Simulation Training for Residents Focused on Mechanical Ventilation: A Randomized Trial Using Mannequin-Based Versus Computer-Based Simulation

Mechanical Ventilation Training Curriculum for Pulmonary Critical Care Fellows during the COVID-19 Pandemic

Background

Mechanical ventilation (MV) management is an essential skill for pulmonary and critical care medicine (PCCM) fellows to master during training. The unprecedented emergence of the coronavirus disease (COVID-19) pandemic highlighted the need for advanced operator competency in MV to improve patients' outcomes.

Objective

We aimed to create a standardized case-based curriculum using a blended approach of high-fidelity simulation, rapid-cycle deliberate practice, video didactics, and hands-on small group sessions for rapid accumulation of knowledge and hands-on skills for PCCM fellows before caring for critically ill patients during the COVID-19 pandemic.

Methods

The MV curriculum consisted of the following steps: 1) baseline written knowledge test with 15 multiple-choice questions covering MV, the latest evidence-based practices, and pathophysiology of COVID-19; 2) baseline confidence survey using a 5-point Likert scale; 3) a one-on-one session using a high-fidelity simulation manikin, a lung simulator, and a mechanical ventilator to test baseline competencies; 4) a structured debriefing tailored per fellow's 50-point competency assessment checklist from the simulation using rapid-cycle deliberate practice; 5) video didactics; 6) a hands-on session in small groups for basic knobology, waveforms, and modes of MV; 7) a one-on-one simulation reassessment session; 8) a written knowledge posttest; and 9) a post-training confidence survey using a 5-point Likert scale.

Results

Eight PCCM fellows completed the training. The mean multiple-choice question score increased from 7.4 ± 2.9 to 10.4 ± 2.4 (P < 0.05), and the simulation scores increased from 17.1 ± 4.4 to 30.8 ± 3.7 (P < 0.05). Comparing the simulation reassessment to the baseline, fellows showed significant improvement (P < 0.05) in assessing indications for MV; implementing rapid sequence intubation for patients with COVID-19; initiating MV and ventilator bundle per best practices; recognizing and managing mucous plugging, ventilator dyssynchrony, and evidence-based treatments for acute respiratory distress syndrome; and developing a care plan for proning. The post-training survey revealed improved learner confidence in all competencies.

Conclusion

This pilot MV curriculum using a blended approach was feasible and allowed PCCM fellows to significantly improve their knowledge and hands-on skills, allowing for the appropriate use of MV during the pandemic. Self-reported improvement scores further reinforced this. The emergent need for novice learners may again be necessary for future pandemic settings where standard training models requiring extensive training time are limited.

A Pilot Standardized Simulation-Based Mechanical Ventilation Curriculum Targeting Pulmonary and Critical Care Medicine and Critical Care Medicine Fellows

Introduction  The mastery of mechanical ventilation (MV) management is challenging, as it requires the integration of physiological and technological knowledge with critical thinking. Our aim was to create a standardized curriculum with assessment tools based on evidence-based practices to identify the skill deficit and improve knowledge in MV management. Methods  For 3 years, 3 hours of standardized curriculum for each first-year pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellows was integrated into the orientation (chronologically): (1) a baseline knowledge pretest; (2) a 1-hour one-on-one case-based simulation session with debriefing. A 34-item competency checklist was used to assess critically thinking and skills and guide the debriefing; (3) a 1-hour group didactic on respiratory mechanics and physiology; (4) a 45-minute hands-on session in small groups of one to three fellows for basic knobology, waveforms, and various modes of mechanical ventilators; (5) a 15-minute group bedside teaching of vented patients covering topics such as techniques to alleviate dyssynchrony and advanced ventilator modes; (6) a one-on-one simulation reassessment session; (7) a knowledge posttest. Fellows' performances at baseline, 1-month posttest, and end-of-first year post-test were compared. Results  Fellows ( n  = 24) demonstrated significant improvement at 1-month posttest in knowledge (54.2% ± 11.0 vs. 76.6 ± 11.7%, p  < 0.001) and MV competency (40.7 ± 11.0% vs. 69.7 ± 9.3%, p  < 0.001), compared with pretest. These improvements were retained at the end-of-year reassessments (knowledge 75.1 ± 14.5% and MV competency 85.5 ± 8.7%; p  < 0.001). Conclusion  Standardized simulation-based MV curriculum may improve the medical knowledge competency, and confidence of first-year PCCM and CCM fellows toward MV management before encountering actual ventilated patients.

Simulation-based Assessment to Measure Proficiency in Mechanical Ventilation among Residents

Background

Mechanical ventilation (MV) skills are essential for clinicians caring for critically ill patients, yet few training programs use structured curricula and appropriate assessments. Objective structured clinical exams (OSCEs) have been used to assess clinical competency in many areas, but there are no OSCE models focused on MV.

Objective

To develop and validate a simulation-based assessment (SBA) with an OSCE structure to assess baseline MV competence among residents and identify knowledge gaps.

Methods

We developed an SBA using a lung simulator and a mechanical ventilator, and an OSCE structure, with six clinical scenarios in MV. We included internal medicine residents at the beginning of their rotation in the respiratory intensive care unit (ICU) of a university-affiliated hospital. A subset of residents was also evaluated with a validated multiple-choice exam (MCE) at the beginning and at the end of the ICU rotation. Scores on both assessments were normalized to range from 0 to 10. We used Cronbach’s α coefficient to assess reliability and Spearman correlation to estimate the correlation between the SBA and the MCE.

Results

We included 80 residents, of whom 42 also completed the MCE examinations. The final version of the SBA had 32 items, and the Cronbach’s α coefficient was 0.72 (95% confidence interval [CI], 0.64–0.81). The average SBA score was 6.2 ± 1.3, and performance was variable across items, with 80% correctly adjusting initial ventilatory settings and only 12% correctly identifying asynchrony. The MCE had 24 questions, and the average score was 7.6 ± 2.4 at the beginning of the rotation and 8.2 ± 2.3 at the end of the rotation (increase of 0.6 points; 95% CI, 0.30–0.90; P < 0.001). There was moderate correlation between the SBA and the MCE (rho = 0.41; P = 0.002).

Conclusion

We developed and validated an objective structured assessment on MV using a pulmonary simulator and a mechanical ventilator addressing the main competencies in MV. The performance of residents in the SBA at the beginning of an ICU rotation was lower than the performance in MCE, highlighting the need for greater emphasis on practical skills in MV during residency.

The Physiological Basis of High-Frequency Oscillatory Ventilation and Current Evidence in Adults and Children: A Narrative Review

High-frequency oscillatory ventilation (HFOV) is a type of invasive mechanical ventilation that employs supra-physiologic respiratory rates and low tidal volumes (V_T) that approximate the anatomic deadspace. During HFOV, mean airway pressure is set and gas is then displaced towards and away from the patient through a piston. Carbon dioxide (CO₂) is cleared based on the power (amplitude) setting and frequency, with lower frequencies resulting in higher V_T and CO₂ clearance. Airway pressure amplitude is significantly attenuated throughout the respiratory system and mechanical strain and stress on the alveoli are theoretically minimized. HFOV has been purported as a form of lung protective ventilation that minimizes volutrauma, atelectrauma, and biotrauma. Following two large randomized controlled trials showing no benefit and harm, respectively, HFOV has largely been abandoned in adults with ARDS. A multi-center clinical trial in children is ongoing. This article aims to review the physiologic rationale for the use of HFOV in patients with acute respiratory failure, summarize relevant bench and animal models, and discuss the potential use of HFOV as a primary and rescue mode in adults and children with severe respiratory failure.

Developing and Implementing Noninvasive Ventilator Training in Haiti during the COVID-19 Pandemic

Background

Noninvasive ventilation (NIV) is an important component of respiratory therapy for a range of cardiopulmonary conditions. The World Health Organization recommends NIV use to decrease the use of intensive care unit resources and improve outcomes among patients with respiratory failure during periods of high patient capacity from coronavirus disease (COVID-19). However, healthcare providers in many low- and middle-income countries, including Haiti, do not have experience with NIV. We conducted NIV training and evaluation in Port-au-Prince, Haiti.

Objectives

To design and implement a multimodal NIV training program in Haiti that would improve confidence and knowledge of NIV use for respiratory failure.

Methods

In January 2021, we conducted a 3-day multimodal NIV training consisting of didactic sessions, team-based learning, and multistation simulation for 36 Haitian healthcare workers. The course included 5 didactic session and 10 problem-based and simulation sessions. All course material was independently created by the study team on the basis of Accreditation Council for Continuing Medical Education-approved content and review of available evidence. All participants completed pre- and post-training knowledge-based examinations and confidence surveys, which used a 5-point Likert scale.

Results

A total of 36 participants were included in the training and analysis, mean age was 39.94 years (standard deviation [SD] = 9.45), and participants had an average of 14.32 years (SD = 1.21) of clinical experience. Most trainees (75%, n = 27) were physicians. Other specialties included nursing (19%, n = 7), nurse anesthesia (3%, n = 1), and respiratory therapy (3%, n = 1). Fifty percent (n = 18) of participants stated they had previous experience with NIV. The majority of trainees (77%) had an increase in confidence survey score; the mean confidence survey score increased significantly after training from 2.75 (SD = 0.77) to 3.70 (SD = 0.85) (P < 0.05). The mean knowledge examination score increased by 39.63% (SD = 15.99%) after training, which was also significant (P < 0.001).

Conclusion

This multimodal NIV training, which included didactic, simulation, and team-based learning, was feasible and resulted in significant increases in trainee confidence and knowledge with NIV. This curriculum has the potential to provide NIV training to numerous low- and middle-income countries as they manage the ongoing COVID-19 pandemic and rising burden of noncommunicable disease. Further research is necessary to ensure the sustainability of these improvements and adaptability to other low- and middle-income settings.

Open access spreadsheet application for learning spontaneous breathing mechanics and mechanical ventilation

Mechanical ventilation, either invasive or noninvasive, is crucial to treat patients with acute or chronic respiratory failure in intensive care units and hospital wards. Optimal gas exchange is not easy to achieve in patients with respiratory failure since a considerable number of variables and mechanisms involving several organs and systems play a substantial role. Moreover, an added difficulty when managing invasive mechanical ventilation is that improvement of gas exchange must be achieved by minimising the risk of ventilator-induced lung injury. Hence, optimal application of mechanical ventilation requires fine tuning of the ventilator settings, tailoring them to each patient's needs. This process cannot be carried out by trial and error but based on a solid knowledge of the concepts and physical laws governing respiratory mechanics. Accordingly, it is important that medical students achieve a good background understanding of respiratory mechanics in undergraduate courses of physiology, and that this training is refreshed later when the student is introduced to mechanical ventilation learning and further when starting clinical training in this therapy [1].

Description and presentation of an open access spreadsheet application for learning spontaneous breathing mechanics and mechanical ventilationhttps://bit.ly/2TyXo1C

Scoring System to Evaluate the Performance of ICU Ventilators in the Pandemic of COVID-19: A Lung Model Study

Ventilators in the intensive care units (ICU) are life-support devices that help physicians to gain additional time to cure the patients. The aim of the study was to establish a scoring system to evaluate the ventilator performance in the context of COVID-19. The scoring system was established by weighting the ventilator performance on five different aspects: the stability of pressurization, response to leaks alteration, performance of reaction, volume delivery, and accuracy in oxygen delivery. The weighting factors were determined with analytic hierarchy process (AHP). Survey was sent out to 66 clinical and mechanical experts. The scoring system was built based on 54 valid replies. A total of 12 commercially available ICU ventilators providing non-invasive ventilation were evaluated using the novel scoring system. A total of eight ICU ventilators with non-invasive ventilation mode and four dedicated non-invasive ventilators were tested according to the scoring system. Four COVID-19 phenotypes were simulated using the ASL5000 lung simulator, namely (1) increased airway resistance (IR) (10 cm H₂O/L/s), (2) low compliance (LC) (compliance of 20 ml/cmH₂O), (3) low compliance plus increased respiratory effort (LCIE) (respiratory rate of 40 and inspiratory effort of 10 cmH₂O), (4) high compliance (HC) (compliance of 50 ml/cmH₂O). All of the ventilators were set to three combinations of pressure support and positive end-expiratory pressure levels. The data were collected at baseline and at three customized leak levels. Significant inaccuracies and variations in performance between different non-invasive ventilators were observed, especially in the aspect of leaks alteration, oxygen and volume delivery. Some ventilators have stable performance in different simulated phenotypes whereas the others have over 10% scoring differences. It is feasible to use the proposed scoring system to evaluate the ventilator performance. In the COVID-19 pandemic, clinicians should be aware of possible strengths and weaknesses of ventilators.

Using a breathing simulator to improve simulation-based education for noninvasive ventilation

Simulation-based medical education is recognised as a highly effective training tool. Novel technologies such as breathing simulators have the potential to revolutionise how we train healthcare professionals to manage patients requiring NIV. https://bit.ly/3f4Hnt1.

Impact of Simulation-based Mastery Learning on Resident Skill Managing Mechanical Ventilators

Background: Caring for patients requiring mechanical ventilation is complex, and residents may lack adequate skill for managing these patients. Simulation-based mastery learning (SBML) is an educational model that trains clinicians to a high standard and can reduce complications. The mastery learning model has not been applied to ventilator management. Objective: The purpose of this study was to determine whether SBML, as compared with traditional training, is an effective strategy for teaching residents the skills necessary to manage patients requiring mechanical ventilation. Methods: We developed an SBML curriculum and a 47-item skills checklist to test ventilator management for patients with normal, restricted, and obstructed lung physiology. A minimum passing standard (MPS) on the checklist was set using the Mastery Angoff method. Residents rotating through the medical intensive care unit in Academic Year 2017-2018 were assigned to SBML or traditional training based on their medical intensive care unit team. The SBML group was pretested on a ventilator simulator using the skills checklist. They then received a 1.5-hour session (45 min didactic and 45 min deliberate practice on the simulator with feedback). At rotation completion, they were posttested on the simulator using the checklist until the MPS was met. Both SBML-trained and traditionally trained groups received teaching during daily bedside rounds and twice weekly didactic lectures. At rotation completion, traditionally trained residents were tested using the same skills checklist on the simulator. We compared pretest and posttest performance among SBML-trained residents and end of the rotation test performances between the SBML-trained and traditionally trained residents. Results: The MPS was set at 87% on the checklist. Fifty-seven residents were assigned to the SBML-trained group and 49 were assigned to the traditionally trained group. Mean checklist scores for SBML-trained residents improved from 51.4% (standard deviation [SD] = 17.5%) at pretest to 86.1% (SD = 7.6%) at initial posttest and 92.5% (SD = 3.7%) at final (mastery) posttest (both P < 0.001). Forty-two percent of residents required more than one attempt at the posttest to meet or exceed the MPS. At rotation completion, the traditionally trained residents had a mean test score of 60.9% (SD = 13.3%). Conclusion: SBML is an effective strategy to train residents on mechanical ventilator management. An SBML curriculum may augment traditional training methods to further equip residents to safely manage ventilated patients.

Impact of Novel Multiinstitutional Curriculum on Critical Care Fellow Ventilator Knowledge

Background: Management of mechanical ventilation (MV) is a curricular milestone for trainees in pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellowships. Though recognition of ventilator waveform abnormalities that could result in patient complications is an important part of management, it is unclear how well fellows recognize these abnormalities.

Objective: To study proficiency of ventilator waveform analysis among first-year fellows enrolled in a MV course compared with that of traditionally trained fellows.

Methods: The study took place from July 2016 to January 2019, with 93 fellows from 10 fellowship programs completing the waveform examination. Seventy-three fellows participated in a course during their first year of fellowship, with part I occurring at the beginning of fellowship in July and part II occurring after 6 months of clinical work. These fellows were given a five-question ventilator waveform examination at multiple time points throughout the two-part course. Twenty fellows from three other fellowship programs who were in their first, second, or third year of fellowship and who did not participate in this course served as the control group. These fellows took the waveform examination a single time, at a median of 23 months into their training.

Results: Before the course, scores were low but improved after 3 days of education at the beginning of the fellowship (18.0 ± 1.6 vs. 45.6 ± 3.0; P < 0.0001). Scores decreased after 6 months of clinical rotations but increased to their highest levels after part II of the course (33.7 ± 3.1 for part II pretest vs. 77.4 ± 2.4 for part II posttest; P < 0.0001). After completing part I at the beginning of fellowship, fellows participating in the course outperformed control fellows, who received a median of 23 months of traditional fellowship training at the time of testing (45.6 ± 3.0 vs. 25.3 ± 2.7; P < 0.0001). There was no difference in scores between PCCM and CCM fellows. In anonymous surveys, the fellows also rated the mechanical ventilator lectures highly.

Conclusion: PCCM and CCM fellows do not recognize common waveform abnormalities at the beginning of fellowship but can be trained to do so. Traditional fellowship training may be insufficient to master ventilator waveform analysis, and a more intentional, structured course for MV may help fellowship programs meet the curricular milestones for MV.

Trends in Surgical Critical Care Training Among General Surgery Residents: Pursuing an Ideal Curriculum

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) provides no specific guidelines for surgical critical care (SCC) training during general surgery residency. Growing emphasis is placed on this experience with increasing case requirements and dedicated SCC content on board certification exams.

METHODS

A digital survey was distributed to ACGME-accredited general surgery residencies via email. Respondents reported number and setting of critical care months during residency and rated comfort level within 5 critical care principles and overall satisfaction with their SCC experience. Study cohorts were formed to compare experiences and competencies between respondents based on setting, months, postgraduate year (PGY) level, and formal surgical intensive care unit (SICU) experience. Differences between cohorts were compared using the Mantel-Haenszel test (P < .05).

RESULTS

Seventy-three residents responded with 45% training at academic centers versus 46% in community hospitals. Approximately 50% completed a formal SICU rotation, while 9% reported no dedicated critical care rotation during residency. Overall, 78% felt satisfied with their SCC experience. Residents training at academic centers were more satisfied overall and felt more comfortable with ventilator management. Those who completed 5 or more months of critical care training reported greater confidence with intravenous sedation and ventilator management, while residents having a formal SICU rotation felt more confident with vasopressor and ventilator management.

DISCUSSION

Variability remains within SCC training among general surgery residents with perceived benefits seen in training at academic centers and completing a formal SICU rotation. Although limited, these findings offer a foundation for developing an effective SCC curriculum.

Effectiveness of simulation based teaching of ventilatory management among non-anaesthesiology residents to manage COVID 19 pandemic - A Quasi experimental cross sectional pilot study

BACKGROUND AND AIMS

Simulation is one of the important learning tools when it comes to skill acquisition and as a supplemental tool for training in high stake situations like COVID-19. The aim of this study is to meet the global requirements of knowledge on ventilatory management, prepare and to evaluate the effectiveness of the teaching module for non-anesthesiology trainees on COVID-19 patients.

METHODS

Quasi experimental cross sectional pilot study was conducted with a sample of twenty-six trainees. A teaching module was prepared and validated which consisted of lectures, audio-video sessions, demonstrations with hands-on training, debriefing, analytical-phase and reflection. Pre and Post evaluations from student t-test and direct observation of procedural skills (DOPS) were used for knowledge and skill assessment respectively and feedback obtained from Likert's score.

RESULTS

Pre- and Post-tests had a mean score of 7.42 ± 2.12 and 14.92 ± 2.9 respectively (P value 0.00001). DOPS included 16 point score, in which 23 trainees (88.4%) met the expectations and above expectations as per training objectives. A five-point Likert's score feedback revealed satisfactory and highly satisfactory scores of 100% (ABG), 96.1% (mechanical ventilation), and 84.6% (ventilation in COVID-19 patients). Overall satisfaction for the workshop among respondents was 100 per cent. Confidences of handling scores were 84.5% (interpreting ABG), 65.3% (maneuvering mechanical ventilation), and 96.15% (intubation in COVID-19 patients).

CONCLUSION

A planned teaching module in ventilation management helps to train non-anaesthesiologists more effectively as a part of COVID-19 preparedness. Simulation with debriefing based training to the medical fraternity is the best alternative in the present pandemic and it will also ensure the safety of health care professionals.

Simulation in Neurocritical Care: Past, Present, and Future

Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.

Mechanical Ventilation Training During Graduate Medical Education: Perspectives and Review of the Literature

BACKGROUND

Management of mechanical ventilation (MV) is an important and complex aspect of caring for critically ill patients. Management strategies and technical operation of the ventilator are key skills for physicians in training, as lack of expertise can lead to substantial patient harm.

OBJECTIVE

We performed a narrative review of the literature describing MV education in graduate medical education (GME) and identified best practices for training and assessment methods.

METHODS

We searched MEDLINE, PubMed, and Google Scholar for English-language, peer-reviewed articles describing MV education and assessment. We included articles from 2000 through July 2018 pertaining to MV education or training in GME.

RESULTS

Fifteen articles met inclusion criteria. Studies related to MV training in anesthesiology, emergency medicine, general surgery, and internal medicine residency programs, as well as subspecialty training in critical care medicine, pediatric critical care medicine, and pulmonary and critical care medicine. Nearly half of trainees assessed were dissatisfied with their MV education. Six studies evaluated educational interventions, all employing simulation as an educational strategy, although there was considerable heterogeneity in content. Most outcomes were assessed with multiple-choice knowledge testing; only 2 studies evaluated the care of actual patients after an educational intervention.

CONCLUSIONS

There is a paucity of information describing MV education in GME. The available literature demonstrates that trainees are generally dissatisfied with MV training. Best practices include establishing MV-specific learning objectives and incorporating simulation. Next research steps include developing competency standards and validity evidence for assessment tools that can be utilized across MV educational curricula.

Critical Appraisal of Anesthesiology Educational Research for 2017

Background

Critical appraisals provide a method for establishing the status of an area of study or evaluating the effectiveness of literature within it. The purpose of this study was to review and appraise studies published in 2017 on medical education in anesthesiology and to provide summaries of the highest-quality medical education research articles in the field.

Methods

Three Ovid MEDLINE databases, Embase.com, Education Resources Information Center (ERIC), and PsycINFO, were searched followed by a manual review of articles published in the highest impact factor journals in both the fields of anesthesiology and medical education. Abstracts were double-screened and quantitative articles subsequently scored by three randomly assigned raters. Qualitative studies were scored by two raters. Two different rubrics were used for scoring quantitative and qualitative studies, both allowed for scores ranging from 1-25.

Results

A total of 864 unique citations were identified through the search criteria. Of those, 62 articles met the inclusion criteria, with 59 quantitative and three qualitative. The top 10 papers with the highest scores were reported and summarized.

Discussion

As the first article to critically review the literature available for education in anesthesiology, we hope that this study will serve as the first manuscript in an annual series that will help individuals involved in anesthesiology education gain an understanding of the highest-quality research in the field. Once this process is repeated, trends can be tracked and serve as a resource to educators and researchers in anesthesiology for years to come.

Development and validation of a questionnaire to assess the knowledge of mechanical ventilation in urgent care among students in their last-year medical course in Brazil

OBJECTIVE

To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

METHODS

A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests.

RESULTS

The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%.

CONCLUSION

The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

A Pilot Study of Simulation Training in Difficult Bag Mask Ventilation Using a Computerized Patient Simulator

OBJECTIVE

Bag mask ventilation (BMV) is fundamental to airway management. Simulation is effective in airway management training, but its effectiveness for difficult BMV training is less clear. We evaluated the difference between type of training (simulation vs on patients) and the pass rate on a post-test on patients.

DESIGN

A single center pilot study was performed with 32 medical students randomized to participate in difficult BMV training on simulators or patients. Pre- and post-training tests on the simulator and on patients were recorded. Surveys of trainee confidence level were collected. The primary goal was to estimate the difference between type of training (simulation vs on patients) and the pass rate on the post-test on patients with an improvement of 10% or more in passing rate considered as a meaningful improvement. Secondary outcomes included whether or not participants passed the simulator post-test, post-test on patient confidence, and pre- and post-test confidence.

MEASUREMENTS AND MAIN RESULTS

Participants trained on the simulator had 13% higher passing rate on the post-test on patients compared to participants trained on patients (88% vs 75%). In addition, subjects that passed the simulator post-test had 11 times the odds of passing a post-test on patients relative to subjects that did not pass the simulator post-test (P = 0.023, odds ratio = 11.0, 95% confidence interval [CI] = 1.48-81.6). Post-training confidence levels were higher among those who passed the simulator pre-test and post-test and received simulator training.

CONCLUSIONS

Simulation training for difficult BMV led to a higher passing rate on a post-test on patients compared to those trained on patients. This finding will need to be confirmed in larger randomized controlled trials. Successfully completing difficult BMV training on a simulator with a passing grade correlated with passing a test on difficult BMV on patients.

Development and Evaluation of a User-Centered Mobile Telestroke Platform

Background: Reperfusion is the most effective acute treatment for ischemic stroke within a narrow therapeutic time window. Ambulance-based telestroke is a novel way to improve stroke diagnosis and timeliness of treatment. This study aims to (1) assess the usability of our ambulance-based telestroke platform and (2) identify strengths and limitations of the system from the user's perspective. Materials and Methods: An ambulance was equipped with a mobile telemedicine system to perform remote stroke assessments. Scripted scenarios were performed by actors during transport and evaluated by physicians using the National Institutes of Health Stroke Scale (NIHSS). Scores obtained during transport were compared with original scripted NIHSS scores. Participants completed the System Usability Scale (SUS), NASA Task Load Index (NASA TLX), audio/video quality scale, and a modified Acceptability of Technology survey to assess perceptions and usability. In addition, interviews were conducted to evaluate user's experience. Descriptive analysis was used for all surveys. Weighted kappa statistics was used to compare the agreement in NIHSS scores. Results: Ninety-one percent (59/65) of mobile scenarios were completed. Median completion time was 9 min (range 4-17 min). There was moderate inter-rater agreement (weighted kappa = 0.46 [95% confidence interval 0.33-0.60, p = 0.0018]) among mobile and original scripted scenarios. The mean SUS score was 68.8 (standard deviation = 15.9). There was variability between usability score and formative feedback among all end-users in the areas of usability issues (i.e., audibility and equipment stability) and safety. Conclusion: Before implementation of a mobile prehospital telestroke program, the use of combined clinical simulation and Plan-Do-Study-Act methodology can improve the quality and optimization of the telemedicine system.

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.

Techniques of cadaver perfusion for surgical training: a systematic review

PURPOSE

The objective of this study was to identify the most appropriate cadaver perfusion techniques for surgical training through a systematic review with a description of the protocols used.

METHODS

The search strategy included PubMed and reference tracking. Studies were identified by searching the electronic Medline databases. The search concepts included perfusion, cadavers and simulation training, and the protocol used is reported. This resulted in a qualitative review of 12 articles out of 250 articles consulted. We collected all the important data from these 12 articles.

RESULTS

Regarding the characteristics of the studies and the declotting or perfusion techniques, the results were heterogeneous. Indeed, in several studies, a good deal of information was unclear or insufficiently precise, making it unfeasible to summarize the data. The methods used were not sufficiently explicit and detailed. However, a majority of the fresh cadavers used tap water for declotting. Perfusion, type of fluid, number of pumps, pressure, pulsatility, and arterial or venous approaches differed greatly. Only two studies fulfilled five of our six realism criteria for surgical simulation.

CONCLUSIONS

This systematic review provided an overview of all the different cadaver perfusion techniques. It could be used to establish a reference method of a simulation model.