"Practicing" medicine without risk: students' and educators' responses to high-fidelity patient simulation

Catheterized chicken for training on ultrasound-guided vascular access: A simple, cost-effective, and effective model

Ultrasound-guided vascular access is a medical procedure that is becoming increasingly common in daily practice and is recommended to avoid iatrogenic complications. One of the procedures with a high-risk rate of complications is the vascular puncture. However, training on this technique can be challenging due to the limited availability of simulation models. We propose a simple, cost-effective, and effective ultrasound-guided vascular access simulation model that utilizes chicken breast and a urine catheter to address this need.

SimLife®: A New Dynamic Model for Head and Neck Surgical Oncology Simulation

The SimLife® model consists in a human cadaver dynamized by pulsatile vascularization. The objective was to evaluate the face, contents, and constructs validity of the SimLife® model in head and neck surgical oncology simulation. Head and neck surgical oncology simulation sessions on SimLife® models were organized with lateral neck dissection and total laryngectomy. Face and contents validity were addressed by questionnaires. Constructs validity was assessed by objective structured assessment of technical skills (OSATS) score. High realism was demonstrated for consistency of tissues (7.1 ± 1.4), color of arteries and veins (7.3 ± 1.9, 8.5 ± 1.1, respectively), and vein consistency (8.5 ± 1.2). The mean OSATS score was 19.7 ± 5.4 for residents and 32.7 ± 1.9 for senior surgeon (P = .0022). SimLife® is a hyperrealistic model for head and neck surgical oncology simulation and it might become a core component of the surgical resident curriculum.

Simulation-Based Education in Acute and Chronic Pain Training

PURPOSE OF REVIEW

The use of simulation-based education (SBE) in medical training has expanded greatly and has grown to include high fidelity and task simulation along with hybrid models using patient actors to enhance education and training of critical events as well as technical skills.

RECENT FINDINGS

In the field of anesthesiology, SBE has been particularly useful for crisis resource management and rare critical scenarios and new research into the use of SBE using task simulation for procedural skill development has been done highlighting the benefits to subspecialty procedural training. Medical simulation has become a common practice in medical training and research. SBE has demonstrated positive outcomes in improving technical skills, knowledge, comfort, and clinical performance. The widespread implementation of SBE in regional anesthesia and chronic pain training varies, with cost and availability being factors. Nonetheless, SBE has shown great potential in enhancing education and preparing physicians in subspecialties of anesthesia.

Debriefing or Feedback: Exploring the Impact of Two Post-Scenario Discussion Methods in the Acquisition and Retention of Non-Technical Skills

INTRODUCTION

There is a paucity of quantitative studies objectively comparing debriefing and feedback as methods for post-scenario discussion and its impact on healthcare teams' acquisition and retention of non-technical skills. The main purpose of this study is to provide some insight on this research question, using a sample of medical students. A secondary objective explores students' opinion and preference on the post-scenario discussion.

MATERIAL AND METHODS

Forty-five medical students were distributed among 15 teams, and randomly allocated to two groups. Each team participated in three different simulated scenarios, with similar levels of difficulty and opportunities to apply specific non-technical skills: leadership, communication, and task management. To assess the acquisition and retention of skills, scenarios occurred on days one (baseline), two (acquisition) and 20 (retention). Team performance was objectively evaluated by an observer, using scenario recordings. Students individually assessed different aspects of debriefing and feedback.

RESULTS

Both debriefing and feedback groups showed similar overall increase in objective scores, with significant increase between days one and two (acquisition), and a smaller increase between days two and 20 (retention). Students indicated debriefing as the preferred discussion method.

CONCLUSION

Debriefing and feedback are effective post-scenario discussion methods, promoting acquisition and retention of non-technical skills, by undergraduate students. Allying debriefing reflexive practice with feedback directive style, and shifting appropriately between facilitation and instruction, can be a good compromise to achieve a timely and educationally meaningful discussion.

Filling the Core EPA 10 assessment void: A framework for individual assessment of Core Entrustable professional activity 10 competencies in medical students

Objectives

The goal of this study was to develop and evaluate a novel curriculum and assessment tool for Core Entrustable Professional Activity (EPA) 10 competencies and entrustment scoring in a cohort of medical students in their emergency medicine (EM) clerkship using a framework of individualized, ad hoc, formative assessment. Core EPA 10 is an observable workplace-based activity for graduating medical students to recognize a patient requiring urgent or emergent care and initiate evaluation and management.

Methods

This is a prospective, pretest-posttest study of medical students during their EM clerkship. Using the Thomas and Kern framework, we created a curriculum of simulation cases about chest pain/cardiac arrest and respiratory distress, which included novel assessment checklists, and instructional videos about recognizing and managing emergencies. Students were individually pretested on EPA 10 competencies using the simulation cases. Two raters scored students using standardized checklists. Students then watched instructional videos, underwent a posttest with the simulation cases, and were scored again by the two raters using the checklists. Differences between pretest and posttest scores were analyzed using paired t-tests and Wilcoxon signed-rank tests.

Results

Seventy-three out of 85 (86%) students completed the curriculum. Mean scores from pretest to final posttest in the chest pain/cardiac arrest and respiratory distress cases significantly improved from 14.8/19 (SD 1.91), to 17.1/19 (SD = 1.00), t(68) = 10.56, p < 0.001, and 8.5/13 (SD 1.79), to 11.1/13(SD 0.89), t(67) = 11.15, p < 0.001, respectively. The kappa coefficients were 0.909 (n = 2698, p < 0.001) and 0.931 (n = 1872, p < 0.001). Median modified Chen entrustment scores improved from 1b (i.e., "Watch me do this") to 2b (i.e., "I'll watch you") for the chest pain/cardiac arrest case (p < 0.001) and 1b/2a (i.e., "Watch me do this"/ "Let's do this together") to 3a (i.e. "You go ahead, and I'll double-check all of your findings") for the respiratory distress case (p < 0.001).

Conclusion

A new directed curriculum of standardized simulation cases and asynchronous instructional videos improved medical student performance in EPA 10 competencies and entrustment scores. This study provides a curricular framework to support formative individualized assessments for EPA 10.

Emergency medicine undergraduate simulation training during the COVID-19 pandemic: A course evaluation

OBJECTIVE

Reduction in patient-facing teaching encounters has limited practical exposure to Emergency Medicine for medical students. Simulation has traditionally provided an alternative to patient-facing learning, with increasing integration in courses. Rapid advancements in technology facilitate simulation of realistic complex simulations encountered in the emergency setting. This study evaluated the efficacy of high-fidelity simulation in undergraduate emergency trauma medicine teaching.

METHODS

A consultant trauma expert delivered an introductory lecture, followed by consultant-led small group transoesophageal echocardiogram (TOE) and chest drain simulations, and a splinting station. Participants then responded to a major trauma incident with simulated patients and high-fidelity mannequins. Pre- and post-surveys were administered to assess change in delegates' trauma surgery knowledge and confidence.

DESIGN

One-group pretest-posttest research design.

SETTING

A higher education institution in the United Kingdom.

PARTICIPANTS

A convenience sample of 50 pre-clinical and clinical medical students.

RESULTS

Recall of the boundaries of the safe triangle for chest drain insertion improved by 46% (p < 0.01), and knowledge of cardinal signs of a tension pneumothorax improved by 26% (p = 0.02). There was a 22% increase in knowledge of what transoesophageal echocardiograms (TOEs) measure (p = 0.03), and 38% increased knowledge of contraindications for splinting a leg (p < 0.01). The average improvement in knowledge across all procedures when compared to baseline was 35.8% immediately post-simulation and 22.4% at six-weeks post-simulation. Confidence working in an emergency setting increased by 24% (p < 0.001) immediately, and by 27.2% (p < 0.001) at six weeks.

CONCLUSIONS

The findings suggest that simulation training within emergency medicine can result in significant increases in both competency and confidence. Benefits were observed over a six-week period. In the context of reduced patient-facing teaching opportunities, emergency medicine simulation training may represent an invaluable mechanism for delivery of teaching.

Comparison of Digital Interactive Case-Based Educational Resource with Virtual Role Play in Dental Undergraduates in Clinical Oral Medicine/Oral Pathology Education

Case-based learning has always been a key element of dental education and the incorporation of technology into the concept became increasingly important during the COVID-19 pandemic. This study aimed to compare the effectiveness of a virtual interactive case resource in oral medicine/oral pathology, Virtual Oral Medicine Clinic (VOMC), with the virtual role play among third-year dental undergraduates. Fifty-one students were randomly assigned into two groups and the control group was subjected to a role play activity, whereas the experimental group was provided with VOMC. Both groups were assessed with an objective structured clinical examination (OSCE) before and after the intervention. Students’ self-perceived usefulness of the interventions was evaluated by a questionnaire and randomly selected students were invited for focus group discussions. Data were analysed using the Wilcoxon signed-rank test and the Mann−Whitney U test. Descriptive statistics were used to analyse student responses. Students in both groups demonstrated significant improvement (p < 0.001) in the post-test compared to the pre-test. Students in the experimental group demonstrated higher overall scores (p < 0.001) when compared to the control group. Though both methods were received favourably by the students, role play was more positively perceived when compared to digital resource. Though VOMC was shown to improve student scores, the perception of VOMC was not quantitatively superior to the role play activity. Hence VOMC can be recommended as an adjunct tool to enhance learning in oral medicine in undergraduate dental students.

Care of the dying - medical student confidence and preparedness: mixed-methods simulation study

OBJECTIVES

Of all doctors, Foundation Year 1 trainees spend the most time caring for dying patients yet report poor preparation and low confidence in providing this care. Despite documented effectiveness of simulation in teaching end-of-life care to undergraduate nurses, undergraduate medicine continues to teach this subject using a more theoretical, classroom-based approach. By increasing undergraduate exposure to interactive dying patient scenarios, simulation has the potential to improve confidence and preparedness of medical students to care for dying patients. The main study objective was to explore whether simulated experience of caring for a dying patient and their family can improve the confidence and preparedness of medical students to provide such care.

METHODS

A mixed-methods interventional study simulating the care of a dying patient was undertaken with serial measures of confidence using the Self Efficacy in Palliative Care (SEPC) tool. Significance testing of SEPC scores was undertaken using paired t-tests and analysis of variance. Post-simulation focus groups gathered qualitative data on student preparedness. Data were transcribed using NVivo software and interpreted using Thematic Analysis.

RESULTS

Thirty-eight 4th-year students participated. A statistically significant post-simulation increase in confidence was seen for all SEPC domains, with sustained confidence observed at 6 months. Focus group data identified six major themes: current preparedness, simulated learning environment, learning complex skills, patient centredness, future preparation and curriculum change.

CONCLUSION

Using simulation to teach medical students how to care for a dying patient and their family increases student confidence and preparedness to provide such care.

Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol

INTRODUCTION

COVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19 increasingly return to the emergency department (ED) for care. This leads to new challenges and threats to patient and clinician safety as suspected patients with COVID-19 need to be quickly detected and isolated among other patients with non-COVID-19-related illnesses. At the front lines, emergency physicians also face continued personal safety concerns and increased work burden, which heighten stress and anxiety, especially given the prolonged course of the pandemic. Burnout, already a serious concern for emergency physicians due to the cumulative stresses of their daily practice, may present as a longer-term outcome of these acute stressors.

METHODS AND ANALYSIS

We will implement a rapidly adaptive simulation-based approach to understand and improve physician preparedness while decreasing physician stress and anxiety. First, we will conduct semi-structured qualitative interviews and human factor observations to determine the challenges and facilitators of COVID-19 preparedness and mitigation of physician stress. Next, we will conduct a randomised controlled trial to test the effectiveness of a simulation preparedness intervention on physician physiological stress as measured by decreased heart rate variability on shift and anxiety as measured by the State-Trait Anxiety Inventory.

ETHICS AND DISSEMINATION

The protocol was reviewed and approved by the Agency for Healthcare Research and Quality for funding, and ethics approval was obtained from the Yale University Human Investigation Committee in 2020 (HIC# 2000029370 and 2000029372). To support ongoing efforts to address clinician stress and preparedness, we will strategically disseminate the simulation intervention to areas most impacted by COVID-19. Using a virtual telesimulation and webinar format, the dissemination efforts will provide hands-on learning for ED and hospital administrators as well as simulation educators.

TRIAL REGISTRATION NUMBER

NCT04614844.

An Infant Phantom for Pediatric Pericardial Access and Electrophysiology Training

Background

Cardiac procedures in infants and children require a high level of skill and dexterity owing to small stature and anatomy. Lower incidence of procedure volume in this population results in fewer clinical opportunities for learning. Simulators have grown in popularity for education and training, though most existing simulators are often cost-prohibitive or model adult anatomy.

Objective

Develop a low-cost simulator for practicing the skills to perform percutaneous pericardial access and cardiac ablation procedures in pediatric patients.

Methods

We describe 2 simulators for practicing cardiac procedures in pediatric patients, with a total cost of less than $500. Both simulators are housed within an infant-size doll. The first simulator is composed of an infant-size heart and a skin-like covering to practice percutaneous pericardial access to the heart. Participants obtained sheath access to the heart under direct visualization. The second simulator houses a child-size heart with 7 touch-activated targets to practice manipulating a catheter through a small heart. This can be performed under direct visualization and with 3-dimensional mapping via CARTO. Participants manipulated a catheter to map the heart by touching the 6 positive targets, avoiding the negative target.

Results

Physicians-in-training improved their time to complete the task between the first and second attempts. Physicians experienced with the tools took less time to complete the task than physicians-in-training.

Conclusion

This inexpensive simulator is anatomically realistic and can be used to practice manipulating procedure tools and develop competency for pediatric cardiac procedures.

A Call for Change. Can 3D Printing Replace Cadavers for Surgical Training?

While cadaveric dissection has stood the test of time because of its widely accepted educational value by experienced surgeons, the introduction advances in 3D printing and biomaterial technologies could potentially provide alternative tools for surgical training. This novel concept in simulation (physical reality) would encompass all the benefits of cadavers in terms of realism and clinical relevance without any of its ethical, infection, safety, and financial concerns.

Evaluation of Training in Pediatric Ultrasound-guided Vascular Cannulation Using a Model

Background:

The study objective was to evaluate a training program and a training model for pediatric ultrasound-guided vascular cannulation (USGVC) by inexperienced operators.

Methods:

An observational descriptive study was conducted at the pediatric intensive care unit of a level-III hospital. The study protocol comprised the following parts: (1) pretraining test; (2) theory and practice training session consisting of an explanation of basic vascular ultrasound concepts plus performing vascular cannulation in a model; (3) posttraining test; and (4) evaluation of the training model.

Results:

A total of 25 health-care professionals participated in the study. All of them possessed the skills to locate vessels and ultrasound planes, and they performed USGVC using the training model. On a 1–5 scale, the model was rated to have 87.6% fidelity with real pediatric patients; the best regarded aspect of it was utility (93%). Differences were found between pre- and post-training scores: 2.72 ± 0.84 versus 4.60 ± 0.50; P < 0.001 (95% confidence interval: −2.28, −1.47). Altogether, 300 ultrasound-guided cannulation procedures were carried out (12 per participant) distributed along the longitudinal axis in plane and the transverse axis out of plane, with 150 punctures in each of them. The success rate for USGVC in the training model was 79.7%, the mean time for the procedure was 115.6 ± 114.9 s, and the mean time for achieving successful cannulation was 87.69 ± 82.81 s. The mean number of trials needed for successful USGVC was 1.49 ± 0.86.

Conclusion:

After undergoing the theory–practice training, participants: (a) improved their knowledge of ultrasound-guided vascular access; (b) positively evaluated the USGVC training model, in particular its utility and fidelity as compared with cannulation in pediatric patients; and (c) achieved a high USGVC success rate in a relatively short time.

Obliterated Posterior Cul-de-sac Laparoscopic Surgical Simulation

BACKGROUND

Obliteration of the posterior cul-de-sac is a challenging, often unexpected surgical finding. Developing the dissection skills required to manage this finding during laparoscopy is essential for optimizing treatment of many pain disorders during hysterectomy or ovarian surgery; however, exposure of trainees to cul-de-sac dissection is variable. Currently, there are no widely available simulation models for teaching and practicing this technique.

METHOD

Our aim is to design a low-cost and high-fidelity laparoscopic simulation model that represents key anatomical structures and emphasizes skills for laparoscopic dissection of an obliterated posterior cul-de-sac.

EXPERIENCE

A three-dimensional model was created and is described. Nine experts (gynecologic surgery fellows and attendings) and 17 residents completed a single 30-minute simulation session and completed several assessments to begin establishing the face validity of this model.

CONCLUSION

Experts and residents rated the obliterated cul-de-sac simulation as highly realistic and useful. Residents showed a statistically significant increase in comfort with the dissection, from a median Likert score of 1 out of 5 (interquartile range 1-1) to 3 out of 5 (interquartile range 2-3) (P<.001). Experts scored better than residents on blinded video grading of model performance (P<.001). This low-cost and easily reproducible model fills a critical gap in gynecologic surgery education.

Understanding how the motivational dimension of learning is influenced by clinical teaching in medical education: A prospective cohort study

Introduction

Many changes of medical curricula have been conducted in the past years. Based on learning psychology, three dimensions of learning have to be covered, in order to create the best possible curricula: Cognitive, metacognitive and motivational. The metacognitive and cognitive dimension (what/how to teach) have always been considered and the motivational dimension has been neglected, although the importance and benefits of motivation in learning have been emphasized repeatedly. One way to influence motivation in medical curricula are the teaching formats, as it has been shown that the construction of a curriculum can influence students' motivation. So far, evidence about the motivational effects of teaching formats are scarce.

Methods

In a prospective interventional cohort study, 145 3rd year medical students were sampled. The effects of a 3-day bedside teaching in the operating theatre and two simulation-based trainings on students' motivation (outcome measure) were analysed. It was hypothesized, that the simulation training and the bedside teaching enhance autonomous motivation and decrease controlled motivation.

Results

The bedside-teaching decreased external (controlled) motivation (-0.14, p = .013, 95% CI [-0.24, -0.03]), alongside with identified (autonomous) motivation (-0.22, p < .001, 95% CI [-0.34, -0.10]). The simulation-based trainings did not change students' motivation.

Conclusion

To prevent the unintended decrease of identified (autonomous) motivation, undergraduates should be supervised and introduced carefully, when attending bedside teaching in unknown medical fields. Simulation-based medical education certainly has plenty of benefits in medical education but its effects on the motivational dimension of learning needs further investigations.

The impact of interprofessional simulation experiences in occupational and physical therapy education: a qualitative study

Abstract Interprofessional experiences are an essential part of preparing occupational and physical therapy students for clinical practice. Simulation has been used to help students achieve clinical competencies, including interprofessional competencies. The following study aimed to explore the students’ perceptions of an interprofessional simulation experience, identify opportunities for the integration of interprofessional experiences across the curriculum, and document the design elements that positively influenced the outcomes of the interprofessional simulation experience. An exploratory case study design was used to examine the study aims. Focus groups were used to collect qualitative data from 85 graduate-level occupational and physical therapy students. Thematic analysis was completed on the focus group transcripts. Results from the students indicated that they perceived the interprofessional simulation experience to be beneficial to the development of affective skills and role identity. The students identified a desire for increased exposure to interprofessional education experiences throughout the curriculum. The design and implementation of the interprofessional simulation were positively received by students due to the emphasis on creating a realistic experience and despite initial student anxiety related to the experience. Interprofessional simulation is a valuable and appropriate method for engaging students in interprofessional education and developing interprofessional skills based on the results of the current study. Documenting the process of designing and implementing an interprofessional simulation may assist other programs in developing interprofessional simulation opportunities for healthcare students.

High-Fidelity Simulation Education and Crisis Resource Management

This article explores high-fidelity simulation in anesthesiology education and provides strategies for its use to improve management of critical events. Educational theories that underlie the use of simulation are described. High-fidelity simulation is useful in teaching technical (diagnostic and procedural) and nontechnical (communication and professionalism) skills, including crisis resource management (CRM) skills. The practice of CRM is fundamental to ensuring patient safety during critical events and to the safe practice of anesthesiology, and its critical elements are presented. A discussion of the use of high-fidelity simulation to learn to combine highly complex procedural skills and CRM is also provided.

Using Virtual Reality in Biomedical Engineering Education

This study explored virtual reality (VR) as an educational tool to offer immersive and experiential learning environments to biomedical engineering (BME) students. VR and traditional two-dimensional (2D) videos were created and used to teach required communication skills to BME students' while working with clinical partners in healthcare settings. The videos of interdisciplinary teams (engineering and nursing students) tackling medical device-related problems, similar to those commonly observed in healthcare settings, were shown to BME students. Student surveys indicated that, through VR videos, they felt more immersed in real-world clinical scenarios while learning about the clinical problems, each team-member's areas of expertise, their roles and responsibilities, and how an interdisciplinary team operated collectively to solve a problem in the presented settings. Students with a prior in-person immersion experience, in the presented settings, reported VR videos to serve as a possible alternative to in-person immersion and a useful tool for their preparedness for real-world clinical immersion. We concluded that VR holds promise as an educational tool to offer simulated clinical scenarios that are effective in training BME students for interprofessional collaborations.

Stakeholder perceptions about the establishment of medical simulation-based learning at a university in a low resource setting: a qualitative study in Uganda

BACKGROUND

Simulation based learning (SBL) is a technique where teachers recreate "real life" clinical experiences for health care teams for purposes of gaining clinical skills in a safe environment. There is evidence that SBL is superior to the traditional clinical teaching methods for acquisition of clinical skills. Although it is well established in resource rich settings, there is limited experience in resource limited settings and there is uncertainty regarding how SBL will be perceived among the stakeholders in medical education. As part of the steps leading to implementation of a SBL program at a university in Uganda, we sought to describe the perceptions of various stakeholders regarding the introduction of SBL methodology into learning at a medical school in Uganda.

METHODS

We conducted a formative qualitative assessment using key informant interviews (KIIs) among faculty members and university administrators and focus group discussions (FGDs) among medical and nursing students at Mbarara University of Science and Technology. Data were collected till saturation point and were transcribed and analyzed manually using open and axial coding approaches to develop themes.

RESULTS

We conducted seven KIIs and three FGDs. Overall, findings were categorized into five broad themes: 1. Motivation to adopt simulation-based learning 2. Prior experience and understanding of simulation-based education 3. Outcomes arising from introduction of medical simulation 4. Drawbacks to establishment of medical simulation; and 5. Potential remedies to the drawbacks. Overall, our data show there was significant buy-in from the institution for SBL, stakeholders were optimistic about the prospects of having a new method of teaching, which they perceived as modern to complement the traditional methods. There was significant knowledge but very limited prior experience of medical simulation. Also, there was some concern regarding how students and faculty would embrace training on lifeless objects, the human resources needed and sustainability of simulation-based learning in the absence of external funding.

CONCLUSION

Stakeholders perceive SBL positively and are likely to embrace the learning methods. Concerns about human resource needs and sustainability need to be addressed to ensure acceptability.

Increasing Medical Student Engagement Through Virtual Rotations in Radiation Oncology

Corona virus disease 2019 (COVID-19) affected medical student clerkships and education around the country. A virtual medical student clerkship was created to integrate didactic education with disease specific lectures for medical students, contouring, and hands on learning with telehealth. Twelve medical students in their 3rd and 4th year were enrolled in this 2 week elective from April 27, 2020 to June 5, 2020. There was significant improvement of overall knowledge about the field of radiation oncology from pre elective to post elective (P < .001). Feedback included enjoying direct exposure to contouring, telehealth, and time with residents. Overall this 2 week rotation was successful in integrating radiation oncology virtually for medical students. This is now being expanded to multiple institutions as an educational resource and future rotations for medical students.

S-Vest: a novel hybrid method to allow standardised patients to put on the objective physical examination findings of a disease

Background

Simulation hybrids combine single modality simulation such as simulated patients (SP) with low-fidelity simulation to create a potentially more powerful set of educational tools. To make a hybrid that is credible, standardised and inexpensive remains a challenge. We describe the development of the simulation vest (S-Vest), an inexpensive, standardised teaching tool that is ‘worn’ by an SP to form a hybrid.

Methods

We have created a vest which contains a set of speakers placed in an anatomical manner and produce sounds. The sounds played from a multitrack audio player are recorded in vivo from a patient with the real disease findings. The SP provides history while the vest provides the objective palpable and auscultatory findings. The speakers are placed in the routine standardised locations taught in physical examination.

Results

We have developed several case scenarios designed for the vest. One of these cases is an elderly patient with aortic stenosis. The aortic stenosis case audio file has four unique tracks recorded over the precordium. Each track is played at the speaker appropriate to the physical exam findings. The SP plays an elderly man with chest pain. The vest provides the sounds of a loud systolic murmur with marked diminishment of S2 and a palpable thrill.

Conclusions

The S-Vest is a low-fidelity, low-cost simulator to use in hybrid and simulation. The S-Vest can be used in a formative and summative Objective Structured Clinical Examination (OSCE) station and in skills attainment for learners in healthcare. We believe these tools will be of significant import to teaching clinical skills.

Efficacy of Clinical Simulation-Based Training in Biomedical Engineering Education

The need for biomedical engineering (BME) students to be trained in real-world healthcare settings, where most medical device industry emerges, is imperative. Clinical immersion helps accomplish this training goal. However, the growing student population in the field of BME and a shortage of clinical collaborators offer serious limitations to the clinical immersion experience. This paper describes the use of a clinical simulation-based training (SBT) tool in BME education as an alternative resource to the real-world clinical immersion experience. Through the inclusion of simulation labs in BME courses, we assessed their efficacy in need-finding and enhancing students' understanding of the current challenges of existing medical technology. We also explored the possibility of offering cross-disciplinary learning environments in these simulation labs, including engineers and students from other healthcare disciplines such as nursing. Simulation labs served as a helpful tool in the need-finding phase of the design process, and the immersed students reported higher adaptive and life-long learning outcomes. Students also reported the simulation lab immersion to be valuable to their future goals as engineers. Furthermore, the SBT labs offered repetitive training in a controlled learning environment, inclusion of an interdisciplinary setting, and feedback through student reflections. The inclusion of simulation lab immersion and SBT labs in the two BME courses served as an useful and alternative educational tool that helped train students to better understand the needs of the healthcare industry while working in interdisciplinary settings.

Simulation-Based Education for Physicians to Increase Oral Anticoagulants in Hospitalized Elderly Patients with Atrial Fibrillation

PURPOSE

This study was intended to determine whether a simulation-based education addressed to physicians was able to increase the proportion of hospitalized elderly with atrial fibrillation prescribed with oral anticoagulants (OACs) compared with the usual practice.

METHODS

We conducted a cluster randomized trial (from April 2015 to September 2018) on 32 Italian internal medicine and geriatric wards randomized 1:1 to intervention or control arms. The physicians of wards randomized to intervention received a computer-based e-learning tool with clinical scenarios (Dr Sim), and those of wards randomized to control received no formal educational intervention. The primary outcome was the OAC prescription rate at hospital discharge in the intervention and control arms.

RESULTS

Of 452 patients scrutinized, 247 were included in the analysis. Of them, 186 (75.3%) were prescribed with OACs at hospital discharge. No difference was found between the intervention and control arms in the post-intervention phase (odds ratio, 1.46; 95% confidence interval [CI], 0.81-2.64). The differences from the pre- to post-intervention phases in the proportions of patients prescribed with OACs (15.1%; 95% CI, 0%-31.5%) and with direct oral anticoagulants (DOACs) (20%; 95% CI, 0%-39.8%) increased more in the intervention than in the control arm.

CONCLUSIONS

This simulation-based course did not succeed in increasing the rate of elderly patients prescribed with OACs at hospital discharge compared with the usual practice. Notwithstanding, over time there was a greater increase in the intervention than in the control arm in the proportion of patients prescribed with OACs and DOACs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03188211.

Developing an undergraduate paediatric simulation workshop in a resource constrained setting: A practical 'how to' guide

Simulation has been increasingly used in the delivery of undergraduate paediatric medical education in recent years, particularly in the context of managing acutely unwell children. We describe our methodology in delivering a simulation workshop within a resource-constrained setting, defined as a clinical environment limited by time, clinical duties and access to appropriate space and/or equipment. An outline for the workshop is provided, with examples of relevant resources, to facilitate the development of similar simulation teaching in other centres. Preliminary evaluation of student feedback is presented, exploring the learning points encountered and aspects of the workshop that students found useful.

ACS/ASE Medical Student Simulation-Based Skills Curriculum Study: Implementation Phase

OBJECTIVE

Patient safety initiatives have revealed a need for standardized medical student skills curricula. In 2014 the America College of Surgeons/Association for Surgical Education Medical Student Simulation-based Skills Research Collaborative initiated a multisite study to implement and study the effect of a skills curriculum during the surgical clerkship.

DESIGN

Students underwent knot-tying and suturing sessions. They performed a self-evaluation survey before and after the modules to assess their comfort level with the skills. Faculty members also evaluated the students at the completion of the skills sessions. The comfort level choices were: needs further review; proficient in simulated setting with assistance; proficient in simulated setting without assistance; and proficient in clinical setting under supervision.

RESULTS

At the completion of the modules greater than 99.3% and 98.5% of students reported that they were proficient in knot-tying and suturing, respectively, in either a simulated or clinical environment. Similarly, when faculty evaluated student performance after a session, simulated or clinically proficiency reached over 97% for both two-handed and instrument knot-tying. The faculty rated the students 86.6% proficient for suturing.

CONCLUSIONS

After completing the modules, a large percentage of students obtained proficiency in knot-tying and suturing, representing technical skills improvements noted by both the participants and the evaluating faculty. The America College of Surgeons/Association for Surgical Education medical student surgical skills modules represent expert developed, low cost, easy to access resources that should continue to be evaluated and disseminated to medical student learners.

Evaluation of the effectiveness of four different training techniques in the development of non-stress testing application skills: A randomised controlled trial

BACKGROUND

A range of teaching methods are employed to upgrade students' skills, lower anxiety levels and improve satisfaction in nursing and midwifery education.

AIM

This study was conducted to evaluate the effect of different training techniques on the development of students' non-stress test (NST) application skills, satisfaction with education and reduction of their anxiety levels.

METHOD

The study was designed as a single-blind randomised controlled trial and carried out in four groups (n = 82), namely, video demonstration (VD), simulation with birth model (SBM), hybrid simulation (HS) and control (CG). A student information form, the NST skills evaluation form and the Spielberger State Anxiety Inventory were used to collect the study data.

RESULTS

Satisfaction with education was higher in the HS and SBM groups compared to the CG and VD groups (p < 0.001). No differences were found between the groups in terms of students' anxiety levels (p > 0.05). While there were no differences between the groups in the preparation phase in terms of NST skill scores (p > 0.05), the differences between the groups in the application and evaluation stages of the procedure were significant (p < 0.001). The highest score regarding the total score medians of NST skills belonged to the HS group, and the differences between the groups were found to be statistically significant (p < 0.001).

CONCLUSION

The findings of this study indicated that simulation techniques enhanced the students' clinical practice skills and satisfaction with their education.

Utilization of high-fidelity simulation for medical student and resident education of allergic-immunologic emergencies

BACKGROUND

The advantages of clinical simulation used in medical education include the acquisition of clinical skills in a controlled setting, promoting a multidisciplinary approach to patient care, and a high degree of learner satisfaction.

OBJECTIVE

We aimed to identify knowledge gaps among Internal Medicine residents and students in the diagnosis and treatment of anaphylaxis and angiotensin-converting enzyme (ACE)-inhibitor-induced angioedema through their participation in a simulation course.

METHODS

We conducted a cohort study involving clinical simulations with a high-fidelity, patient-simulator. The cases (antibiotic-induced anaphylaxis and ACE-inhibitor-induced angioedema) were standardized and algorithmic. Participants completed a pre- and post- simulation knowledge assessment and course evaluation. A follow-up knowledge survey was sent out 6 to 12 months after the course completion.

RESULTS

Twelve groups comprising 45 medical students and residents completed the anaphylaxis course. All groups diagnosed anaphylaxis after more than 2-organ-system involvement had manifested, and half of the groups made the diagnosis after the patient-simulator was in anaphylactic shock. Half gave an incorrect dose of epinephrine, and most of the participants were inexperienced in epinephrine auto-injector (EAI) administration. Eight groups comprising 27 participants completed the ACE-inhibitor-angioedema course. Six of the groups correctly diagnosed the patient-simulator, but multiple incorrect treatments were given, and only 1 group successfully intubated the patient-simulator. Knowledge improved immediately after the simulation, and knowledge specific to EAI treatment seemed to be retained long-term. All participants agreed that the simulation was practical to their education.

CONCLUSION

Clinical simulation improves knowledge on the diagnosis and treatment of anaphylaxis and ACE-inhibitor-induced angioedema. We advocate that clinical simulation be incorporated at institutions with appropriate capabilities.

Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis

OBJECTIVE

The purpose was to analyse the effectiveness of high-fidelity patient simulation (HFPS) based on life-threatening clinical condition scenarios on undergraduate and postgraduate nursing students' learning outcomes.

DESIGN

A systematic review and meta-analysis were conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and its reporting was checked against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

DATA SOURCES

PubMed, Scopus, CINAHL with Full Text, Wiley Online Library and Web of Science were searched until July 2017. Author contact, reference and citation lists were checked to obtain additional references.

STUDY SELECTION

To be included, available full-texts had to be published in English, French, Spanish or Italian and (a) involved undergraduate or postgraduate nursing students performing HFPS based on life-threatening clinical condition scenarios, (b) contained control groups not tested on the HFPS before the intervention, (c) contained data measuring learning outcomes such as performance, knowledge, self-confidence, self-efficacy or satisfaction measured just after the simulation session and (d) reported data for meta-analytic synthesis.

REVIEW METHOD

Three independent raters screened the retrieved studies using a coding protocol to extract data in accordance with inclusion criteria.

SYNTHESIS METHOD

For each study, outcome data were synthesised using meta-analytic procedures based on random-effect model and computing effect sizes by Cohen's d with a 95% CI.

RESULTS

Thirty-three studies were included. HFPS sessions showed significantly larger effects sizes for knowledge (d=0.49, 95% CI [0.17 to 0.81]) and performance (d=0.50, 95% CI [0.19 to 0.81]) when compared with any other teaching method. Significant heterogeneity among studies was detected.

CONCLUSIONS

Compared with other teaching methods, HFPS revealed higher effects sizes on nursing students' knowledge and performance. Further studies are required to explore its effectiveness in improving nursing students' competence and patient outcomes.

Medical simulation in pharmacology learning and retention: A comparison study with traditional teaching in undergraduate medical students

The purpose of the study was to determine whether low-high fidelity medical simulation improves learning and long-lasting retention of pharmacology knowledge, compared to lecture alone, in undergraduate medical students. Ninety students, before a 45-minute lecture, were randomized into three groups - sham (S), low (LF), and high fidelity (HF) simulation - to participate in an interactive simulation session. To evaluate immediate and long-lasting retention, a 20-item structured questionnaire on inotropic agents was administered to 90 students before and after a 45-minute lecture, after simulation, and 3 months later. In all groups, the rate of correct answers increased after lecture, while no difference was observed between different groups (P = 0.543). After simulation, students in the HF group provided more correct answers compared to S or LF group (P > 0.001). After 3 months, a significant decrease in the number of correct answers was observed in S (P < 0.001) and LF (P < 0.001) groups, but not in the HF group (P = 0.066). Moreover, HF simulation resulted in an increased number of correct answers compared to the LF (P < 0.001) or S simulation (P < 0.001). These data suggest that advanced medical simulation teaching applied to pharmacology is associated with more effective learning and long-lasting retention compared to lecture alone.

Application of high-fidelity simulation in critical care residency training as an effective learning, assessment, and prediction tool for clinical performance

BACKGROUND/PURPOSE

This study was conducted to assess: 1) the impact of the HFS curriculum on residents' knowledge and skills, and 2) the correlation between learning outcomes and the clinical performance.

METHODS

An HFS-based curriculum was implemented for junior residents prior to their ICU rotations. Residents completed written tests before (pre-test) and after (post-test) the curriculum and were assessed on their performance during the simulation sessions. Clinical performance was evaluated using global rating for knowledge, clinical skills, and leadership and decision-making skills.

RESULTS

Complete data on pre-, post-test, simulation performance assessment, and clinical performance evaluation were available for 69 residents. Residents scored higher on their written post-test (64.6) compared with the pre-test (57.0) (p < 0.01). The simulation performance of residents improved between their first (3.43) and second (3.60) sessions (p < 0.05). Post-test scores correlated poorly with simulation performance (r = 0.03-0.28). Multivariable linear regression analysis revealed that clinical performance correlated better and significantly with simulation performance than the post-test for knowledge and clinical skills.

CONCLUSION

HFS is an effective training strategy, and can also be a complementary assessment tool to the written examinations and has better correlation with clinical performance.

Eye-Hand Coordination Patterns of Intermediate and Novice Surgeons in a Simulation-Based Endoscopic Surgery Training Environment

Endoscopic surgery procedures require specific skills, such as eye-hand coordination to be developed. Current education programs are facing with problems to provide appropriate skill improvement and assessment methods in this field. This study aims to propose objec-tive metrics for hand-movement skills and assess eye-hand coordination. An experimental study is conducted with 15 surgical residents to test the newly proposed measures. Two computer-based both-handed endoscopic surgery practice scenarios are developed in a simulation environment to gather the participants' eye-gaze data with the help of an eye tracker as well as the related hand movement data through haptic interfaces. Additionally, participants' eye-hand coordination skills are analyzed. The results indicate higher correla-tions in the intermediates' eye-hand movements compared to the novices. An increase in intermediates' visual concentration leads to smoother hand movements. Similarly, the novices' hand movements are shown to remain at a standstill. After the first round of practice, all participants' eye-hand coordination skills are improved on the specific task targeted in this study. According to these results, it can be concluded that the proposed metrics can potentially provide some additional insights about trainees' eye-hand coordi-nation skills and help instructional system designers to better address training requirements.

Comparison of simulation debriefs with traditional needs assessment methods: a qualitative exploratory study in a critical care community setting

OBJECTIVE

To better understand the potential of a needs assessment approach using qualitative data from manikin-based and virtual patient simulation debriefing sessions compared with traditional data collection methods (ie, focus groups and interviews).

DESIGN

Original data from simulation debrief sessions was compared and contrasted with data from an earlier assessment of critical care needs in a community setting (using focus groups and interviews), thus undertaking secondary analysis of data. Time and cost data were also examined. Debrief sessions were coded using deductive and inductive techniques. Matrices were used to explore the commonalities, differences and emergent findings across the methods.

SETTING

Critical care unit in a community hospital setting.

RESULTS

Interviews and focus groups yielded 684 and 647 min of audio-recordings, respectively. The manikin-based debrief recordings averaged 22 min (total=130 min) and virtual patient debrief recordings averaged 31 min (total=186 min). The approximate cost for the interviews and focus groups was $13 560, for manikin-based simulation debriefs was $4030 and for the virtual patient debriefs was $3475. Fifteen of 20 total themes were common across the simulation debriefs and interview/focus group data. Simulation-specific themes were identified, including fidelity (environment, equipment and psychological) and the multiple roles of the simulation instructor (educative, promoting reflection and assessing needs).

CONCLUSIONS

Given current fiscal realities, the dual benefit of being educative and identifying needs is appealing. While simulation is an innovative method to conduct needs assessments, it is important to recognise that there are trade-offs with the selection of methods.

Simulation-based education: A narrative review of the use of VERT in radiation therapy education

Simulation has a long history in medical and health science training and education. The literature describing this history is extensive. The role simulation plays in many health disciplines has evolved, as has the focus of the literature around it. The Virtual Environment for Radiotherapy Training (VERT) system is a relative newcomer to radiation therapy education and, similar to the literature around radiation therapy (RT) education, is still in its infancy. This narrative review sets the scene of simulation-based education within the health sciences and considers the lessons learned from published work on VERT to date. The evidence suggests that future inquiry involving VERT should explore different ways in which VERT can be used to contribute to the skillset required by the radiation therapist of tomorrow.

Use of Simulation in Performance Improvement

Human error and system failures continue to play a substantial role in preventable errors that lead to adverse patient outcomes or death. Many of these deaths are not the result of inadequate medical knowledge and skill, but occur because of problems involving communication and team management. Anesthesiologists pioneered the use of simulation for medical education in an effort to improve physician performance and patient safety. This article explores the use of simulation for performance improvement. Educational theories that underlie effective simulation programs are described as driving forces behind the advancement of simulation in performance improvement.

Traffic flow and microbial air contamination in operating rooms at a major teaching hospital in Ghana

BACKGROUND

Current literature examining the relationship between door-opening rate, number of people present, and microbial air contamination in the operating room is limited. Studies are especially needed from low- and middle-income countries, where the risk of surgical site infections is high.

AIM

To assess microbial air contamination in operating rooms at a Ghanaian teaching hospital and the association with door-openings and number of people present. Moreover, we aimed to document reasons for door-opening.

METHODS

We conducted active air-sampling using an MAS 100^® portable impactor during 124 clean or clean-contaminated elective surgical procedures. The number of people present, door-opening rate and the reasons for each door-opening were recorded by direct observation using pretested structured observation forms.

FINDINGS

During surgery, the mean number of colony-forming units (cfu) was 328 cfu/m³ air, and 429 (84%) of 510 samples exceeded a recommended level of 180 cfu/m³. Of 6717 door-openings recorded, 77% were considered unnecessary. Levels of cfu/m³ were strongly correlated with the number of people present (P = 0.001) and with the number of door-openings/h (P = 0.02). In empty operating rooms, the mean cfu count was 39 cfu/m³ after 1 h of uninterrupted ventilation and 52 (51%) of 102 samples exceeded a recommended level of 35 cfu/m³.

CONCLUSION

The study revealed high values of intraoperative airborne cfu exceeding recommended levels. Minimizing the number of door-openings and people present during surgery could be an effective strategy to reduce microbial air contamination in low- and middle-income settings.

Ultrasound-Guided Vascular Access Simulator for Medical Training: Proposal of a Simple, Economic and Effective Model

OBJECTIVE

To present a simple and affordable model able to properly simulate an ultrasound-guided venous access.

DESIGN

The simulation was made using a latex balloon tube filled with water and dye solution implanted in a thawed chicken breast with bones.

RESULTS

The presented model allows the simulation of all implant stages of a central catheter. The obtained echogenicity is similar to that observed in human tissue, and the ultrasound identification of the tissues, balloon, needle, wire guide and catheter is feasible and reproducible.

CONCLUSION

The proposed model is simple, economical, easy to manufacture and capable of realistically and effectively simulating an ultrasound-guided venous access.

Does the unexpected death of the manikin in a simulation maintain the participants' perceived self-efficacy? An observational prospective study with medical students

BACKGROUND

The death of a simulated patient is controversial. Some educators feel that having a manikin die is prejudicial to learning; others feel it is a way of better preparing students for these situations. Perceived self-efficacy (PSE) reflects a person's perception of their ability to carry out a task. A high PSE is necessary to manage a task efficiently. In this study, we measured the impact of the death of a simulated patient on medical students' perceived self-efficacy concerning their ability to cope with a situation of cardiac arrest.

METHODS

We carried out a single-centre, observational, prospective study. In group 1 (n = 27), pre-graduate medical students were warned of the possible death of the manikin; group 2 students were not warned (n = 29). The students' PSE was measured at the end of the simulated situation and after the debriefing.

RESULTS

The PSE of the two groups was similar before the debriefing (p = 0.41). It had significantly progressed at the end of the debriefing (p < 0,001). No significant difference was noted between the 2 groups (p = 0.382).

CONCLUSIONS

The simulated death of the manikin did not have a negative impact on the students' PSE, whether or not they had been warned of the possible occurrence of such an event. Our study helps defend the position which supports the inclusion of unexpected death of the manikin in a simulation setting.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Provider Training to Screen and Initiate Evidence-Based Pediatric Obesity Treatment in Routine Practice Settings: A Randomized Pilot Trial

INTRODUCTION

This randomized pilot trial evaluated two training modalities for first-line, evidence-based pediatric obesity services (screening and goal setting) among nursing students.

METHOD

Participants (N = 63) were randomized to live interactive training or Web-facilitated self-study training. Pretraining, post-training, and 1-month follow-up assessments evaluated training feasibility, acceptability, and impact (knowledge and skill via simulation). Moderator (previous experience) and predictor (content engagement) analyses were conducted.

RESULTS

Nearly all participants (98%) completed assessments. Both types of training were acceptable, with higher ratings for live training and participants with previous experience (ps < .05). Knowledge and skill improved from pretraining to post-training and follow-up in both conditions (ps < .001). Live training demonstrated greater content engagement (p < .01).

CONCLUSIONS

The training package was feasible, acceptable, and efficacious among nursing students. Given that live training had higher acceptability and engagement and online training offers greater scalability, integrating interactive live training components within Web-based training may optimize outcomes, which may enhance practitioners' delivery of pediatric obesity services.

Neonatology faculty development using simulation

The goal of faculty development activities is to supply the public with knowledgeable, skilled, and competent physicians who are prepared for high performance in the dynamic and complex healthcare environment. Current faculty development programs lack evidence-based support and are not sufficient to meet the professional needs of practicing physicians. Simulation activities for faculty development offer an alternative to traditional, teacher-centric educational offerings. Grounded in adult learning theory, simulation is a learner-centric, interactive, efficient, and effective method to train busy professionals. Many of the faculty development needs of clinical neonatologists can be met by participating in simulation-based activities that focus on technical skills, teamwork, leadership, communication, and patient safety.

The Use of Clinical Simulation Systems to Train Critical Care Physicians

Intensive care units are complex and dynamic clinical environments in which the delivery of appropriate and timely care to critically ill patients depends on the integrated and efficient actions of providers with specialized training. The use of realistic clinical simulator systems can help to facilitate and standardize the training of critical-care physicians, nurses, respiratory therapists, and pharmacists without having the training process jeopardize the well-being of patients. In this article, we review the current state of the art of patient simulator systems and their applications to critical-care medicine, and we offer some examples and recommendations on how to integrate simulator systems into critical-care training.

A brief simulation intervention increasing basic science and clinical knowledge

BACKGROUND

The United States Medical Licensing Examination (USMLE) is increasing clinical content on the Step 1 exam; thus, inclusion of clinical applications within the basic science curriculum is crucial. Including simulation activities during basic science years bridges the knowledge gap between basic science content and clinical application.

PURPOSE

To evaluate the effects of a one-off, 1-hour cardiovascular simulation intervention on a summative assessment after adjusting for relevant demographic and academic predictors.

METHODS

This study was a non-randomized study using historical controls to evaluate curricular change. The control group received lecture (n l=515) and the intervention group received lecture plus a simulation exercise (n l+s=1,066). Assessment included summative exam questions (n=4) that were scored as pass/fail (≥75%). USMLE-style assessment questions were identical for both cohorts. Descriptive statistics for variables are presented and odds of passage calculated using logistic regression.

RESULTS

Undergraduate grade point ratio, MCAT-BS, MCAT-PS, age, attendance at an academic review program, and gender were significant predictors of summative exam passage. Students receiving the intervention were significantly more likely to pass the summative exam than students receiving lecture only (P=0.0003).

DISCUSSION

Simulation plus lecture increases short-term understanding as tested by a written exam. A longitudinal study is needed to assess the effect of a brief simulation intervention on long-term retention of clinical concepts in a basic science curriculum.