The randomised DEBRIEF-SIM trial

INTRODUCTION

Debriefing is a critical phase in simulation-based education that is extremely time-consuming for the instructors. The aim of the study was to assess whether a collective debriefing was non-inferior to an individual debriefing to improve learning outcomes after a simulation session.

METHODS

This randomised controlled multicentre non-inferiority study included pairs comprising one resident and one student nurse in anaesthesia. Each pair underwent two sessions of a simulated life-threatening emergency held at a 6-week interval. Six participant pairs underwent simulation sessions every half-day of training. The debriefing performed after the first session was either individual (1 debriefing by pair; individual group) or collective (1 debriefing by 6 pairs; collective group). The primary outcome was the evolution of a 34-parameter technical skill score (Delta-TSS-34) between the two simulation sessions. The non-inferiority margin was 5. The change in the Anaesthetists' Non-Technical Skills score (Delta-ANTS), and the debriefing duration per participant pair were secondary endpoint measures.

RESULTS

Respectively 23 and 21 pairs were included in the collective and individual groups. Delta-TSS-34 was non-inferior in the collective group compared to the individual group (mean intergroup difference [95% confidence interval]: 2.71 [0.44-4.98]). Delta-ANTS did not significantly differ between the two groups (median [interquartile range]: 22 [10-37] versus 25 [17-35], p = 0.57; respectively in the collective and individual groups). The debriefing duration per participant pair was significantly lower in the collective group (10 [10-11] min versus 27 [25-28] min; p < 0.001).

CONCLUSION

Collective debriefing was non-inferior to individual debriefing to improve learning outcomes after simulation of medical emergencies and allows a significant reduction in the time dedicated to the debriefing.

Brick in the wall? Linking quality of debriefing to participant learning in team training of interprofessional students

Background

The evidence for the conventional wisdom that debriefing quality determines the effectiveness of learning in simulation-based training is lacking. We investigated whether the quality of debriefing in using simulation-based training in team training correlated with the degree of learning of participants.

Methods

Forty-two teams of medical and undergraduate nursing students participated in simulation-based training sessions using a two-scenario format with after-action debriefing. Observers rated team performance with an 11-item Teamwork Assessment Scales (TAS) instrument (three subscales, team-based behaviours (5-items), shared mental model (3-items), adaptive communication and response (3-items)). Two independent, blinded raters evaluated video-recorded facilitator team prebriefs and debriefs using the Objective Structured Assessment of Debriefing (OSAD) 8-item tool. Descriptive statistics were calculated, t-test comparisons made and multiple linear regression and univariate analysis used to compare OSAD item scores and changes in TAS scores.

Results

Statistically significant improvements in all three TAS subscales occurred from scenario 1 to 2. Seven faculty teams taught learners with all scores ≥3.0 (except two) for prebriefs and all scores ≥3.5 (except one) for debriefs (OSAD rating 1=done poorly to 5=done well). Linear regression analysis revealed a single statistically significant correlation between debrief engagement and adaptive communication and response score without significance on univariate analysis.

Conclusions

Quality of debriefing does not seem to increase the degree of learning in interprofessional education using simulation-based training of prelicensure student teams. Such a finding may be due to the relatively high quality of the prebrief and debrief of the faculty teams involved in the training.

Medical student satisfaction and confidence in simulation-based learning in Rwanda - Pre and post-simulation survey research

INTRODUCTION

Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, comfort with undertaking taught tasks, inter-professional communication, teamwork and teaching skills. This study aimed to evaluate Rwandan medical students' attitudes, satisfaction and confidence level with SBL.

METHODS

Fifth year medical students at the University of Rwanda were given a short course on paediatric acute care using simulation. The simulation sessions were locally developed cases based on the pRRAPID materials, developed at the University of Leeds (UK). Equipment included low fidelity infant mannequins, basic airway devices, IV access, and monitoring. A four-part, Likert-scale questionnaire was distributed to medical students before and after their four-week simulation program.

RESULTS

57 pre-simulation and 49 post-simulation questionnaires were completed. Confidence in skills increased in all fifteen domains of the questionnaire with the total skill confidence score rising from 44.0 (±12.3) to 56.2 (±8.8) after the simulation-based intervention (p < 0.001). Satisfaction and attitudes towards simulation-based learning in this setting were very positive.

CONCLUSION

The simulation-based intervention was well received by students in this setting. Satisfaction was high and the simulation exercise increased the students' confidence. Previous research has demonstrated that SBL is effective and the results of this study now demonstrate that it is well received in our setting. As we move from knowledge-based education to a competency-based education culture, faculties in this setting should invest in providing SBL opportunities throughout the medical school curriculum.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Assessing quality and resources during campus-wide simulation integration

INTRODUCTION

Our simulation center, supported by four departments (Surgery, OB/GYN, Urology, and Anesthesiology), is accredited as a comprehensive Accredited Educational Institute (AEI) and is now expanding to accommodate all departments on campus.

METHODS

A 61-point questionnaire was administered to 44 stakeholders, representing all of UME and GME. Data were compared for AEI vs. non-AEI activities.

RESULTS

Responses were collected from all 44 groups (100% response rate). Overall, 43 simulation activities were hosted within the AEI and 40 were hosted by non-AEI stakeholders. AEI activities were more likely to be mandatory (93% vs. 75%, p = 0.02), have written learning objectives (79% vs 43%, p < 0.001), and use validated assessment metrics (33% vs. 13%, p = 0.03).

CONCLUSION

These data suggest that the AEI courses are more robust in terms of structured learning and assessment compared to non-AEI courses. Campus-wide application of uniform quality standards is anticipated to require significant faculty, course, and program development.

Analysis of previous training with simulated models on the success rate of ultrasound-guided supraclavicular block. Prospective cohort study

INTRODUCTION

The teaching based on simulation and acquisition of skills is changing the paradigm of education and restructuring the clinical residences, with the aim of acquiring better skills, increasing procedural success, reducing complications, as well as providing safe, effective, and efficient and focused care of the patient. Peripheral nerve blocks have advanced as techniques for anatomical repairs, use of neurostimulator, and ultrasound. The posgraduate anaesthesiology program implemented a teaching program that included phases of theoretical teaching, training with simulated models, and application in real scenarios.

OBJECTIVE

To analyse the success, the management of the ultrasound equipment and the incidence of complications of ultrasound-guided supraclavicular blocks (BSE) in the clinical scenario, performed by residents of anaesthesiology previously trained with a theoretical and simulated model.

METHODS

Prospective cohort study among residents of anaesthesiology (R1, R2, R3, R4), who received previous theoretical-practical training on simulated models. The evaluation was performed by expert anaesthesiologists, with video analysis of the ultrasound screen performed at the time of BSE initiation.

RESULTS

The evaluation included 16 residents, who performed 156 BSE. None had previous experience in ultrasound-guided blocks. The success of the block was 96.15%. The team management was excellent (from 86% to 95%), with no significant differences among the residents. (P=.61) The incidence of complications was 0.64%, corresponding to arterial puncture.

CONCLUSIONS

In BSE, previous training with a theoretical and simulated model could increase the probability of success and reduce complications. With adequate training, first year residents managed to successfully carry out the procedure.

In-situ Interprofessional Perinatal Drills: The Impact of a Structured Debrief on Maximizing Training While Sensing Patient Safety Threats

Introduction In-situ interprofessional emergency team training improves participants' with confidence and knowledge and identifies latent safety threats. This study examined the impact of a structured debrief on an interprofessional perinatal team's ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced and checklist compliance would increase during subsequent in-situ perinatal team training. Methods Two in-situ training sessions were held six months apart. The perinatal emergency response team provided care for a standardized patient with preterm twin gestation. Each session included off-ward delivery and resuscitation of the first infant, transportation to appropriate inpatient units, cesarean delivery, and resuscitation of the second twin. Postpartum hemorrhage ensued, requiring massive transfusion protocol activation. Medical experts assessed team performance with critical action checklists. A structured debrief identified latent safety threats, developed action plans, and reviewed checklist compliance. Checklist compliance rates were analyzed using a z-ratio test. Results The first training session: seven teams (75 staff) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session: four teams (45 staff) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. Post-hoc power calculation was <10%. Conclusions In-situ interprofessional perinatal emergency team training is feasible, identifies latent patient safety threats, and may improve team competency.

Kirkpatrick's Evaluation of Simulation and Debriefing in Health Care Education: A Systematic Review

BACKGROUND

Simulation is an integral component of health care education. Research suggests a positive relationship between simulation and learning outcomes. Kirkpatrick's framework is a four-level model based on the premise that learning resulting from training programs can be classified into four levels: reaction, learning, behavior, and results. Evaluation of educational impact provides valuable feedback to educators that may assist with development and improvement of teaching methods.

METHOD

This review is based on the PRISMA guidelines for conducting a systematic review. Inclusion criteria included articles (a) written in the English language, (b) published between 2000 and 2016, (c) describing a debriefing intervention after high-fidelity patient simulation, and (d) based in health care.

RESULTS

Thirteen studies met criteria for inclusion in the review.

CONCLUSION

Results indicated a paucity of studies at the highest levels of evaluation, indicating an area where future research is needed to assist with the development and improvement of simulation education. [J Nurs Educ. 2018;57(7):393-398.].

A simulation-based curriculum to introduce key teamwork principles to entering medical students

BACKGROUND

Failures of teamwork and interpersonal communication have been cited as a major patient safety issue. Although healthcare is increasingly being provided in interdisciplinary teams, medical school curricula have traditionally not explicitly included the specific knowledge, skills, attitudes, and behaviors required to function effectively as part of such teams.

METHODS

As part of a new "Foundations" core course for beginning medical students that provided a two-week introduction to the most important themes in modern healthcare, a multidisciplinary team, in collaboration with the Center for Experiential Learning and Assessment, was asked to create an experiential introduction to teamwork and interpersonal communication. We designed and implemented a novel, all-day course to teach second-week medical students basic teamwork and interpersonal principles and skills using immersive simulation methods. Students' anonymous comprehensive course evaluations were collected at the end of the day. Through four years of iterative refinement based on students' course evaluations, faculty reflection, and debriefing, the course changed and matured.

RESULTS

Four hundred twenty evaluations were collected. Course evaluations were positive with almost all questions having means and medians greater than 5 out of 7 across all 4 years. Sequential year comparisons were of greatest interest for examining the effects of year-to-year curricular improvements. Differences were not detected among any of the course evaluation questions between 2007 and 2008 except that more students in 2008 felt that the course further developed their "Decision Making Abilities" (OR 1.69, 95% CI 1.07-2.67). With extensive changes to the syllabus and debriefer selection/assignment, concomitant improvements were observed in these aspects between 2008 and 2009 (OR = 2.11, 95% CI: 1.28-3.50). Substantive improvements in specific exercises also yielded significant improvements in the evaluations of those exercises.

CONCLUSIONS

This curriculum could be valuable to other medical schools seeking to inculcate teamwork foundations in their medical school's preclinical curricula. Moreover, this curriculum can be used to facilitate teamwork principles important to inter-disciplinary, as well as uni-disciplinary, collaboration.

Interprofessional simulation training for perioperative management team development and patient safety

Establishment of a perioperative management team construct including anaesthesiologists, surgeons, nurses, and other medical staff is essential to optimize safe surgical care. Simulation based education and training provides a unique and effective approach to development of competency and application of relevant technical and non-technical perioperative professional skills such as meta-cognitive ability, caution, shared decision-making, leadership and communication. Development of high functioning perioperative teams can be accomplished through simulation based training.

The effects of using high-fidelity simulators and standardized patients on the thorax, lung, and cardiac examination skills of undergraduate nursing students

BACKGROUND

Existing research literature indicates that the use of various simulation techniques in the training of physical examination skills develops students' cognitive and psychomotor abilities in a realistic learning environment while improving patient safety.

OBJECTIVES

The study aimed to compare the effects of the use of a high-fidelity simulator and standardized patients on the knowledge and skills of students conducting thorax-lungs and cardiac examinations, and to explore the students' views and learning experiences.

DESIGN

A mixed-method explanatory sequential design.

SETTINGS

The study was conducted in the Simulation Laboratory of a Nursing School, the Training Center at the Faculty of Medicine, and in the inpatient clinics of the Education and Research Hospital.

PARTICIPANTS

Fifty-two fourth-year nursing students.

METHODS

Students were randomly assigned to Group I and Group II. The students in Group 1 attended the thorax-lungs and cardiac examination training using a high-fidelity simulator, while the students in Group 2 using standardized patients. After the training sessions, all students practiced their skills on real patients in the clinical setting under the supervision of the investigator.

RESULTS

Knowledge and performance scores of all students increased following the simulation activities; however, the students that worked with standardized patients achieved significantly higher knowledge scores than those that worked with the high-fidelity simulator; however, there was no significant difference in performance scores between the groups. The mean performance scores of students on real patients were significantly higher compared to the post-simulation assessment scores (p<0.001).

CONCLUSIONS

Results of this study revealed that use of standardized patients was more effective than the use of a high-fidelity simulator in increasing the knowledge scores of students on thorax-lungs and cardiac examinations; however, practice on real patients increased performance scores of all students without any significant difference in two groups.

Post-event debriefings during neonatal care: why are we not doing them, and how can we start?

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

A randomized trial comparing didactics, demonstration, and simulation for teaching teamwork to medical residents

RATIONALE

Effective teamwork is fundamental to the management of medical emergencies, and yet the best method to teach teamwork skills to trainees remains unknown.

OBJECTIVES

In a cohort of incoming internal medicine interns, we tested the hypothesis that expert demonstration of teamwork principles and participation in high-fidelity simulation would each result in objectively assessed teamwork behavior superior to traditional didactics.

METHODS

This was a randomized, controlled, parallel-group trial comparing three teamwork teaching modalities for incoming internal medicine interns. Participants in a single-day orientation at the Vanderbilt University Center for Experiential Learning and Assessment were randomized 1:1:1 to didactic, demonstration-based, or simulation-based instruction and then evaluated in their management of a simulated crisis by five independent, blinded observers using the Teamwork Behavioral Rater score. Clinical performance was assessed using the American Heart Association Advanced Cardiac Life Support algorithm and a novel "Recognize, Respond, Reassess" score.

MEASUREMENTS AND MAIN RESULTS

Participants randomized to didactics (n = 18), demonstration (n = 17), and simulation (n = 17) were similar at baseline. The primary outcome of average overall Teamwork Behavioral Rater score for those who received demonstration-based training was similar to simulation participation (4.40 ± 1.15 vs. 4.10 ± 0.95, P = 0.917) and significantly higher than didactic instruction (4.40 ± 1.15 vs. 3.10 ± 0.51, P = 0.045). Clinical performance scores were similar between the three groups and correlated only weakly with teamwork behavior (coefficient of determination [Rs(2)] = 0.267, P < 0.001).

CONCLUSIONS

Among incoming internal medicine interns, teamwork training by expert demonstration resulted in similar teamwork behavior to participation in high-fidelity simulation and was more effective than traditional didactics. Clinical performance was largely independent of teamwork behavior and did not differ between training modalities.

Improving Trainee Competency and Comfort Level with Needle Driving Using Simulation Training

OBJECTIVE

To assess whether a combination of lecture and model simulation improves resident competency and comfort level with needle driving for interventional pain medicine procedures.

DESIGN

Prospective, observational study.

METHOD

Trainees who rotated through the University of California, Irvine, outpatient pain medicine clinic were recruited for the study. Subjects were given a brief lecture and completed a survey with questions regarding their level of comfort with interventional pain medicine procedures. This was followed by a timed trial on a training simulator where the objective was to drive a needle to the target. After the trial, the subject was then given a 30-minute practice session with the simulation model. The subject was then asked to repeat the timed trial and complete a post-simulation survey.

RESULTS

All measures of the level of comfort increased significantly after subjects underwent the simulation training. In addition, subjects were able to significantly decrease their entrance time (P= 0.002), total time (P= 0.033), and vertical (P≤ 0.001) and horizontal deviation (P≤ 0.001) from the final target point after the simulation training.

CONCLUSIONS

Our study demonstrates that simulation training may improve both trainee comfort level and competency with needle driving. After a brief lecture and a 30-minute training session with the simulator, subjective comfort measures and competency measures (more subjects were able to reach the target, vertical and horizontal deviations from the target decreased) were significantly improved. This suggests that simulation may be a helpful tool in teaching needle driving skills.

[Patient safety in anesthesiology : Multimodal strategies for perioperative care]

The concept of patient safety is more of a presence in modern day medicine than ever before. All measures and processes aiming at preempting and preventing critical incidents and accidents in patient care are collectively grouped under this concept. With the Declaration of Helsinki in 2010 modern anesthesiology has undertaken a fundamental role in the clinical implementation and perioperative clinicians are confronted with a multitude of theories, models, methods and tools targeted at improving or facilitating optimized patient safety. One of the biggest challenges lies in their synergistic combination to create a functioning concept for perioperative risk management while also incorporating individual strengths and weaknesses. The aim of the present paper is to provide a structured overview of the various components presently available for increasing perioperative patient safety.

Debriefing after Simulation-Based Non-Technical Skill Training in Healthcare: A Systematic Review of Effective Practice

Non-technical skills training in healthcare frequently uses high-fidelity simulation followed by a facilitated discussion known as debriefing. This type of training is mandatory for anaesthesia training in Australia and New Zealand. Debriefing by a skilled facilitator is thought to be essential for new learning through feedback and reflective processes. Key elements of effective debriefing need to be clearly identified to ensure that the training is evidence-based. We undertook a systematic review of empirical studies where elements of debriefing have been systematically manipulated during non-technical skills training. Eight publications met the inclusion criteria, but seven of these were of limited generalisability. The only study that was generalisable found that debriefing by novice instructors using a script improved team leader performance in paediatric resuscitation. The remaining seven publications were limited by the small number of debriefers included in each study and these reports were thus analogous to case reports. Generally, performance improved after debriefing by a skilled facilitator. However, the debriefer provided no specific advantage over other post-experience educational interventions. Acknowledging their limitations, these studies found that performance improved after self-led debrief, no debrief (with experienced practitioners), standardised multimedia debrief or after reviewing a DVD of the participants’ own eye-tracking. There was no added performance improvement when review of a video recording was added to facilitator-led debriefing. One study reported no performance improvement after debriefing. Without empirical evidence that is specific to the healthcare domain, theories of learning from education and psychology should continue to inform practices and teaching for effective debriefing.

The role of simulation in continuing medical education for acute care physicians: a systematic review

OBJECTIVES

We systematically reviewed the effectiveness of simulation-based education, targeting independently practicing qualified physicians in acute care specialties. We also describe how simulation is used for performance assessment in this population.

DATA SOURCES

Data source included: DataMEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL Database of Controlled Trials, and National Health Service Economic Evaluation Database. The last date of search was January 31, 2013.

STUDY SELECTION

All original research describing simulation-based education for independently practicing physicians in anesthesiology, critical care, and emergency medicine was reviewed.

DATA EXTRACTION

Data analysis was performed in duplicate with further review by a third author in cases of disagreement until consensus was reached. Data extraction was focused on effectiveness according to Kirkpatrick's model. For simulation-based performance assessment, tool characteristics and sources of validity evidence were also collated.

DATA SYNTHESIS

Of 39 studies identified, 30 studies focused on the effectiveness of simulation-based education and nine studies evaluated the validity of simulation-based assessment. Thirteen studies (30%) targeted the lower levels of Kirkpatrick's hierarchy with reliance on self-reporting. Simulation was unanimously described as a positive learning experience with perceived impact on clinical practice. Of the 17 remaining studies, 10 used a single group or "no intervention comparison group" design. The majority (n = 17; 44%) were able to demonstrate both immediate and sustained improvements in educational outcomes. Nine studies reported the psychometric properties of simulation-based performance assessment as their sole objective. These predominantly recruited independent practitioners as a convenience sample to establish whether the tool could discriminate between experienced and inexperienced operators and concentrated on a single aspect of validity evidence.

CONCLUSIONS

Simulation is perceived as a positive learning experience with limited evidence to support improved learning. Future research should focus on the optimal modality and frequency of exposure, quality of assessment tools and on the impact of simulation-based education beyond the individuals toward improved patient care.

Interprofessional simulation to improve safety in the epilepsy monitoring unit

OBJECTIVE

Patient safety is critical for epilepsy monitoring units (EMUs). Effective training is important for educating all personnel, including residents and nurses who frequently cover these units. We performed a needs assessment and developed a simulation-based team training curriculum employing actual EMU sentinel events to train neurology resident-nurse interprofessional teams to maximize effective responses to high-acuity events.

METHODS

A mixed-methods design was used. This included the development of a safe-practice checklist to assess team response to acute events in the EMU using expert review with consensus (a modified Delphi process). All nineteen incoming first-year neurology residents and 2 nurses completed a questionnaire assessing baseline knowledge and attitudes regarding seizure management prior to and following a team training program employing simulation and postscenario debriefing. Four resident-nurse teams were recorded while participating in two simulated scenarios. Employing retrospective video review, four trained raters used the newly developed safe-practice checklist to assess team performance. We calculated the interobserver reliability of the checklist for consistency among the raters. We attempted to ascertain whether the training led to improvement in performance in the actual EMU by comparing 10 videos of resident-nurse team responses to seizures 4-8months into the academic year preceding the curricular training to 10 that included those who received the training within 4-8months of the captured video.

RESULTS

Knowledge in seizure management was significantly improved following the program, but confidence in seizure management was not. Interrater agreement was moderate to high for consistency of raters for the majority of individual checklist items. We were unable to demonstrate that the training led to sustainable improvement in performance in the actual EMU by the method we used.

CONCLUSIONS

A simulated team training curriculum using a safe-practice checklist to improve the management of acute events in an EMU may be an effective method of training neurology residents. However, translating the results into sustainable benefits and confidence in management in the EMU requires further study.

A systematic review of the effectiveness of simulation debriefing in health professional education

OBJECTIVE

The objective of this review was to identify, appraise and synthesise the best available evidence for the effectiveness of debriefing as it relates to simulation-based learning for health professionals.

BACKGROUND

Simulation is defined as a technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. The use of simulation for health professional education began decades ago with the use of low-fidelity simulations and has evolved at an unprecedented pace. Debriefing is considered by many to be an integral and critical part of the simulation process. However, different debriefing approaches have developed with little objective evidence of their effectiveness.

INCLUSION CRITERIA

Studies that evaluated the use of debriefing for the purpose of simulation-based learning for health professionals were included. Simulation studies not involving health professionals and those conducted in other settings such as such as military or aviation were excluded.

REVIEW METHODS

A review protocol outlining the inclusion and exclusion criteria was submitted, peer reviewed by the Joanna Briggs Institute (JBI) for Evidence Based Practice, and approved prior to undertaking the review. A comprehensive search of studies published between January 2000 and September 2011 was conducted across ten electronic databases. Two independent reviewers assessed each paper prior to inclusion or exclusion using the standardised critical appraisal instruments for evidence of effectiveness developed by the Joanna Briggs Institute.

RESULTS

Ten randomised controlled trials involving various debriefing methods were included in the review. Meta-analysis was not possible because of the different outcomes, control groups and interventions in the selected studies. The methods of debriefing included: post simulation debriefing, in-simulation debriefing, instructor facilitated debriefing and video-assisted instructor debriefing. In the included studies there was a statistically significant improvement pre-test to post-test in the performance of technical and nontechnical skills such as: vital signs assessment; psychomotor skills; cardiopulmonary resuscitation; task management; team working; and situational awareness, regardless of the type of debriefing conducted. Additionally, only one study reported consistent improvement in these outcomes with the use of video playback during debriefing. In two studies the effect of the debrief was evident months after the initial simulation experiences.

CONCLUSION

These results support the widely held assumption that debriefing is an important component of simulation. It is recommended therefore that debriefing remains an integral component of all simulation-based learning experiences. However, the fact that there were no clinical or practical differences in outcomes when instructor facilitated debriefing was enhanced by video playback is an important finding since this approach is currently considered to be the 'gold standard' for debriefing. This finding therefore warrants further research.

Successful debriefing - best methods to achieve positive learning outcomes: a literature review

The past several years have seen a dramatic increase in the use of simulation in nursing education. The process of debriefing, or guided reflection, follows these simulation activities. Although facilitated debriefing is recommended in the simulation literature, very few research articles reported results of the effectiveness of debriefing. A literature search was conducted using PubMed, Academic Search Complete, CINAHL, ERIC, and PsychInfo to identify articles and studies examining simulation and debriefing methods. A limited number of studies were found, that examined traditional faculty facilitated debriefing versus alternate forms of debriefing, debriefing versus no debriefing, and perceptions of debriefing. In most cases, improvement was noted in learners regardless of the debriefing process used. This review is grouped in two sections: (a) studies comparing debriefing strategies and (b) studies examining perceptions of the usefulness of debriefing.

[Bringing clinical simulation into an Anesthesia residency training program in a university hospital. Participants' acceptability assessment]

INTRODUCTION

Clinical simulation is currently an integral part of the curriculum of the Anesthesiology residency programs in other countries. We aimed to describe and evaluate the insertion of simulation in an anesthesia residency training program.

METHODS

Activities feasible to be used for training in a simulated environment were classified into 2 modules: workshops for technical skills conducted with first year residents, and high fidelity simulation scenarios performed with second and third year residents. After each activity, and using an anonymous questionnaire, residents assessed their satisfaction and objectives accomplished.

RESULTS

A total of 18 activities: 6 skills workshops and 12 high fidelity scenarios were assessed. A total of 206 questionnaires were analyzed, corresponding to 41 residents. Almost all (96%) of respondents agreed or strongly agreed that workshops met the objectives and should be mandatory in the anesthesia curriculum; however, 11% agreed that the activity caused anxiety and/or nervousness. The high fidelity scenarios were considered realistic and consistent with the objectives by 97% of residents, and 42% felt that workshops caused anxiety and/or nervousness.

CONCLUSIONS

The inclusion of simulation has been well accepted by the residents. The activities have been described as realistic, and limited to the objectives, essential points in adult education, as according to Kolb's learning model this is associated with profound, useful and long lasting knowledge.

Objective structured assessment of debriefing: bringing science to the art of debriefing in surgery

OBJECTIVE

: To identify the features of effective debriefing and to use this to develop and validate a tool for assessing such debriefings.

INTRODUCTION

: Simulation-based training has become an accepted means of surgical skill acquisition. A key component of this is debriefing-yet there is a paucity of research to guide best practice.

METHODS

: Phase 1-Identification of best practice and tool development. A search of the Medline, Embase, PsycINFO, and ERIC databases identified current evidence on debriefing. End-user input was obtained through 33 semistructured interviews conducted with surgeons (n = 18) and other operating room personnel (n = 15) from 3 continents (UK, USA, Australia) using standardized qualitative methodology. An expert panel (n = 7) combined the data to create the Objective Structured Assessment of Debriefing (OSAD) tool. Phase 2-Psychometric testing. OSAD was tested for feasibility, reliability, and validity by 2 independent assessors who rated 20 debriefings following high-fidelity simulations.

RESULTS

: Phase 1: 28 reports on debriefing were retrieved from the literature. Key components of an effective debriefing identified from these reports and the 33 interviews included: approach to debriefing, learning environment, learner engagement, reaction, reflection, analysis, diagnosis of strengths and areas for improvement, and application to clinical practice. Phase 2: OSAD was feasible, reliable [inter-rater ICC (intraclass correlation coefficient) = 0.88, test-retest ICC = 0.90], and face and content valid (content validity index = 0.94).

CONCLUSIONS

: OSAD provides an evidence-based, end-user informed approach to debriefing in surgery. By quantifying the quality of a debriefing, OSAD has the potential to identify areas for improving practice and to optimize learning during simulation-based training.

Evolution of the Pediatric Advanced Life Support course: enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors

OBJECTIVE

To describe the history of the Pediatric Advanced Life Support course and outline the new developments in instructor training that will impact the way debriefing is conducted during Pediatric Advanced Life Support courses.

OUTLINE

The Pediatric Advanced Life Support course, first released by the American Heart Association in 1988, has seen substantial growth and change over the past few decades. Over that time, Pediatric Advanced Life Support has become the standard for resuscitation training for pediatric healthcare providers in North America. The incorporation of high-fidelity simulation-based learning into the most recent version of Pediatric Advanced Life Support has helped to enhance the realism of scenarios and cases, but has also placed more emphasis on the importance of post scenario debriefing. We developed two new resources: an online debriefing module designed to introduce a new model of debriefing and a debriefing tool for real-time use during Pediatric Advanced Life Support courses, to enhance and standardize the quality of debriefing by Pediatric Advanced Life Support instructors. In this article, we review the history of Pediatric Advanced Life Support and Pediatric Advanced Life Support instructor training and discuss the development and implementation of the new debriefing module and debriefing tool for Pediatric Advanced Life Support instructors.

CONCLUSION

The incorporation of the debriefing module and debriefing tool into the 2011 Pediatric Advanced Life Support instructor materials will help both new and existing Pediatric Advanced Life Support instructors develop and enhance their debriefing skills with the intention of improving the acquisition of knowledge and skills for Pediatric Advanced Life Support students.

RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines

OBJECTIVE

To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats.

DESIGN

Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals.

SETTING

Academia, referral practice and general practice.

RESULTS

A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed.

CONCLUSIONS

Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

The effectiveness of debriefing in simulation-based learning for health professionals: A systematic review

BACKGROUND

Simulation is defined as a technique used to replace or amplify real experiences with guided experiences that evoke or replace substantial aspects of the real world in a fully interactive manner. The use of simulation for educational purposes began decades ago with the use of low-fidelity simulations and has evolved at an unprecedented pace. Debriefing is considered by many to be an integral and critical part of the simulation process. However, different debriefing approaches have developed with little objective evidence of their effectiveness.

OBJECTIVES

The aim of this review was to identify, appraise and synthesise the best available evidence for the effectiveness of debriefing as it relates to simulation-based learning for health professionals.

INCLUSION CRITERIA

This review included any health professional participants regardless of gender, age or profession.Studies that evaluated the use of debriefing for the purpose of simulation-based learning were included.The review included randomised controlled trials.Outcome measures included objectively measured outcomes such as situational awareness, communication skills, teamwork, knowledge acquisition, and performance of psychomotor skills as assessed by validated instruments such the Anaesthesia Non-Technical Skills Scale, the Emergency Response Performance Tool, and the Clinical Simulation Tool.

SEARCH STRATEGY

A three-stage comprehensive search strategy was utilised to search across ten electronic databases. English language studies published between January 2000 and September 2011 were considered for inclusion.

METHODOLOGICAL QUALITY

Two independent reviewers assessed the methodological quality of each study selected for retrieval using standardised Joanna Briggs Institute critical appraisal tools.

DATA COLLECTION

Data were extracted from studies using the standardised data extraction tool from the Joanna Briggs Institute DATA SYNTHESIS: Meta-analysis was not possible because of the different outcomes, control groups and interventions in the selected studies. Findings are therefore presented in narrative form.

RESULTS

Ten randomised controlled trials involving various debriefing methods were eligible for inclusion in this review. The methods of debriefing included: post simulation debriefing, in-simulation debriefing, instructor facilitated debriefing and video-assisted instructor debriefing. In the included studies there was a statistically significant improvement pre-test to post-test in the performance of technical and nontechnical skills such as: vital signs assessment; psychomotor skills; cardiopulmonary resuscitation; task management; team working; and situational awareness, regardless of the type of debriefing conducted. Additionally, four of the studies reported improvement in these outcomes without the use of video playback during debriefing. In one study the effect of the educational intervention was evident 6-9 months after the initial simulation experience.

CONCLUSIONS

The results of this systematic review support the widely held assumption that debriefing is an important component of simulation. It is recommended therefore that debriefing remain an integral component of all simulation-based learning experiences. However, the fact that there were no clinical or practical differences in outcomes when instructor facilitated debriefing was enhanced by video playback is an important finding since this approach is currently considered to be the 'gold standard' for debriefing.

Adaptive coordination development in student anaesthesia teams: a longitudinal study

Although adaptive coordination has been highlighted by several studies, research dealing with how adaptive coordination develops is still rare. Thus, the aim of this study was to investigate the development of coordination mechanisms and their task-related adaptation in a longitudinal observation of medical simulation-based training of final year students. We recorded six anaesthesia teams during a sequence of four task scenarios, and each scenario comprised of a routine and a complication phase. After trained observers rated sub-tasks within each scenario for explicit and implicit coordination, statistical analysis revealed a statistically significant effect of previous scenarios on coordination development in the routine phases. While the amount of explicit coordination decreased, implicit coordination increased, revealing adaptive coordination as a skill developed through repeated group interaction. We conclude that anaesthesia training should consider cost- and patient safety-benefits of implicit and explicit coordination and focus on adaptive coordination.

PRACTITIONER SUMMARY

Group coordination is crucial to anaesthesia team performance. Results of this longitudinal observation of six anaesthesia teams during four medical simulation-based training scenarios document that teams develop adaptive patterns of coordination. This study also demonstrates that adaptive coordination is a trainable skill within crisis resource management training.

Review article: simulation in anesthesia: state of the science and looking forward

PURPOSE

Within the field of anesthesia, simulation has been used as a tool for training and assessment for over 30 years. The purpose of this review is to evaluate the state of the science in terms of its effectiveness as an approach to both training and assessment in anesthesia. Articles in the area of simulation and anesthesia published up to and including 2011 were reviewed for inclusion in this narrative review.

PRINCIPAL FINDINGS

Simulation-based training is generally well received by participants, it can lead to improved performance in subsequent simulation events, and some transfer of learning to the clinical setting is evident. There is also some early evidence that well-designed performance assessments could have the required reliability and validity to support high-stakes examinations. However, further work is needed in order to set standards and establish the predictive validity to support such assessments.

CONCLUSION

For simulation to realize its potential impact, further research is needed to understand how to optimize this modality of learning more effectively, how to transfer knowledge of research findings to practice, and also how to broaden the simulation modalities used in anesthesia. In future, the optimal use of simulation will depend on a clear understanding of what can and cannot be accomplished with simulation and its various modalities.