Simulation-based medical education: an ethical imperative

Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review

SUMMARY STATEMENT

This review aimed to explore existing literature on the use of in situ simulation to identify latent safety threats in emergency medicine. Studies were required to take place in a clinically active emergency department and have either a primary or secondary aim of identifying latent safety threats. A total of 2921 articles were retrieved through database searches and a total of 15 were deemed to meet the inclusion criteria.Latent safety threats were detected by a variety of methods including documentation during debrief/discussion (66%), during the simulation itself (33%), participant surveys (20%), and video analysis (20%). Using a multimodality approach with input from observers and participants from different professional backgrounds yielded the highest number of threats per simulation case (43 per case). Equipment was the most commonly reported threat (83%), followed by teamwork/communication (67%). Some studies did not report on mitigation of identified risks; formal processes should be implemented for the management of latent safety threats identified by in situ simulation. Future research should focus on translational outcomes to further strengthen the position of in situ simulation in emergency medicine.

Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

Learning with our peers: peer-led versus instructor-led debriefing for simulated crises, a randomized controlled trial

BACKGROUND

Although peer-assisted learning is known to be effective for reciprocal learning in medical education, it has been understudied in simulation. We aimed to assess the effectiveness of peer-led compared to instructor-led debriefing for non-technical skill development in simulated crisis scenarios.

METHODS

Sixty-one undergraduate medical students were randomized into the control group (instructor-led debriefing) or an intervention group (peer debriefer or peer debriefee group). After the pre-test simulation, the participants underwent two more simulation scenarios, each followed by a debriefing session. After the second debriefing session, the participants underwent an immediate post-test simulation on the same day and a retention post-test simulation two months later. Non-technical skills for the pre-test, immediate post-test, and retention tests were assessed by two blinded raters using the Ottawa Global Rating Scale (OGRS).

RESULTS

The participants' non-technical skill performance significantly improved in all groups from the pre-test to the immediate post-test, with changes in the OGRS scores of 15.0 (95% CI [11.4, 18.7]) in the instructor-led group, 15.3 (11.5, 19.0) in the peer-debriefer group, and 17.6 (13.9, 21.4) in the peer-debriefee group. No significant differences in performance were found, after adjusting for the year of medical school training, among debriefing modalities (P = 0.147) or between the immediate post-test and retention test (P = 0.358).

CONCLUSIONS

Peer-led debriefing was as effective as instructor-led debriefing at improving undergraduate medical students' non-technical skill performance in simulated crisis situations. Peer debriefers also improved their simulated clinical skills. The peer debriefing model is a feasible alternative to the traditional, costlier instructor model.

Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review

A double-lumen tube or bronchial blocker positioning using flexible bronchoscopy for lung isolation and one-lung ventilation requires specific technical competencies. Training to acquire and retain such skills remains a challenge in thoracic anesthesia. Recent technological and innovative developments in the field of simulation have opened up exciting new horizons and possibilities. In this narrative review, we examine the latest development of existing training modalities while investigating, in particular, the use of emergent techniques such as virtual reality bronchoscopy simulation, virtual airway endoscopy, or the preoperative 3D printing of airways. The goal of this article is, therefore, to summarize the role of existing and future applications of training models/simulators and virtual reality simulators for training flexible bronchoscopy and lung isolation for thoracic anesthesia.

Crisis-ready educational skills of life support in newborns and adults' scenarios: the impact of simulation-based training on student proficiency

OBJECTIVE

Aim: To assess the impact of multidisciplinary simulation training on the educational outcomes of medical students in the emergency care of adults and newborns and implement changes in the curriculum to master simulation scenarios more.

PATIENTS AND METHODS

Materials and Methods: To assess the differences in learning outcomes between medical students who study the same curriculum without simulation interventions and those who undergo multidisciplinary emergency care simulation training. A quasi-experimental approach was used to assign students to the Intervention Group or the Control Group.

RESULTS

Results: According to individual criteria, the lowest scores in both groups were obtained for the stages that required the greatest accuracy and correct technique. After the appropriate cycle of initiation, the results in both groups improved significantly, but the results of students from the first group were significantly higher than those of students from the second group. Despite the absence of a significant difference in the average overall score for the skills, students in the first group significantly improved the accuracy and correctness of the criteria that assess the technical aspects of performance, while students in the second group mainly improved the quality of the descriptive and communicative parts of the practical skill.

CONCLUSION

Conclusions: We believe that reallocating curricular time to additional hours dedicated to simulation scenarios will better prepare aspiring healthcare professionals for the demanding and dynamic nature of their career, as we continue to increase our understanding of the potential of simulation-based education.

Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results

INTRODUCTION

Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures.

MATERIALS AND METHODS

A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center.

RESULTS

A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model.

CONCLUSIONS

Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

E-Health: A Game Changer in Fetal and Neonatal Cardiology?

Technological advancements have greatly impacted the healthcare industry, including the integration of e-health in pediatric cardiology. The use of telemedicine, mobile health applications, and electronic health records have demonstrated a significant potential to improve patient outcomes, reduce healthcare costs, and enhance the quality of care. Telemedicine provides a useful tool for remote clinics, follow-up visits, and monitoring for infants with congenital heart disease, while mobile health applications enhance patient and parents' education, medication compliance, and in some instances, remote monitoring of vital signs. Despite the benefits of e-health, there are potential limitations and challenges, such as issues related to availability, cost-effectiveness, data privacy and security, and the potential ethical, legal, and social implications of e-health interventions. In this review, we aim to highlight the current application and perspectives of e-health in the field of fetal and neonatal cardiology, including expert parents' opinions.

Sepsis and Clinical Simulation: What Is New? (and Old)

BACKGROUND

Sepsis is a critical and potentially fatal condition affecting millions worldwide, necessitating early intervention for improved patient outcomes. In recent years, clinical simulation has emerged as a valuable tool for healthcare professionals to learn sepsis management skills and enhance them.

METHODS

This review aims to explore the use of clinical simulation in sepsis education and training, as well as its impact on how healthcare professionals acquire knowledge and skills. We conducted a thorough literature review to identify relevant studies, analyzing them to assess the effectiveness of simulation-based training, types of simulation methods employed, and their influence on patient outcomes.

RESULTS

Simulation-based training has proven effective in enhancing sepsis knowledge, skills, and confidence. Simulation modalities vary from low-fidelity exercises to high-fidelity patient simulations, conducted in diverse settings, including simulation centers, hospitals, and field environments. Importantly, simulation-based training has shown to improve patient outcomes, reducing mortality rates and hospital stays.

CONCLUSION

In summary, clinical simulation is a powerful tool used for improving sepsis education and training, significantly impacting patient outcomes. This article emphasizes the importance of ongoing research in this field to further enhance patient care. The shift toward simulation-based training in healthcare provides a safe, controlled environment for professionals to acquire critical skills, fostering confidence and proficiency when caring for real sepsis patients.

Automating medical simulations

OBJECTIVE

This study aims to explore speech as an alternative modality for human activity recognition (HAR) in medical settings. While current HAR technologies rely on video and sensory modalities, they are often unsuitable for the medical environment due to interference from medical personnel, privacy concerns, and environmental limitations. Therefore, we propose an end-to-end, fully automatic objective checklist validation framework that utilizes medical personnel's uttered speech to recognize and document the executed actions in a checklist format.

METHODS

Our framework records, processes, and analyzes medical personnel's speech to extract valuable information about performed actions. This information is then used to fill the corresponding rubrics in the checklist automatically.

RESULTS

Our approach to activity recognition outperformed the online expert examiner, achieving an F1 score of 0.869 on verbal tasks and an ICC score of 0.822 with an offline examiner. Furthermore, the framework successfully identified communication failures and medical errors made by physicians and nurses.

CONCLUSION

Implementing a speech-based framework in medical settings, such as the emergency room and operation room, holds promise for improving care delivery and enabling the development of automated assistive technologies in various medical domains. By leveraging speech as a modality for HAR, we can overcome the limitations of existing technologies and enhance workflow efficiency and patient safety.

Heart rate responses in critical care trainees during airway intubation: a comparison between the simulated and clinical environments

OBJECTIVE

This study aimed to compare the heart rate response to stress during airway intubations in clinical practice and a simulated environment.

METHODS

Twenty-five critical care registrars participated in the study over a 3-month period. Heart rate data during intubations was recorded by a FitBit® Charge 2 worn by each participant during their clinical practice, and during a single simulated airway management scenario. The heart rate range was calculated by subtracting the baseline working heart rate (BWHR) from the maximum functional heart rate (MFHR). For each airway intubation performed participants recorded an airway diary entry. Data from intubations performed in the clinical environment was compared to data from a simulated environment. Heart rate changes were observed in two ways: percentage rise (median) across the 20-min intubation period and; percentage rise at point of intubation (median).

RESULTS

Eighteen critical care registrars completed the study, mean age 31.8 years (SD = 2.015, 95% CI = 30.85-32.71). Throughout the 20-min peri-intubation recording period there was no significant difference in the median change in heart rates between the clinical (14.72%) and simulation (15.96%) environment (p = 0.149). At the point of intubation there was no significant difference in the median change in heart rate between the clinical (16.03%) and the simulation (25.65%) environment groups (p = 0.054).

CONCLUSION

In this small population of critical care trainees, a simulation scenario induced a comparable heart rate response to the clinical environment during intubation. This provides evidence that simulation scenarios are able to induce a comparable physiological stress response to the clinical environment and thus facilitates effective teaching of a high-risk procedure in a safe manner.

The Hibiscus Model: A Feasible Cadaveric Model Using Continuous Arterial Circulation for Intracranial Bypass Training and Its Validation

OBJECTIVE

The frequency of intracranial bypass procedures has declined. Thus it is difficult for neurosurgeons to develop the necessary skills for this complex procedure. We present a perfusion-based cadaveric model to provide a realistic training experience with high anatomic and physiological fidelity, as well as instantaneous assessment of bypass patency. Validation was assessed by evaluating the educational impact and skill improvement of the participants.

METHODS

Fourteen participants attended a hands-on revascularization course with 7 cadaveric models connected to a continuous arterial circulation system pumping a red-colored solution through the entire cranial vasculature, mimicking blood circulation. The ability to perform a vascular anastomosis was evaluated initially. Further, a questionnaire on prior experience was provided. At the end of the 36-hour course, the ability to perform an intracranial bypass was reexamined and the participants completed a self-assessment questionnaire.

RESULTS

Initially, only 3 attendees were able to perform an end-to-end anastomosis within the time limit, and only 2 of these anastomoses showed adequate patency. After having accomplished the course, all participants were able to complete a patent end-to-end anastomosis within the time limit, thus demonstrating a significant improvement. Further, both overall educational gain and surgical skills were regarded as remarkable (n = 11 and n = 9).

CONCLUSIONS

Simulation-based education is considered an important aspect of medical and surgical development. The presented model is a feasible and accessible alternative to the prior models used for cerebral bypass training. This training may serve as a helpful and widely available tool to improve neurosurgeons' development irrespective of financial resources.

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.

A novel interventional pain simulation-based education curriculum: Implementation to enhance procedural training

Several studies have demonstrated the benefits of simulation-based education (SBE) across all trainee levels in various medical fields. These benefits include allowing trainees greater autonomy and the opportunity to learn from mistakes in bioethical and procedural scenarios without compromising patient safety. While much progress has been made, there is little research on the implementation of SBE in pain medicine. This study investigated the effects of interventional pain SBE on 37 pain medicine fellows at the Brigham and Women's Hospital Pain Medicine Fellowship. The study found that fellows' performance, knowledge, and comfort were enhanced by the implementation of this curriculum.

A Promising Future for Hands-On At-Home Training in Pediatric Surgery

INTRODUCTION

 Sufficient training is needed to acquire and retain the procedural skills needed for the surgical correction of congenital anatomical malformations. This study aims to assess the opinions of trainees and pediatric surgeons on the use of simulation-based continued at-home training, which can help to acquire these skills.

METHODS

 This study consisted of two parts. First, an international survey among trainees and pediatric surgeons assessed their opinions on simulation-based at-home training for pediatric surgical procedures (5-point Likert scale). Second, participants of pediatric colorectal courses were instructed to practice the posterior sagittal anorectoplasty procedure at-home on a simulation model and, subsequently, complete a questionnaire regarding their opinions on continuous at-home training (5-point Likert scale).

RESULTS

 A total of 163 participants (83% pediatric surgeons) completed the international survey (response rate 43%). Overall, participants considered the training useful for both laparoscopic (mean 4.7) and open procedures (mean 4.2) and agreed that it may be used at home after a hands-on course (mean 4.3).Twenty participants completed the questionnaire on continued training (response rate 36%). All agreed that at-home training was of added value (mean 4.5) and that the skills were transferable to the clinical setting (mean 4.3). At-home training was regarded a suitable exercise after a hands-on workshop (mean 4.3), but less so without a workshop (mean 3.7, p=0.017).

CONCLUSION

 Participating trainees and pediatric surgeons were of the opinion that simulation models and at-home training have added value. This implies that simulation-based training may be used more often in pediatric surgical training.

The Use of an Inanimate Simulation Model for the Correction of an Anorectal Malformation in the Training of Colorectal Pediatric Surgery

INTRODUCTION

 An anorectal malformation (ARM) is a congenital malformation that requires surgical correction. To acquire the skills needed to perform this complex procedure, an affordable simulation model has previously been developed and validated. The aim of this study is to evaluate the suitability of this ARM model (with perineal fistula) for training in hands-on workshops.

MATERIALS AND METHODS

 The ARM model consists of a wooden casing with disposable perineal body. Participants in several international pediatric colorectal hands-on workshops in 2019 and 2020 were asked to participate. They were divided in a target group and an experienced group based on experience. All practiced the posterior sagittal anorectoplasty procedure on the model with multimodality guidance. Subsequently, statements on the suitability of the model for use during hands-on workshops were scored on a 5-point Likert scale.

RESULTS

 A total of 80 participants were included (43 surgical specialists, 13 pediatric surgery fellows, and 25 residents). Nearly, all statements scored at least a mean of >4.0, all scored significantly better than a neutral opinion. The target group (n = 58) scored higher compared with the experienced group (n = 22) on "transferability of the skills to the clinical setting" (means 4.4 vs. 4.0, p = 0.038); however, the "suitability as a replacement for an animal model" scored significantly lower (means 3.6 vs. 3.9, p = 0.049). No other differences were found.

CONCLUSION

 This affordable ARM model was regarded a suitable model for training during preclinical hands-on workshops and could be used for the specified steps of the procedure.

Simulation-based training as a continuous means of vascular surgical education—a roadmap

Background

Simulation-based training has become an important part of the educational approach in many professions. Over the past decades it has slowly found recognition in the medical field and in surgery in particular. Research has clearly shown the advantages of learning and honing skills on simulators in safe environments, especially for junior doctors. For this purpose, a number of models and methods have been developed to enable open vascular surgery training.

Methods

Extensive research was performed for the development of simulation-based training for vascular surgery. Different types of models and techniques were investigated. Aspects of specific theoretical and practical means of education and training were considered. This initiated the development of a simulation center for open vascular surgery.

Results

Perfused simulators and necessary surgical instruments were acquired for open vascular surgery training at the Simulation Center of the Styrian state hospitals, located at the University Hospital, Graz Medical University, in Graz. A fully equipped mock operating room is available for simulation. In-house junior and senior doctors from the Department of Vascular Surgery have the monthly opportunity to perform simulation-based training. Courses for all state hospitals are planned twice per year.

Conclusion

Simulation-based training is a safe, efficient, and well-manageable possibility for improving the education of future experts in open vascular surgery. It can help hone simple skills such as suture techniques as well as prepare for complex surgical procedures. In time we hope to further integrate simulation-based training in the existing curriculum.

The effect of simulation-based education before a cadaver dissection course

Although the methods for medical education continue to evolve due to the development of medicines, the cadaver dissection course still plays a fundamental role. The cadaver dissection course allows students to learn to handle instruments correctly while actively exploring three-dimensional anatomy. However, dissection comes with the risk of accidental injury. In recent years, the number of classes offered for the cadaver dissection course has decreased while the amount of knowledge required in clinical medicine has increased. Simulation-based education (SBE) has been proven to be an effective educational method that enhances the development of practical skills by integrating learners' knowledge and skills. This study aimed to investigate the effect of SBE as a preparatory education course when taken prior to a medical student's enrollment in the cadaver dissection course. In the present study, an SBE assuming practical cadaver dissection course was performed in the Clinical Simulation Center. The frequency of injury rates per 1000 h of cadaver dissection course was significantly less in 2017 and 2018 compared to that in 2016. Two years after the implementation of the SBE, average student self-efficacy scores and written examination scores significantly increased, whereas self-contentment scores were relatively unchanged. The results showed that the implementation of SBE decreased the incidence of injuries and improved students' overall self-efficacy scores and increased acquisition of knowledge evident on written examination score. Therefore, SBE as a preparatory education course may effectively promote the combined development of dissection skills and anatomical knowledge in the subsequent fundamental cadaver dissection course.

Step-by-step development and evaluation of a 3D printed home-made low-cost pediatric tracheobronchial tree for foreign body aspiration extractions

OBJECTIVES

The management of foreign body aspirations (FBA) is dreaded by pediatric physicians due to the high risk of respiratory distress and a potential fatal outcome, favored by a lack of experience of young specialists. Furthermore, there has been an increasing requirement for low-cost simulation. The aim was to describe the step-by-step manufacturing process and to validate a low-cost, easily home-made training model of pediatric tracheo-bronchial tree (pTBT) for simulation-based training in order to teach young physicians to practice foreign body (FBA) extractions.

METHODS

A simulator was designed in order to reproduce the physical and esthetic properties of a pTBT. The production cost of a single simulator was estimated. The simulator was then tested by experienced physicians using a rigid bronchoscope. A manufacturing manual of the simulator is hereby presented. A group of 7 experienced pediatric otolaryngologists performed a FBA extraction in the conditions of installation of an operating room.

RESULTS

The result of the survey showed a high fidelity of the simulator in mimicking the biological esthetics and physical properties of a pTBT during a FBA extraction (mean 4.3 ± 0.8). The total cost of the custom-made simulator is about 20.5 € ($23.4) for the production of the first simulator.

CONCLUSIONS

A highly realistic and easily reproducible pediatric tracheo-bronchial tree simulator is presented and can therefore be used during simulation-based training.

Clinical relevant haptic simulation learning and training in tooth preparation

Clinical dentistry is a complex activity which the procedure of most dental treatment are almost irreversible changes. Patient safety is a major challenge in clinical dental care. This is the reason why simulation-based learning and training is emphasized in dental education. In this article, the authors presented the clinical relevant haptic simulation learning and training in tooth preparation. The practical framework to set up the simulation environment from real patients in haptic 3D virtual reality dental training simulator Simodont® (Nissin Dental Products Inc., Nieuw-Vennep, Netherlands). Then, the trainee can repeatedly practice in Simodont® before performing the clinical procedure on real patient. Taken together, the implementation of this model in dental education may not only enhance trainees’ self-confidence and performance, but also facilitate patient safety during clinical dental care.

The development and clinical efficacy of simulation training of open duct-to-mucosa pancreaticojejunostomy using pancreas and intestine silicone models

Purpose

As pancreaticojejunostomy (PJ) is a challenging anastomosis, an education program is needed to train young surgeons to perform PJ. This study evaluated the effects of simulation-based training of open PJ using pancreas and intestine silicone models.

Methods

Five videos pancreatobiliary clinical fellows who did not perform PJ participated in this study. After watching the master video created by a senior pancreatobiliary surgeon, each trainee performed the PJ using silicone models and recorded them 10 times using a video camera. Of these videos, 5 were randomly duplicated due to the validation of the scoring system. The scoring system developed consisted of 20 scores. Three pancreatobiliary professors scored their performance by watching videos.

Results

The mean procedure time of the 5 trainees was 25.4 minutes (range, 23.5–27.3 minutes) in the first video and 15.8 minutes (range, 13.8–19.1 minutes) in the 10th video. The mean score was 12.6 (range, 5–19) and 18.3 (range, 15–20) in the first and 10th videos, respectively. The scores were similar among the duplicated videos for each supervisor.

Conclusion

This education system would help pancreatobiliary trainees to overcome learning curves efficiently without ethical issues related to animal models or direct practice to human patients.

Summative assessments of web-based patient simulations of pre-clinical local anaesthesia and non-surgical extraction

INTRODUCTION

The purpose of this study was to evaluate the use of web-based patient simulations, a whole-task simulation, in oral surgery education for second-year pre-clinical dental students on learning outcomes regarding cognitive, psychomotor and professional interpersonal skills for two topics: local anaesthesia and non-surgical extractions.

MATERIALS AND METHODS

In 2018-19, using an experimental design in a live course, we evaluated two web-based patient simulations on student learning outcomes in an introductory course on oral maxillofacial surgery. The study was repeated across two semesters, Fall (N = 109) and Spring (N = 112), on two different topics, namely local anaesthesia and extractions, respectively. Learning outcomes were evaluated for each topic with two different assessment formats: a student-recorded role-play video project and a fifty-item multiple-choice test.

RESULTS

For both topics, local anaesthesia and non-surgical extractions, students in the group, Web Sim, who used the web-based patient simulation over and above the online lesson material earned significantly higher scores in the role-play patient video project compared with the group, No Web Sim, who only used the online lesson materials. However, scores on the fifty-item multiple-choice test did not differ significantly between groups.

CONCLUSIONS

The results suggest that the web-based patient simulation as a formative assessment type is a useful scaffolding tool for the summative student-recorded role-play patient video project due to the similarity in activity types that support clinical learning objectives.

Best Practices and Theoretical Foundations for Simulation Instruction Using Rapid-Cycle Deliberate Practice

STATEMENT

Rapid-cycle deliberate practice (RCDP) is a learner-centered simulation instructional strategy that identifies performance gaps and targets feedback to improve individual or team deficiencies. Learners have multiple opportunities to practice observational, deductive, decision-making, psychomotor, and crisis resource management skills. As its implementation grows, simulationists need to have a shared mental model of RCDP to build high-quality RCDP-based initiatives. To compare and make general inferences from RCDP data, each training needs to follow a similar structure. This article seeks to describe the fundamentals of RCDP, including essential components and potential variants. We also summarize the current published evidence regarding RCDP's effectiveness. This article serves to create a shared understanding of RCDP, provide clear definitions and classifications for RCDP research, and provide options for future RCDP investigation.

Simulated Patient Environment: A Training Tool for Healthcare Professionals in COVID-19 Era

BACKGROUND

An in-situ simulation model with a simulated patient environment is a training tool that was implemented for the front-line workers managing COVID-19 respiratory infection outbreak in a hospital of National Importance, situated in southern part of India. The objective of this training tool was to improve the preparedness of health care workers and the control measures to manage any respiratory infection outbreaks. Also, to provide good patient care and patient safety during the sudden outbreak of SARS-CoV-2, the pathogen causing pandemic respiratory infection outbreak worldwide.

METHODS

Simulated patient environment is a kind of functional mock drill that was applied to assess and improve the readiness of the healthcare workers of the hospital to identify the patient at the screening area, guide the patient for investigation and inform the public health system during an outbreak of an infection. The faculty of the Department of Microbiology, Community and Family Medicine, and General Medicine were the educators and demonstrators. Fifty healthcare workers from All India Institute of Medical Sciences (AIIMS), Mangalagiri, Ministry of Health and Family Welfare (MOHFW), Government of India, such as doctors, epidemiologists, nurses, laboratory technicians, laboratory attendants, members of infection control team and biomedical waste management team participated in this program.

RESULTS

Statistical analysis of the results with pre-intervention and post-intervention assessments and feedback from the participants was done at the end of the program. The difference between the mean of pre-intervention and post-intervention scores in doctors, nurses, and other health care professionals was statistically very highly significant (P-value <0.001).

CONCLUSION

The training method was the simulation of management of pandemic respiratory infection outbreaks in the most realistic manner possible to test or evaluate the capability of more than one function in the context of an emergency event. An in-situ simulation is an effective method that is close to real-life scenario, to measure the readiness and effectiveness of an emergency response plan. Hence, it is a useful tool to assess disaster preparedness against any type of outbreak.

COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol

BACKGROUND

Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness.

METHODS

We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare.

DISCUSSION

Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes.

TRIAL REGISTRATION

NCT03375918.

PROTOCOL VERSION

1.0 (November 10, 2020).

Inside the skin of a patient with diabetes: fostering cognitive empathy through insulin pump simulation

In order to best treat a patient, the carer must be able to clearly see their point of view. In the case of the complexities of insulin pump therapy, physicians may not fully understand the common challenges that drive patients to non-adherence. The author undertook a three-day simulation using wearable technology to explore this experience. This form of simulation represents a simple yet effective means by which to foster cognitive empathy in undergraduate and postgraduate medical education settings alike.

Simulation-based curriculum development: lessons learnt in Global Health education

BACKGROUND

Simulation based medical education (SBME) allows learners to acquire clinical skills without exposing patients to unnecessary risk. This is especially applicable to Emergency Medicine training programs where residents are expected to demonstrate proficiency in the management of time critical, low frequency, and highly-morbidity conditions. This study aims to describe the process through which a SBME curriculum was created, in a limited simulation resource setting at a 4-year Emergency Medicine (EM) residency program at the American University of Beirut Medical Center.

METHODS

A case-based pilot simulation curriculum was developed following Kern's 6 step approach to curriculum design. The curricular objectives were identified through an anonymous survey of the program's residents and faculty. Curriculum outcomes were assessed, and the curriculum was revised to address curricular barriers. Evaluations of the revised curriculum were collected during the simulation sessions and through a whole revised curriculum evaluation at the end of the first year of its implementation.

RESULTS

14/20 residents (70%) and 8/8 faculty (100%) completed the needs assessment from which objectives for the pilot curriculum were developed and implemented through 6 2-h sessions over a 1-year period. Objectives were not met and identified barriers included cost, scheduling, resources, and limited faculty time. The revised curriculum addressed these barriers and 24 40-min sessions were successfully conducted during the following year. The sessions took place 3 at a time, in 2-h slots, using the same scenario to meet the objectives of the different learners' levels. 91/91 evaluations were collected from participants with overall positive results. The main differences between the pilot and the revised curricula included: a better understanding of the simulation center resources and faculty's capabilities.

CONCLUSION

Simulation-based education is feasible even with limited-resources. However, understanding the resources available, and advocating for protected educator time are essential to implementing a successful EM simulation curriculum.

Realization of Open Software Chain for 3D Modeling and Printing of Organs in Simulation Centers: Example of Renal Pelvis Reconstruction

OBJECTIVE

Three-dimensional (3D) printing has many uses in healthcare such as in surgical training. It is becoming an interesting tool finding new pedagogical purposes in medical simulation. In this study, using a process consisting of 3D modeling, a simulator dedicated to pyeloplasty was designed, manufactured, and evaluated by experts.

DESIGN

With the aid of open-source software and computer-aided design software, 3D models of a renal parenchyma, a renal pelvis and a ureter were created. This renal apparatus was processed and crafted with additive manufacturing using soft polymer materials. Polyvinyl alcohol material was used to print the components in order to make them dissectible and to evaluate their use in surgical teaching.

SETTING AND PARTICIPANTS

Seven expert surgeons evaluated the model by performing a pyeloplasty sequence established in a previous work. An evaluation grid with 8 items related to surgical movement was rated on a 5-point Likert scale to assess how similar working with the model was to actual surgery.

RESULTS

Three items were rated with a score greater than or equal to 4 (Needle penetration, Thread-sliding, and Cutting Strength). Suture strength was rated with a score above 3.5 for both renal pelvis and ureter, whereas elasticity was rated below 3. Handling and mobility properties were rated above 3 for the renal pelvis and below 3 for the ureter. The cost of the unit was $0.30 per renal unit. The primary difference identified was a difference in elongation between polyvinyl alcohol material and real biological tissue.

CONCLUSIONS

It is feasible to generate and print a low cost upper urinary tract model from patient data imagery using environmentally friendly products that can be used effectively in surgical training. The simulator has been able to reproduce sensations related to surgical movements for a low cost. Hereafter, research into the pedagogical benefits provided to students, and through them, patients, should be performed. 3D printing models can offer new opportunities for healthcare simulation specific to different surgical fields.

Objective Structured Assessment of Debriefing (OSAD) in simulation-based medical education: Translation and validation of the German version

Debriefing is essential for effective learning during simulation-based medical education. To assess the quality of debriefings, reliable and validated tools are necessary. One widely used validated tool is the Objective Structured Assessment of Debriefing (OSAD), which was originally developed in English. The aim of this study was to translate the OSAD into German, and to evaluate the reliability and validity of this German version (G-OSAD) according the 'Standards of Educational and Psychological Measurement'. In Phase 1, the validity evidence based on content was established by a multistage cross-cultural adaptation translation of the original English OSAD. Additionally, we collected expert input on the adequacy of the content of the G-OSAD to measure debriefing quality. In Phase 2, three trained raters assessed 57 video recorded debriefings to gather validity evidence based on internal structure. Interrater reliability, test-retest reliability, internal consistency, and composite reliability were examined. Finally, we assessed the internal structure by applying confirmatory factorial analysis. The expert input supported the adequacy of the content of the G-OSAD to measure debriefing quality. Interrater reliability (intraclass correlation coefficient) was excellent for the average ratings (three raters: ICC = 0.848; two raters: ICC = 0.790), and good for the single rater (ICC = 0.650). Test-retest reliability was excellent (ICC = 0.976), internal consistency was acceptable (Cronbach's α = 0.865), and composite reliability was excellent (ω = 0.93). Factor analyses supported the unidimensionality of the G-OSAD, which indicates that these G-OSAD ratings measure debriefing quality as intended. The G-OSAD shows good psychometric qualities to assess debriefing quality, which are comparable to the original OSAD. Thus, this G-OSAD is a tool that has the potential to optimise the quality of debriefings in German-speaking countries.

Simulation Based Training and Assessment in Open Vascular Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to systematically review the literature and give evidence based recommendations for future initiatives for simulation based training (SBT) and assessment in open vascular surgery.

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic review of PubMed, Embase, and the Cochrane Library was performed, with the last search on 31 March 2020, to identify studies describing SBT and assessment in open vascular surgery. Kirkpatrick's levels for efficacy of training were evaluated. Validity evidence for assessment tools was evaluated according to the recommended contemporary framework by Messick.

RESULTS

Of 2 844 studies, 51 were included for data extraction. A high degree of heterogeneity in reporting standards and varying types of simulation was found. Vascular anastomosis was the most frequently simulated technical skill (43%). Assessment was mostly carried out using the Objective Structured Assessment of Technical Skills (55%). Validity evidence for assessment tools was found using outdated frameworks, and only one study used Messick's framework. Self directed training is valuable, the low trainer to trainee ratio is important to maximise efficiency, and experienced vascular surgeons are the most effective trainers.

CONCLUSION

Carefully designed and structured SBT is effective and can improve technical skills, especially in less experienced trainees. However, the supporting evidence lacks homogeneity in the reporting standards and types of simulations. Pass/fail standards that support proficiency based learning and studies investigating skills transfer should be the focus in future studies. Validity evidence of assessment tools needs to be addressed using contemporary frameworks.

Simulation in Neonatal Echocardiography

There is a growing interest in neonatologists to train in echocardiography. Recommendations for training have been published by medical societies and working groups, but concerns exist on their feasibility in the face of limited resources. Simulators are increasingly used for training in medicine, including echocardiography. They have the potential to help overcome the shortage of training opportunities. We describe the currently available 2 echocardiography simulators designed for neonatology. Both systems are based on real 3-dimensional echocardiographic data and use an electromagnetic tracking system. Although limited data exist proving their effectiveness, deduction from other disciplines support this assumption.

Real-time light-guided vocal fold injection as a simulation-based training tool

OBJECTIVE

Cricothyroid (CT) approach for vocal fold injection (VFI) has advantages of a low complication rate, suitability for in-office practice, and good patient compliance. However, it requires a high level of experience and a steep learning curve due to invisibility of needle. Recently, real-time light-guided VFI (RL-VFI) was developed for safe and precise injection into laryngeal structures under light guidance. Herein, we describe the development of a simulation-based training (SBT) program using RL-VFI for CT approach and report its preliminary application with in-training otolaryngologists.

METHODS

The workshop comprised 3 sessions: mini-lectures, and two hands-on training courses of conventional VFI and RL-VFI. Excised canine larynges and the device for RL-VFI were prepared for hands-on courses. Comfort levels for VFI was evaluated using visual analogue scale after each session. Trainees were requested to identify the needle tip on the target point lateral to vocal process. The time (s) to reach the target point was measured in all procedures. After workshop, all participants filled out questionnaires regarding their future preference for conventional VFI and RL-VFI.

RESULTS

Eleven otolaryngology residents participated in the study. The mean comfort levels were 1.7 ± 1.6, 5.5 ± 2.6, 4.8 ± 1.7, and 7.5 ± 1.6 for pre-workshop, post-lecture, post-conventional VFI, and post-RL-VFI (P < .001). The mean time (s) to reach the target point were 146.4 ± 90.1 and 42.7 ± 40.5 for conventional VFI and RL-VFI (P = .004). The mean preference scores were 4.2 ± 1.3 and 8.7 ± 1.3 for conventional VFI and RL-VFI (P = .004).

CONCLUSION

SBT program using RL-VFI might improve the comfort levels of trainees for VFI with CT approach. It would be helpful for trainees to practice VFI before trying it on actual patients.

LEVEL OF EVIDENCE

N/A.

Design of an interface for teaching cardiovascular physiology to anesthesia clinicians with a patient simulator connected to a minimally invasive cardiac output monitor (LiDCO rapid®)

Cardiovascular physiology can be simulated in patient simulators but is limited to the simulator monitor curves and parameters, missing some important data that today is known as essential to fluid management and therapeutic decision in critical ill and high-risk surgical patients. Our main objective was to project and implement a unidirectional communication channel between a pre-existing patient simulator and a minimally invasive cardiac output monitor (LiDCO rapid®); a monitor that connects to real patients and interprets the arterial wave. To connect the patient simulator to the hemodynamic monitor, firstly, we had to assess both systems and design a communication channel between them. LiDCO monitor accepts as an input an analog voltage varying between 0 V and 5 V and that every volt is directly proportional to a blood pressure (mmHg) value ranging from 0 mmHg (0 V) to 500 mmHg (5 V). A Raspberry Pi 0 (Rpi0) with a WIFI chip integrated was needed and added to a digital analogue converter connected to the board. We designed a system that allowed us to collect, interpret and modify data, and feed it to the LiDCO rapid® monitor. We had developed a Python® script with three independent threads and a circular buffer to handle the data transmission between both systems. The LiDCO hemodynamic monitor successfully received data sent from our setup like a real patient arterial wave pulse and interpreted it to estimate several hemodynamic parameters, as cardiac output, stroke volume, systemic vascular resistance, pulse pressure variation, and stroke volume variation. The connection between the patient simulator and the LiDCO monitor is being used to create arterial curves and other hemodynamic parameters for clinical scenarios where residents and anesthesiologists can simulate a variety of unstable hemodynamic conditions, preparing them to face similar situations with real patients in a safe environment and with their own monitors.

Simulation in Exercise Science and Physiology—No Longer a Luxury but a Necessity

The depreciation in placement opportunities has placed pressures on university academics for some time now. Today, the coalescence of this supply issue and the global health pandemic have forced the consideration of alternative placement options. Simulation-based learning experiences (SBLEs) is one such approach, providing students with a diverse range of clinical experiences in a safe and well-placed manner. The documented effectiveness of these experiences in preparing the future health care workforce has been strong, but exists largely in medicine and nursing spheres. SBLEs have been recognized in Australia as providing a commensurate education experience to that of a traditional practicum hour resulting in a portion of total practicum hours being accrued by this activity. In March of this year, the Exercise & Sports Science Australia, accrediting body for exercise science, exercise physiology, and sports science, has lifted the restriction on mandated hours that can be apportioned to simulation-based placement. This “green light” will enable more academics to explore the opportunities within simulation-based learning, although the question regarding being able to deliver quality educational experience remains. This commentary provides an overview of key peer-reviewed literature and simulation design recommendations. Despite being founded on nursing simulation best practice standards, the lessons learned could help direct simulation designers in exercise science and physiology curricula as they strive to meet a rapidly changing practicum placement landscape while maintaining quality teaching and learning environments.

Relationship between ratings of performance in the simulated and workplace environments among emergency medicine residents

Objectives

The Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.

Methods

All Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.

Results

We collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2= 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2= 0.47).

Conclusions

No correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.

Lessons learned in preparing for and responding to the early stages of the COVID-19 pandemic: one simulation's program experience adapting to the new normal

Use of simulation to ensure an organization is ready for significant events, like COVID-19 pandemic, has shifted from a "backburner" training tool to a "first choice" strategy for ensuring individual, team, and system readiness. In this report, we summarize our simulation program's response during the COVID-19 pandemic, including the associated challenges and lessons learned. We also reflect on anticipated changes within our program as we adapt to a "new normal" following this pandemic. We intend for this report to function as a guide for other simulation programs to consult as this COVID-19 crisis continues to unfold, and during future challenges within global healthcare systems. We argue that this pandemic has cemented simulation programs as fundamental for any healthcare organization interested in ensuring its workforce can adapt in times of crisis. With the right team and set of partners, we believe that sustained investments in a simulation program will amplify into immeasurable impacts across a healthcare system.

IM, Akram A. Evaluation of basic surgical skill workshop at undergraduate level in the discipline of surgery

OBJECTIVE

To evaluate the effectiveness of basic surgical skill workshop at under graduate level.

METHODS

This was randomized controlled study (cross-over design) conducted at Al-Nafees Medical College and hospital from 1st January to November 30th 2017. Undergraduate medical students of Year-5 MBBS were randomized into two groups to undergo surgical skills training. One was workshop or interventional Group-A, other was traditional teaching or control Group-B. Online random sampling calculator was used for randomization. Both groups were given a pretest and post-test in the form of two OSATS station.

RESULTS

Total 49 students were enrolled in the study; Group-A had 25 whereas Group-B had 24 students. There was significant difference (p=0.000) in mean post-test scores of Group-A (36.28±6.75) and Group-B (24.17±5.09) out of 53 on OSATS station-1. Significant statistical difference (p=0.000) in the mean score of post-tests of Group-A (26.08±18.34) and Group-B (14.42±9.24) out of 37 was also noted on OSATS station-2. There was no significant difference in mean pretest scores on both stations in both groups.

CONCLUSIONS

This study has suggestions in development of curriculum as it provides a quantitative substantiation indicating that workshop teaching as a learning strategy can essentially augment traditional teaching of technical skills to undergraduate medical students.

The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK

In this paper, we describe the potential of simulation to improve hospital responses to the COVID-19 crisis. We provide tools which can be used to analyse the current needs of the situation, explain how simulation can help to improve responses to the crisis, what the key issues are with integrating simulation into organisations, and what to focus on when conducting simulations. We provide an overview of helpful resources and a collection of scenarios and support for centre-based and in situ simulations.

Physician Versus Nonphysician Instruction: Evaluating an Expert Curriculum-Competent Facilitator Model for Simulation-Based Central Venous Catheter Training

INTRODUCTION

Healthcare simulation supports educational opportunities while maintaining patient safety. To reduce costs and increase the availability of training, a randomized controlled study evaluated central venous catheter (CVC) insertion training in the simulation laboratory with nonphysician competent facilitators (NPCFs) as instructors.

METHOD

A group of learners naive to central line placement participated in a blended curriculum consisting of interactive online materials and simulation-based training. Learners were randomized to training with NPCFs or attending physician faculty. The primary outcome was simulated CVC insertion task performance, graded with a validated checklist by blinded physician reviewers. Learner knowledge and satisfaction were also evaluated. Analysis was conducted using noninferiority testing.

RESULTS

Eighty-five students, 11 attending physicians, and 7 NPCFs voluntarily participated. Noninferiority testing of the difference in CVC insertion performance between NPCF-trained learners versus physician-trained learners found no significant difference [rejecting the null hypothesis of inferiority using an 8% noninferiority margin (P < 0.01)]. In addition, there was no difference found between the 2 groups on pre/post knowledge scores, self-reported learner comfort, course satisfaction, or instructor satisfaction.

CONCLUSIONS

An introductory CVC curriculum can be taught to novice learners by carefully trained and supported NPCFs and achieve skill and knowledge outcomes similar to learners taught by physicians.

ViSiElse: an innovative R-package to visualize raw behavioral data over time

The scientific community encourages the use of raw data graphs to improve the reliability and transparency of the results presented in articles. However, the current methods used to visualize raw data are limited to one or two numerical variables per graph and/or small sample sizes. In the behavioral sciences, numerous variables must be plotted together in order to gain insight into the behavior in question. In this article, we present ViSiElse, an R-package offering a new approach in the visualization of raw data. ViSiElse was developed with the open-source software R to visualize behavioral observations over time based on raw time data extracted from visually recorded sessions of experimental observations. ViSiElse gives a global overview of a process by creating a visualization of the timestamps for multiple actions and all participants into a single graph; individual or group behavior can then be easily assessed. Additional features allow users to further inspect their data by including summary statistics and time constraints.

Unsupervised Machine Learning Algorithms Examine Healthcare Providers' Perceptions and Longitudinal Performance in a Digital Neonatal Resuscitation Simulator

Background: Frequent simulation-based education is recommended to improve health outcomes during neonatal resuscitation but is often inaccessible due to time, resource, and personnel requirements. Digital simulation presents a potential alternative; however, its effectiveness and reception by healthcare professionals (HCPs) remains largely unexplored. Objectives: This study explores HCPs' attitudes toward a digital simulator, technology, and mindset to elucidate their effects on neonatal resuscitation performance in simulation-based assessments. Methods: The study was conducted from April to August 2019 with 2-month (June-October 2019) and 5-month (September 2019-January 2020) follow-up at a tertiary perinatal center in Edmonton, Canada. Of 300 available neonatal HCPs, 50 participated. Participants completed a demographic survey, a pretest, two practice scenarios using the RETAIN neonatal resuscitation digital simulation, a posttest, and an attitudinal survey (100% response rate). Participants repeated the posttest scenario in 2 months (86% response rate) and completed another posttest scenario using a low-fidelity, tabletop simulator (80% response rate) 5 months after the initial study intervention. Participants' survey responses were collected to measure attitudes toward digital simulation and technology. Knowledge was assessed at baseline (pretest), acquisition (posttest), retention (2-month posttest), and transfer (5-month posttest). Results: Fifty neonatal HCPs participated in this study (44 females and 6 males; 27 nurses, 3 nurse practitioners, 14 respiratory therapists, and 6 doctors). Most participants reported technology in medical education as useful and beneficial. Three attitudinal clusters were identified by a hierarchical clustering algorithm based on survey responses. Although participants exhibited diverse attitudinal paths, they all improved neonatal resuscitation performance after using the digital simulator and successfully transferred their knowledge to a new medium. Conclusions: Digital simulation improved HCPs' neonatal resuscitation performance. Medical education may benefit by incorporating technology during simulation training.

Evaluation of a Mobile Telesimulation Unit to Train Rural and Remote Practitioners on High-Acuity Low-Occurrence Procedures: Pilot Randomized Controlled Trial

Background

The provision of acute medical care in rural and remote areas presents unique challenges for practitioners. Therefore, a tailored approach to training providers would prove beneficial. Although simulation-based medical education (SBME) has been shown to be effective, access to such training can be difficult and costly in rural and remote areas.

Objective

The aim of this study was to evaluate the educational efficacy of simulation-based training of an acute care procedure delivered remotely, using a portable, self-contained unit outfitted with off-the-shelf and low-cost telecommunications equipment (mobile telesimulation unit, MTU), versus the traditional face-to-face approach. A conceptual framework based on a combination of Kirkpatrick’s Learning Evaluation Model and Miller’s Clinical Assessment Framework was used.

Methods

A written procedural skills test was used to assess Miller’s learning level— knows —at 3 points in time: preinstruction, immediately postinstruction, and 1 week later. To assess procedural performance (shows how), participants were video recorded performing chest tube insertion before and after hands-on supervised training. A modified Objective Structured Assessment of Technical Skills (OSATS) checklist and a Global Rating Scale (GRS) of operative performance were used by a blinded rater to assess participants’ performance. Kirkpatrick’s reaction was measured through subject completion of a survey on satisfaction with the learning experiences and an evaluation of training.

Results

A total of 69 medical students participated in the study. Students were randomly assigned to 1 of the following 3 groups: comparison (25/69, 36%), intervention (23/69, 33%), or control (21/69, 31%). For knows, as expected, no significant differences were found between the groups on written knowledge (posttest, P=.13). For shows how, no significant differences were found between the comparison and intervention groups on the procedural skills learning outcomes immediately after the training (OSATS checklist and GRS, P=1.00). However, significant differences were found for the control versus comparison groups (OSATS checklist, P<.001; GRS, P=.02) and the control versus intervention groups (OSATS checklist, P<.001; GRS, P=.01) on the pre- and postprocedural performance. For reaction, there were no statistically significant differences between the intervention and comparison groups on the satisfaction with learning items (P=.65 and P=.79) or the evaluation of the training (P=.79, P=.45, and P=.31).

Conclusions

Our results demonstrate that simulation-based training delivered remotely, applying our MTU concept, can be an effective way to teach procedural skills. Participants trained remotely in the MTU had comparable learning outcomes (shows how) to those trained face-to-face. Both groups received statistically significant higher procedural performance scores than those in the control group. Participants in both instruction groups were equally satisfied with their learning and training (reaction). We believe that mobile telesimulation could be an effective way of providing expert mentorship and overcoming a number of barriers to delivering SBME in rural and remote locations.

Simulation-based Education for Endoscopic Third Ventriculostomy: A Comparison Between Virtual and Physical Training Models

BACKGROUND

The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."

OBJECTIVE

To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.

METHODS

Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.

RESULTS

The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P < .001 and 3.9; SD = 0.8 vs 4.2, SD = 0.6; P = .02, respectively). Overall task fidelity across the 2 simulators was not perceived as significantly different.

CONCLUSION

Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

Loss of resistance: A randomised controlled trial assessing four low-fidelity epidural puncture simulators

BACKGROUND

Detecting loss of resistance (LOR) can either be taught with dedicated simulators, with a cost ranging from &OV0556;1500 to 3000, or with the 'Greengrocer's Model', requiring simply a banana.

OBJECTIVES

The purpose of this study was to compare three dedicated epidural puncture training simulators and a banana in their ability to simulate LOR. Our hypothesis was that there was a difference between the four simulators when comparing the detection of LOR.

DESIGN

Single-blinded, randomised, controlled study.

SETTING

Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Switzerland.

PARTICIPANTS

Fifty-five consultant anaesthesiologists.

INTERVENTIONS

The participants were asked to insert an epidural catheter in four different epidural puncture training simulators: Lumbar Puncture Simulator II (Kyoto Kagaku, Kyoto, Japan), Lumbar Epidural Injection Trainer (Erler-Zimmer, Lauf, Germany), Normal Adult Lumbar Puncture/Epidural Tissue (Simulab Corp., Seattle, Washington, USA) and a banana. The simulators were placed in identical boxes to blind the participants.

MAIN OUTCOME MEASURES

The primary outcome was the detection of LOR rated on a 100-mm visual analogue scale, in which 0 mm represented 'completely unrealistic' and 100 mm represented 'indistinguishable from a real patient'.

RESULTS

The mean visual analogue scale scores for LOR in the four simulators were significantly different: 60 ± 25 mm [95% confidence interval (CI), 55 to 65 mm], 50 ± 29 mm (95% CI, 44 to 55 mm), 64 ± 24 mm (95% CI, 58 to 69 mm) and 49 ± 32 mm (95% CI, 44 to 54 mm); P less than 0.001, Friedman test.

CONCLUSION

Two of the three dedicated epidural simulators were rated more realistic in detecting LOR than the banana, but some participants preferred the banana to the other three simulators. Given the relative cost of a banana compared with a dedicated simulator, we suggest that a banana be used to teach the technique of LOR for epidural puncture.

TRIAL REGISTRATION

KEK Nr: Req-2015-z087.

Simulation in endoscopy: Practical educational strategies to improve learning

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

Simulation-based educational package to improve delivery of the deeply impacted fetal head at caesarean section

Deeply impacted fetal head at caesarean section at full dilation is a rare obstetric emergency, and exposure for trainees can be limited. We aimed to pilot and evaluate a hospital-based training program incorporating mastery learning principles for trainees performing caesarean section at full dilation. We demonstrated improvements in knowledge, skills and self-confidence, and feel that this educational package shows promise as an important component of obstetric training, and warrants further exploration in the future.