Evaluating the impact of simulation on translational patient outcomes

Impact of in situ simulation training on quality of postnatal stabilization and resuscitation-a before-and-after, non-controlled quality improvement study

This study aimed to evaluate the impact of in situ simulation-based training on quality indicators of patient care at a level IV neonatal intensive care unit. A before-and-after, non-controlled quality improvement study was performed at the Division of Neonatology, Medical University of Graz. The educational intervention comprised a period of 4 months, with structured in situ simulation training delivered regularly for neonatal providers and nurses in interprofessional teams. The primary study outcome was the quality of non-technical skills and team interaction during actual postnatal stabilization and resuscitation. This was assessed using video recording during two 2-month observational phases before (pre-training) and after the educational intervention (post-training). Delivery room video recordings were assessed by two external, blinded neonatologists using the Anaesthetists' Non-Technical Skills (ANTS) score. Furthermore, we collected clinical patient data from video-recorded neonates during the pre- and post-training periods, and training participants' individual knowledge of neonatal resuscitation guidelines was assessed using a before- and after-questionnaire. A total of 48 healthcare professionals participated in 41 in situ simulation trainings. The level of non-technical skills and team interaction was already high in the pre-training period, and it did not further improve afterwards. Nonetheless, we observed a significant increase in the teamwork event "evaluation of plans" (0.5 [IQR 0.0-1.0] versus 1.0 [1.0-2.0], p = 0.049). Following the educational intervention, training participants' knowledge of neonatal resuscitation guidelines significantly improved, although there were no differences in secondary clinical outcome parameters.

CONCLUSION

We have successfully implemented a neonatal in situ simulation training programme. The observed improvement in one teamwork event category in the post-training period demonstrates the effectiveness of the training curriculum, while also showing the potential of in situ simulation training for improving postnatal care and, ultimately, patient outcome.

WHAT IS KNOWN

• In situ simulation-based training is conducted in the real healthcare environment, thus promoting experiential learning which is closely aligned with providers' actual work. • In situ simulation-based training may offer an additional benefit for patient outcomes in comparison to other instructional methodologies.

WHAT IS NEW

• This observational study investigated translational patient outcomes in preterm neonates before and after delivery of high-frequency in situ simulation-based training at a level IV neonatal intensive care unit. • There was a significant increase in the frequency of one major teamwork event following the delivery of in situ simulation-based training, indicating a notable improvement in the non-technical skills domain, which is closely linked to actual team performance.

Improving quality through simulation; developing guidance to design simulation interventions following key events in healthcare

Simulation educators are often requested to provide multidisciplinary and/or interprofessional simulation training in response to critical incidents. Current perspectives on patient safety focus on learning from failure, success and everyday variation. An international collaboration has led to the development of an accessible and practical framework to guide the implementation of appropriate simulation-based responses to clinical events, integrating quality improvement, simulation and patient safety methodologies to design appropriate and impactful responses. In this article, we describe a novel five-step approach to planning simulation-based interventions after any events that might prompt simulation-based learning in healthcare environments. This approach guides teams to identify pertinent events in healthcare, involve relevant stakeholders, agree on appropriate change interventions, elicit how simulation can contribute to them and share the learning without aggravating the second victim phenomenon. The framework is underpinned by Deming's System of Profound Knowledge, the Model for Improvement and translational simulation. It aligns with contemporary socio-technical models in healthcare, by emphasising the role of clinical teams in designing adaptation and change for improvement, as well as encouraging collaborations to enhance patient safety in healthcare. For teams to achieve this adaptive capacity that realises organisational goals of continuous learning and improvement requires the breaking down of historical silos through the creation of an infrastructure that formalises relationships between service delivery, safety management, quality improvement and education. This creates opportunities to learn by design, rather than chance, whilst striving to close gaps between work as imagined and work as done.

Translational simulation revisited: an evolving conceptual model for the contribution of simulation to healthcare quality and safety

The simulation community has effectively responded to calls for a more direct contribution by simulation to healthcare quality and safety, and clearer alignment with health service priorities, but the conceptual framing of this contribution has been vague. The term 'translational simulation' was proposed in 2017 as a "functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions" (Brazil V. Adv Simul. 2:20, 2017). Six years later, this conceptual framing is clearer. Translational simulation has been applied in diverse contexts, affording insights into its strengths and limitations. Three core concepts are identifiable in recently published translational simulation studies: a clear identification of simulation purpose, an articulation of the simulation process, and an engagement with the conceptual foundations of translational simulation practice. In this article, we reflect on current translational simulation practice and scholarship, especially with respect to these three core concepts, and offer a further elaborated conceptual model based on its use to date.

Low-cost otolaryngology simulation models for early-stage trainees: a scoping review

BACKGROUND

Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature.

METHODS

This scoping review followed the five stages of Arksey and O'Malley's Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as "low-cost," "cost-effective," or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents.

RESULTS

Of the 1706 studies screened, 17 met inclusion criteria. Most studies were conducted in HICs. Most models were low-fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation.

CONCLUSION

Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.

A view from the top: A qualitative exploration of top-level health care leaders' perceptions on the implementation of simulation-based education in postgraduate medical education

INTRODUCTION

Although there is substantial evidence supporting the benefits of simulation-based education (SBE), its widespread and effective implementation remains challenging. The aim of this study was to explore the perceptions of top-level health care leaders regarding SBE and the barriers and facilitators that influence its wide implementation as part of the postgraduate surgical curricula in Denmark.

METHODS

We conducted semi-structured interviews with top-level health care leaders who were chosen based on their roles in ensuring high-quality patient care delivery and developing strategies to achieve the goals of the entire health care system. The interview transcripts were translated into English, and a thematic approach was used to code and inductively analyse the data. We used the Consolidated Framework for Implementation Research to identify and understand the determinants to a successful implementation of SBE.

RESULTS

We interviewed 13 participants from different political and administrative levels. We found that the participants had limited knowledge about SBE, which highlighted a disconnection between these leaders and the educational environment. This was further compounded by a lack of effective communication and inadequate information dissemination between simulation centres and higher-level organisations. While participants recognised the benefits of SBE for doctors in training, they expressed concerns about the implementation given the already strained health care system and limited resources. The need for evidence, particularly in the context of patient safety, was emphasised to facilitate SBE implementation. Although participants supported the implementation of SBE, it was unclear who should initiate action.

DISCUSSION

This study highlighted the perspectives of top-level health care leaders regarding SBE and identified the determinant factors for a successful implementation. Effective communication channels are crucial to enhance collaborations and reduce the disconnection between the different health care organisational levels. Strategic implementation processes, including the roles and responsibilities, should be defined and established. These will inform decisions regarding the implementation strategies to effectively integrate SBE into the residency training curricula.

Simulation Improves Emergency Medicine Residents' Clinical Performance of Aorta Point-of-Care Ultrasound

Purpose

Using point-of-care ultrasound (POCUS) to diagnose abdominal aortic aneurysm (AAA) is an essential skill in emergency medicine (EM). While simulation-based POCUS education is commonly used, the translation to performance in the emergency department (ED) is unknown. We investigated whether adding case-based simulation to an EM residency curriculum was associated with changes in the quantity and quality of aorta POCUS performed by residents in the ED.

Methods

A case-based simulation was introduced to resident didactics at our academic, Level I trauma center. A case of undifferentiated abdominal pain was presented, which required examination of an ultrasound phantom to diagnose an AAA, with a hands-on didactic. We compared the quantity, quality, and descriptive analyses of aorta POCUS performed in the ED during the four months before and after the simulation.

Results

For participating residents (17/32), there was an 86% increase in total studies and an 80% increase in clinical studies. On an opportunity-adjusted, per-resident basis, there was no significant difference in median total scans per 100 shifts (4.4 [interquartile range (IQR) 0-15.8 vs 8.3 [IQR] 3.3-23.6, P = 0.21) or average total quality scores (3.2 ± 0.6 vs 3.2 ± 0.5, P = 0.92). The total number of limited or inadequate studies decreased (43% vs 19%, P = 0.02), and the proportion of scans submitted by interns increased (7% vs 54%, P = < .001).

Conclusion

After simulation training, aorta POCUS was performed more frequently, and ED interns contributed a higher proportion of scans. While there was no improvement in quantity or quality scores on a per-resident basis, there were significantly fewer incomplete or limited scans.

Evaluating the Impact of Assessment Metrics for Simulated Central Venous Catheterization Training

INTRODUCTION

Performance assessment and feedback are critical factors in successful medical simulation-based training. The Dynamic Haptic Robotic Trainer (DHRT) allows residents to practice ultrasound-guided needle insertions during simulated central venous catheterization (CVC) procedures while providing detailed feedback and assessment. A study was performed to examine the effectiveness of the DHRT in training the important skills of needle tip tracking and aspiration and how these skills impact procedural complications in simulated CVC.

METHODS

The DHRT data were collected for 163 residents at 2 hospitals for 6 simulated needle insertions. Users were given automated feedback on 5 performance metrics, which measure aspiration rate, arterial punctures, punctures through and through the vein, loss of access to the vein, and successful access to the vein. Aspiration rates and tip tracking rates were analyzed to determine their significance in preventing CVC complications and improving performance.

RESULTS

Tip tracking rates higher than 40% were 2.3 times more likely to result in successful venous access than rates less than 10%. Similarly, aspiration rates higher than 80% were 2.6 times more likely to result in successful venous access than rates less than 10%. Proper tip tracking and aspiration both reduced mechanical complications. Resident performance improved for all metrics except tip tracking.

CONCLUSIONS

Proper tip tracking and aspiration both reduced complications and increased the likelihood of success. However, the skill of tip tracking was not effectively learned through practice without feedback. Therefore, ultrasound-guided needle-based procedures, including CVC, can be improved by providing specific feedback to users on their ultrasound usage to track needle insertions.

Powerful medical education improves health care quality and return on investment

INTRODUCTION

Powerful medical education (PME) involves the use of new technologies informed by the science of expertise that are embedded in laboratories and organizations that value evidence-based education and support innovation. This contrasts with traditional medical education that relies on a dated apprenticeship model that yields uneven results. PME involves an amalgam of features, conditions and assumptions, and contextual variables that comprise an approach to developing clinical competence grounded in education impact metrics including efficiency and cost-effectiveness.

METHODS

This article is a narrative review based on SANRA criteria and informed by realist review principles. The review addresses the PME model with an emphasis on mastery learning and deliberate practice principles drawn from the new science of expertise. Pub Med, Scopus, and Web of Science search terms include medical education, the science of expertise, mastery learning, translational outcomes, cost effectiveness, and return on investment. Literature coverage is comprehensive with selective citations.

RESULTS

PME is described as an integrated set of twelve features embedded in a group of seven conditions and assumptions and four context variables. PME is illustrated via case examples that demonstrate improved ventilator patient management learning outcomes compared to traditional clinical education and mastery learning of breaking bad news communication skills. Evidence also shows that PME of physicians and other health care providers can have translational, downstream effects on patient care practices, patient outcomes, and return on investment. Several translational health care quality improvements that derive from PME include reduced infections; better communication among physicians, patients, and families; exceptional birth outcomes; more effective patient education; and return on investment.

CONCLUSIONS

The article concludes with challenges to hospitals, health systems, and medical education organizations that are responsible for producing physicians who are expected to deliver safe, effective, and cost-conscious health care.

Low-Cost Otolaryngology Simulation Models for Early-Stage Trainees: A Scoping Review

Importance

There is a notable lack of low-cost OHNS simulation models that are relevant for early medical trainees and students. By conducting this study, we will understand the current landscape of low-cost otolaryngology-head and neck surgery simulation for early medical trainees and students.

Objectives

Medical simulation is essential for surgical training yet is often too expensive and inaccessible in low- and middle-income countries (LMICs). Furthermore, in otolaryngology-head and neck surgery (OHNS), while simulation training is often focused on senior residents and specialists, there is a critical need to target general practitioners who carry a significant load of OHNS care in countries with limited OHNS providers. This scoping review aims to describe affordable, effective OHNS simulation models for early-stage trainees and non-OHNS specialists in resource-limited settings and discuss gaps in the literature.

Evidence Review

This scoping review followed the five stages of Arksey and O'Malley's Scoping Review Methodology. Seven databases were used to search for articles. Included articles discussed physical models of the ear, nose, or throat described as "low-cost," "cost-effective," or defined as <$150 if explicitly stated; related to the management of common and emergent OHNS conditions; and geared towards undergraduate students, medical, dental, or nursing students, and/or early-level residents.

Findings

Of the 1706 studies screened, 17 met the inclusion criteria. Most studies were conducted in HICs. Most models were low fidelity (less anatomically realistic) models. The most common simulated skills were peritonsillar abscess aspiration and cricothyrotomy. Information on cost was limited, and locally sourced materials were infrequently mentioned. Simulations were evaluated using questionnaires and direct observation.

Conclusion and Relevance

Low-cost simulation models can be beneficial for early medical trainees and students in LMICs, addressing resource constraints and improving skill acquisition. However, there is a notable lack of contextually relevant, locally developed, and cost-effective models. This study summarizes existing low-cost OHNS simulation models for early-stage trainees and highlights the need for additional locally sourced models. Further research is needed to assess the effectiveness and sustainability of these models.

Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study

BACKGROUND

A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program.

METHODS

A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale).

RESULTS

35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance.

CONCLUSIONS

We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

Advanced imaging and modeling in neonatal simulation

Advances in modeling and imaging have resulted in realistic tools that can be applied to education and training, and even direct patient care. These include point-of-care ultrasound (POCUS), 3-dimensional and digital anatomic modeling, and extended reality. These technologies have been used for the preparation of complex patient care through simulation-based clinical rehearsals, direct patient care such as the creation of patient devices and implants, and for simulation-based education and training for health professionals, patients and families. In this section, we discuss these emerging technologies and describe how they can be utilized to improve patient care.

Interactive computer-assisted learning as an educational method for learning pediatric interproximal dental caries identification

OBJECTIVE

We developed a web-based tool to measure the amount and rate of skill acquisition in pediatric interproximal caries diagnosis among pre- and postdoctoral dental students and identified variables predictive for greater image interpretation difficulty.

STUDY DESIGN

In this multicenter prospective cohort study, a convenience sample of pre- and postdoctoral dental students participated in computer-assisted learning in the interpretation of bitewing radiographs of 193 children. Participants were asked to identify the presence or absence of interproximal caries and, where applicable, locate the lesions. After every case, participants received specific visual and text feedback on their diagnostic performance. They were requested to complete the 193-case set but could complete enough cases to achieve a competency performance standard of 75% accuracy, sensitivity, and specificity.

RESULTS

Of 130 participants, 62 (47.7%) completed all cases. The mean change from initial to maximal diagnostic accuracy was +15.3% (95% CI, 13.0-17.7), sensitivity was +10.8% (95% CI, 9.0-12.7), and specificity was +15.5% (95% CI, 12.9-18.1). The median number of cases completed to achieve competency was 173 (interquartile range, 82-363). Of these 62 participants, 45 (72.6%) showed overall improvement in diagnostic accuracy. Greater numbers of interproximal lesions (P < .001) and the presence of noninterproximal caries (P < .001) predicted greater interpretation difficulty.

CONCLUSIONS

Computer-assisted learning led to improved diagnosis of interproximal caries on bitewing radiographs among pre- and postdoctoral dental students.

Curriculum and assessment tool for less invasive surfactant administration: an international Delphi consensus study

BACKGROUND

Training and assessment of operator competence for the less invasive surfactant administration (LISA) procedure vary. This study aimed to obtain international expert consensus on LISA training (LISA curriculum (LISA-CUR)) and assessment (LISA assessment tool (LISA-AT)).

METHODS

From February to July 2022, an international three-round Delphi process gathered opinions from LISA experts (researchers, curriculum developers, and clinical educators) on a list of items to be included in a LISA-CUR and LISA-AT (Round 1). The experts rated the importance of each item (Round 2). Items supported by more than 80% consensus were included. All experts were asked to approve or reject the final LISA-CUR and LISA-AT (Round 3).

RESULTS

A total of 153 experts from 14 countries participated in Round 1, and the response rate for Rounds 2 and 3 was >80%. Round 1 identified 44 items for LISA-CUR and 22 for LISA-AT. Round 2 excluded 15 items for the LISA-CUR and 7 items for the LISA-AT. Round 3 resulted in a strong consensus (99-100%) for the final 29 items for the LISA-CUR and 15 items for the LISA-AT.

CONCLUSIONS

This Delphi process established an international consensus on a training curriculum and content evidence for the assessment of LISA competence.

IMPACT

This international consensus-based expert statement provides content on a curriculum for the less invasive surfactant administration procedure (LISA-CUR) that may be partnered with existing evidence-based strategies to optimize and standardize LISA training in the future. This international consensus-based expert statement also provides content on an assessment tool for the LISA procedure (LISA-AT) that can help to evaluate competence in LISA operators. The proposed LISA-AT enables standardized, continuous feedback and assessment until achieving proficiency.

Reviews in Medical Education: Advances in Simulation to Address New Challenges in Neurology

Simulation is an engaging modality of medical education that leverages adult learning theory. Since its inception, educators have used simulation to train clinicians in bedside procedures and neurologic emergencies, as well as in communication, teamwork, and leadership skills. Many applications of simulation in neurology are yet to be fully adopted or explored. However, challenges to traditional educational paradigms, such as the shift to competency-based assessments and the need for remote or hybrid platforms, have created an impetus for neurologists to embrace simulation. In this article, we explore how simulation might be adapted to meet these current challenges in neurologic education by reviewing the existing literature in simulation from the field of neurology and beyond. We discuss how simulation can engage neurology trainees who seek interactive, contextualized, on-demand education. We consider how educators can incorporate simulation for competency-based evaluations and procedural training. We foresee a growing role of simulation initiatives that assess bias and promote equity. We also provide tangible solutions that make simulation an educational tool that is within reach for any educator in both high-resource and low-resource settings.

A national needs assessment to identify technical procedures in plastic surgery for simulation-based training

Medical simulation is not developed and integrated into plastic surgery unlike other surgical specialties despite the procedures being complex and require practice. First step in enhancing simulation in plastic surgery is to clarify the need among peers. The objective of the study was to identify and prioritize the technical procedures that should be included in a simulation-based curriculum for residency training in plastic surgery. A panel of participants with key roles in the Danish plastic surgery specialist training program was appointed. Participation was voluntary. A national need assessment study was performed using a three-round Delphi process to collect information from the participants. In round 1, participants reported all the procedures that a newly qualified specialist in plastic surgery should be able to perform. In round 2, participants replied to a survey exploring the frequency of the procedures, the number of surgeons performing the procedure, the risk or discomfort for patients treated by an inexperienced surgeon and the feasibility of training the procedure in simulation, resulting in a preliminary ranking of procedures. In round 3, participants eliminated and reprioritized the identified procedures according to importance. Thirty-five of 37 agreed to enter the expert panel. The response rate was 97%, 86% and 86% for rounds 1, 2 and 3, respectively. Twenty-nine of 136 procedures identified in round 1 reached the final prioritized list of procedures relevant for simulation training in plastic surgery.

Thinking Beyond the Temporal Bone Lab: A Systematic Process for Expanding Surgical Simulation in Otolaryngology Training

The COVID-19 pandemic led to a temporary lapse in the development of otolaryngology trainee operative skills due to the cancellation of elective procedures and redeployment of trainees and attendings to COVID-19 units. Although transient, this disruption provided an opportunity for otolaryngology programs to develop contingency plans and formalize nascent simulation training curricula. Integration of formal simulation training alongside current didactic and surgical education may offset lost exposure during surgically lean times while providing the framework and resources for enhanced baseline training. Here, we provide an up-to-date overview of surgical simulation models in otolaryngology and identify easily implementable, low-cost, low fidelity models for junior trainees. By taking advantage of rapid advancements in technology and a paradigm shift to a more hands-on approach in medical education, formal simulation training may prove to be a beneficial tool at all stages of residency training, allowing for expanded peer-mentored skill development and providing a safe haven during unforeseen disruptions in surgical case volume.

Neurosurgery resident training using blended learning concepts: course development and participant evaluation

OBJECTIVE

Restrictions on working time and healthcare expenditures, as well as increasing subspecialization with caseload requirements per surgeon and increased quality-of-care expectations, provide limited opportunities for surgical residents to be trained in the operating room. Yet, surgical training requires goal-oriented and focused practice. As a result, training simulators are increasingly utilized. The authors designed a two-step blended course consisting of a personalized adaptive electronic learning (e-learning) module followed by simulator training. This paper reports on course development and the evaluation by the first participants.

METHODS

Adaptive e-learning was curated by learning engineers based on theoretical information provided by clinicians (subject matter experts). A lumbar spine model for image-guided spinal injections was used for the simulator training. Residents were assigned to the e-learning module first; after its completion, they participated in the simulator training. Performance data were recorded for each participant’s e-learning module, which was necessary to personalize the learning experience to each individual’s knowledge and needs. Simulator training was organized in small groups with a 1-to-4 instructor-to-participant ratio. Structured assessments were undertaken, adapted from the Student Evaluation of Educational Quality.

RESULTS

The adaptive e-learning module was curated, reviewed, and approved within 10 weeks. Eight participants have taken the course to date. The overall rating of the course is very good (4.8/5). Adaptive e-learning is well received compared with other e-learning types (8/10), but scores lower regarding usefulness, efficiency, and fun compared with the simulator training, despite improved conscious competency (32.6% ± 15.1%) and decreased subconscious incompetency (22.8% ± 10.2%). The subjective skill level improved by 20%. Asked about the estimated impact of the course, participants indicated that they had either learned something new that they plan to use in their practice (71.4%) or felt reassured in their practice (28.6%).

CONCLUSIONS

The development of a blended training course combining adaptive e-learning and simulator training in a rapid manner is feasible and leads to improved skills. Simulator training is rated more valuable by surgical trainees than theoretical e-learning; the impact of this type of training on patient care needs to be further investigated.

Implementation of simulation-based health systems science modules for resident physicians

BACKGROUND

Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains.  METHODS: Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January - March 2021.

RESULTS

A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures.

CONCLUSIONS

The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

In Situ Simulation for Adoption of New Technology to Improve Sepsis Care in Rural Emergency Departments

OBJECTIVES

The aims of the study were to evaluate whether in situ (on-site) simulation training is associated with increased telemedicine use for patients presenting to rural emergency departments (EDs) with severe sepsis and septic shock and to evaluate the association between simulation training and telehealth with acute sepsis bundle (SEP-1) compliance and mortality.

METHODS

This was a quasi-experimental study of patients presenting to 2 rural EDs with severe sepsis and/or septic shock before and after rollout of in situ simulation training that included education on sepsis management and the use of telehealth. Unadjusted and adjusted analyses were conducted to describe the association of simulation training with sepsis process of care markers and with mortality.

RESULTS

The study included 1753 patients, from 2 rural EDs, 629 presented before training and 1124 presented after training. There were no differences in patient characteristics between the 2 groups. Compliance with several SEP-1 bundle components improved after training: antibiotics within 3 hours, intravenous fluid administration, repeat lactic acid assessment, and vasopressor administration. The use of telemedicine increased from 2% to 5% after training. Use of telemedicine was associated with increases in repeat lactic acid assessment and reassessment for septic shock. We did not demonstrate an improvement in mortality across either of the 2 group comparisons.

CONCLUSIONS

We demonstrate an association between simulation and improved care delivery. Implementing an in situ simulation curriculum in rural EDs was associated with a small increase in the use of telemedicine and improvements in sepsis process of care markers but did not demonstrate improvement in mortality. The small increase in telemedicine limited conclusions on its impact.

Simulation training in endoscopic skull base surgery: A scoping review

Objective

Methods

Results

Conclusions

The Global Healthcare Simulation Economy: A Scoping Review

Healthcare simulation is a technique that creates a situation or environment that allows persons to experience a representation of a real health care event for the purpose of practice, learning, evaluation, or gaining an understanding of systems or human actions. The use of healthcare simulation has grown rapidly over the last decade. In this review, we describe the global healthcare simulation economy. We reviewed the literature describing the global healthcare simulation economy using four research databases (Google Scholar, MEDLINE, Embase, and EconLit) as well as alternative sources. The specific aims were to examine the major economic themes facing the healthcare simulation economy. We found that the global healthcare simulation market is segmented based on product & services, fidelity, end-user, and geography. The market has experienced new player entry over the last few years, with most businesses focused in North America, Europe, and Asia-Pacific. The global healthcare simulation market is expected to reach between $3.19 and $7.7 billion by 2027, with a compound annual growth rate of 14.6% to 17.8%. Political and trade issues between America and China may increase the cost of goods in the short term. There are no global regulations on the use of healthcare simulation for training, licensing, or certification. Therefore, individual countries, states, and healthcare specialties establish individual regulations. We conclude that the major economic issues facing the global healthcare simulation economy include market segmentation, the entry of new players, and differential global growth. These factors, plus recent political and trade issues, and lack of regulations, could impact decision-making.

Research Hotspots and Trend Exploration on the Clinical Translational Outcome of Simulation-Based Medical Education: A 10-Year Scientific Bibliometric Analysis From 2011 to 2021

BACKGROUND

In recent decades, an increasing number of studies have focused on the clinical translational effect of simulation-based medical education (SBME). However, few scientific bibliometric studies have analyzed the research hotspots and publication trends. This study aimed to investigate research hotspots and future direction in the clinical translational outcome of SBME via bibliometrics.

METHOD

Relevant publications on the clinical translational outcomes of SBME from 2011 to 2021 were identified and retrieved from the Web of Science Core Collection (WOSCC). Software including VOSviewer (1.6.17) and CiteSpace (5.8R3) and a platform (bibliometric.com) were employed to conduct bibliographic and visualized analysis on the literature.

RESULTS

A total of 1,178 publications were enrolled. An increasing number of publications were observed in the past decades from 48 in 2011 to 175 in 2021. The United States accounted for the largest number of publications (488, 41.4%) and citations (10,432); the University of Toronto and Northwestern University were the leading institutions. Academic Medicine was the most productive journal concerning this field. McGaghie W C and Konge L were the most influential authors in this area. The hot topic of the translational outcome of SBME was divided into 3 stages, laboratory phase, individual skill improvement, and patient outcome involving both technical skills and non-technical skills. Translational research of comprehensive impact and collateral outcomes could be obtained in the future.

CONCLUSION

From the overall trend of 10 years of research, we can see that the research is roughly divided into three phases, from laboratory stage, individual skill improvement to the patient outcomes, and comprehensive impacts such as skill retention and collateral effect as cost-effectiveness is a major trend of future research. More objective evaluation measurement should be designed to assess the diverse impact and further meta-analysis and randomized controlled trials are needed to provide more clinical evidence of SBME as translational science.

Use of clinical simulation to train healthcare teams in conflict management: A scoping review

OBJECTIVE

To assess and analyze the impact of clinical simulation as a training tool in healthcare teams ability to resolve and manage conflicts, through an exploratory systematic review.

METHODS

A structured literature review was performed with the terms [Clinical Simulation OR Patient Simulation OR Simulation Training OR High Fidelity simulation Training] AND [Conflict OR Conflict Resolution] in the following databases: MEDLINE, LILACS, Cochrane, Scielo, PubMed, CINHAL, ScienceDirect, MEDES, IBECS y DOCUMED. Articles were considered if they involved clinical simulation oriented to training of healthcare professionals or trainees in conflict management, using clinical scenarios, and excluding those studies older than 20 years. Absence of debriefing was not considered an exclusion criterion, neither the use of simulation along with other methodologies. A quantitative analysis was performed.

RESULTS

10 articles were retrieved, mostly with quasi-experimental designs, in which clinical simulation was designed as an interprofessional training and was used with multiple other methodologies like roleplay, reflexive practice and audiovisual aids, strategy that suggest an increase its effectivity. Different scenarios have been recreated, like decision-making divergences and management of medical errors, in order to apply the competences of mediation, communication, emotional skills among others, and followed by debriefing. The use of validated scales and conventional assessment methods reveal a positive impact on satisfaction, perception and learning of students, as well as transfer to clinical practice and decrease in errors.

CONCLUSION

Multiple studies describe and support the use of clinical simulation for training in management and resolution of conflicts among healthcare professionals. Simulation is accepted by participants, developing transfer of skills and competences and impact at the organizational level. Nonetheless, studies are recent and limited in number, making this area a developing field that promotes future research.

The horizon of pediatric cardiac critical care

Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.

Rethinking Our Annual Congress-Meeting the Needs of Specialist Physicians by Partnering With Provincial Simulation Centers

Canada's maintenance of certification programs for physicians has evolved to emphasize assessment activities. Our organization recognized the importance of offering more practice assessment opportunities to our members to enhance their practice and help them comply with a regulation from our provincial professional body related to ongoing continuing education. This led us to rethink our annual congress and enrich the program with a curriculum of interdisciplinary simulation sessions tailored to meet the needs of a broad audience of specialists. Our challenges are similar to those of many national specialty societies having limited access to simulation facilities, instructors, and simulation teams that can cover the breadth and scope of perceived and unperceived simulation needs for their specialty. Our innovative solution was to partner with local experts to develop 22 simulation sessions over the past three years. The response was very positive, drawing 867 participants. Over 95% of participants either agreed or strongly agreed that their simulation session (1) met their learning objectives, (2) was relevant for their practice, and (3) encouraged them to modify their practice. Narrative comments from a survey sent to the 2018 participants four months after their activity indicated several self-reported changes in their practice or patient outcomes. We were able to centralize offers from organizations that had previously worked in silo to develop simulation sessions meeting the needs of our members. Proposing simulation sessions allowed our organization to establish long-term partnerships and to expend our "educational toolbox" to address skill gaps not usually addressed during annual meetings.

Simulation in neonatal care: towards a change in traditional training?

Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement.

CONCLUSION

Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority.

WHAT IS KNOWN

• Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation.

WHAT IS NEW

• There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.

Developing a Real-Time Electroencephalogram-Guided Anesthesia-Management Curriculum for Educating Residents: A Single-Center Randomized Controlled Trial

BACKGROUND

Different anesthetic drugs and patient factors yield unique electroencephalogram (EEG) patterns. Yet, it is unclear how best to teach trainees to interpret EEG time series data and the corresponding spectral information for intraoperative anesthetic titration, or what effect this might have on outcomes.

METHODS

We developed an electronic learning curriculum (ELC) that covered EEG spectrogram interpretation and its use in anesthetic titration. Anesthesiology residents at a single academic center were randomized to receive this ELC and given spectrogram monitors for intraoperative use versus standard residency curriculum alone without intraoperative spectrogram monitors. We hypothesized that this intervention would result in lower inhaled anesthetic administration (measured by age-adjusted total minimal alveolar concentration [MAC] fraction and age-adjusted minimal alveolar concentration [aaMAC]) to patients ≥60 old during the postintervention period (the primary study outcome). To study this effect and to determine whether the 2 groups were administering similar anesthetic doses pre- versus postintervention, we compared aaMAC between control versus intervention group residents both before and after the intervention. To measure efficacy in the postintervention period, we included only those cases in the intervention group when the monitor was actually used. Multivariable linear mixed-effects modeling was performed for aaMAC fraction and hospital length of stay (LOS; a non-prespecified secondary outcome), with a random effect for individual resident. A multivariable linear mixed-effects model was also used in a sensitivity analysis to determine if there was a group (intervention versus control group) by time period (post- versus preintervention) interaction for aaMAC. Resident EEG knowledge difference (a prespecified secondary outcome) was compared with a 2-sided 2-group paired t test.

RESULTS

Postintervention, there was no significant aaMAC difference in patients cared for by the ELC group (n = 159 patients) versus control group (N = 325 patients; aaMAC difference = -0.03; 95% confidence interval [CI], -0.09 to 0.03; P =.32). In a multivariable mixed model, the interaction of time period (post- versus preintervention) and group (intervention versus control) led to a nonsignificant reduction of -0.05 aaMAC (95% CI, -0.11 to 0.01; P = .102). ELC group residents (N = 19) showed a greater increase in EEG knowledge test scores than control residents (N = 20) from before to after the ELC intervention (6-point increase; 95% CI, 3.50-8.88; P < .001). Patients cared for by the ELC group versus control group had a reduced hospital LOS (median, 2.48 vs 3.86 days, respectively; P = .024).

CONCLUSIONS

Although there was no effect on mean aaMAC, these results demonstrate that this EEG-ELC intervention increased resident knowledge and raise the possibility that it may reduce hospital LOS.

Higher Speciality Training Boot Camp in Otolaryngology: A Quantitative and Qualitative Analysis of the Northern National Formative Specialty Training 3 Induction Course

Background Opportunities for new otolaryngology trainees to develop their skills as they embark on specialty training can be limited. Our facility hosted a national simulation-based boot camp for new otolaryngology trainees in the UK. This study aimed to assess the effectiveness of the boot camp in improving trainee confidence as they transitioned from core surgical training (CST) to higher specialty training (HST) in otolaryngology. Methodology We conducted a prospective study on the effectiveness of the boot camp on trainee induction. The boot camp included hands-on simulation, small group teaching and didactic lectures addressing technical skills in the fields of otology, laryngology, rhinology, facial plastics, and paediatrics, as well as non-technical skills involving human factors, simulated ward round, and cognitive simulation. The boot camp curriculum reflected the competencies expected by the Joint Committee of Surgical Training (JCST) at this level of training. Participants completed a pre- and post-course questionnaire addressing their self-confidence for the technical and non-technical skills they developed during the boot camp. All participants were invited to participate in an interview 12 months after the boot camp. Results A total of 27 new otolaryngology trainees (approximately half of all new otolaryngology trainees in the UK) participated in the boot camp. A significant increase in median confidence was observed for all technical and non-technical stations (p < 0.0001). The increase in confidence observed was similar for participants regardless of prior experience in otolaryngology. Five candidates were interviewed a year after the boot camp. Analysis of the transcripts generated distinct comments that were grouped into five key themes. Conclusions A simulation-based boot camp mapped to the JCST curriculum can increase the confidence of new otolaryngology Specialty Training 3 trainees during their transition from CST to HST. It can provide valuable and durable technical and non-technical skills to aid trainees in the clinic, theatre environment, and when on-call during their inaugural year of training.

"Sim One, Do One, Teach One": A Simulation-Based Trauma Orientation for Pediatric Residents in the Emergency Department

OBJECTIVES

The objective of this study was to determine the effectiveness of a simulation-based curriculum in improving confidence in trauma resuscitation skills and increasing attendance during trauma resuscitations for pediatric residents during their emergency medicine rotation.

METHODS

A simulation-based orientation curriculum was implemented for the 2017-2018 academic year. Participants completed a qualitative survey before and after each session to assess their comfort level with skills required in a trauma resuscitation. Responses were compared using the Wilcoxon ranked sum test. Nursing documentation was reviewed for the 2016-2017 and 2017-2018 academic years to determine the frequency of resident attendance at trauma resuscitations. Pediatric resident attendance before and after intervention were compared via χ2 analysis.

RESULTS

Survey responses showed a significant increase in confidence in all skills assessed, including primary and secondary survey performance, knowledge of pediatric resident role, knowledge of necessary equipment, ability to determine acuity of patient illness or injury, and ability to differentiate between modes of oxygen delivery (P < 0.01). There was no statistically significant change in the frequency of pediatric resident attendance at trauma bay resuscitations before and after curriculum implementation (21.2% vs 25.7%, P = 0.09).

CONCLUSIONS

Through the implementation of a simulation-based trauma orientation for pediatric residents, we were able to improve self-reported confidence in trauma resuscitation skills. This improvement did not result in an increased attendance at trauma resuscitations. Next steps include identifying additional barriers to pediatric resident attendance at trauma bay resuscitations.

Does simulation improve clinical performance in management of postpartum hemorrhage?

BACKGROUND

Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited.

OBJECTIVE

This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program.

STUDY DESIGN

This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant.

RESULTS

Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032).

CONCLUSION

The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.

Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

BACKGROUND

Rapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.

METHODS

Costs for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.

RESULTS

All costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.

CONCLUSIONS

We have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

Re-examining the value proposition for Competency-Based Medical Education

The adoption of competency-based medical education (CBME) by Canadian postgraduate training programs has created a storm of excitement and controversy. Implementing the system-wide Competency by Design (CBD) project initiated by the Royal College of Physicians & Surgeons of Canada (RCPSC), is an ambitious transformative change challenge. Not surprisingly, tensions have arisen across the country around the theoretical underpinnings of CBME and the practicalities of implementation, resulting in calls for evidence justifying its value. Assumptions have been made on both sides of the argument contributing to an atmosphere of unhealthy protection of the status quo, premature conclusions of CBME's worth, and an oversimplification of risks and costs to participants. We feel that a renewed effort to find a shared vision of medical education and the true value proposition of CBME is required to recreate a growth-oriented mindset. Also, the aspirational assertion of a direct link between CBME and improved patient outcomes requires deferral until further implementation and study has occurred. However, we perceive more concrete and immediate value of CBME arises from the societal contract physicians have, the connection to maintaining self-regulation, and the potential customization of training for learners.

Use of simulation in teaching haematological aspects to undergraduate medical students improves student's knowledge related to the taught theoretical underpinnings

BACKGROUND

Simulation is an educational method which has several modalities and applications. In the last few decades Simulation-Based Medical Education (SBME) has become a significant influence in medical education. Despite the recognized potential of simulation to be used widely in support of healthcare education, there are no studies focused on the role of simulation in teaching haematology. Moreover, the reaction level is the most commonly reported in medical education. This study evaluates, at two levels of Kirkpatrick's model, the effectiveness of incorporating SBME in teaching haematological aspects to medical students.

METHODS

A total of 84 second year medical students from two cohorts received theoretical components of Haematopoietic and Immune System in 4 credits course, delivered using lecture approach. First cohort students (n = 49) participated in interactive learning tutorials to discuss clinical vignettes. Second cohort (n = 35) students participated in simulation sessions where the tutorial's clinical vignettes were developed to clinical simulation scenarios conducted in the simulation centre. The potential influence of the simulation in learning enhancement was evaluated using Kirkpatrick's Evaluation Framework.

RESULTS

The students rated the simulation sessions highly and found them to be a valuable learning experience. The category performance summary, generated by the assessment platform, demonstrates improvement in the student's knowledge enhanced by the SBME.

CONCLUSIONS

Adaptation of SBME in teaching haematological aspects is a feasible way to improve the student's knowledge related to the taught theoretical foundations. SBME has the potential to enhance the undergraduate medical curriculum and it is expected, in the near future, to be an increasingly recommended educational strategy to bridge the gap between theory and practice.

Evaluation of a simulation faculty training workshop in a low-resource setting: a qualitative study

Introduction

Simulation instructor training courses are infrequent in low-resource countries. PediSTARS India organisation has been conducting a Training of Trainers (TOT) workshop annually since 2014 and has trained 380 instructors in the last 6 years. The objective of this study is to evaluate this workshop using the basic Kirkpatrick model with a blended evaluation approach.

Methods

A qualitative study design was used with purposive sampling from the 2018 workshop cohort. An initial online questionnaire gathered demographic and professional profile of participants. Semistructured interviews with those who consented explored their perceptions about the workshop and their experiences using simulation for training at their workplaces. The analysis was done based on a deductive research approach around the framework of the first three levels of the Kirkpatrick model.

Results

A total of 11 in-depth interviews were conducted. Participants reported long-term retention, translation and positive impact of the knowledge and skills gained at the TOT workshop. The results achieved saturation and underwent respondent validation.

Conclusion

This study provides evidence to support simulation faculty training workshops as an effective educational intervention in promoting simulation-related workplace-based education and training among health practitioners and that follow-up activity may be useful in some cases. This is the first study of its kind in a low-resource setting, and supports similar simulation instructor training in these settings and provides a blueprint for such training. Follow-up studies are required to evaluate the longer term impact of this simulation instructor training.

"Omepralith": A novel simulation model for training in sialoendoscopy

INTRODUCTION

There are no previously described training models for learning or teaching how to remove lithiasis from the salivary ducts. Therefore, we present a new simulation model to enable us to faithfully represent the process of endoscopic lithiasis extraction by sialoendoscopy.

MATERIALS AND METHODS

A simulation model was developed using a pig's head, omeprazole spheres were used to simulate lithiasis in the various ducts of each salivary gland and a Dormia basket was used to train in extraction of the lithiasis model.

RESULTS

Twenty-seven residents in training and/or young specialists were successfully trained in this technique using this model. Twenty-six (96.3%) considered the model useful for training in the use of baskets; all of them were able to capture the omeprazole sphere in the salivary duct. A satisfaction rate of 92.25 out of 100 points was obtained through an anonymous survey.

CONCLUSION

We describe a novel simulation model using omeprazole spheres, which allows the surgeon to practice how to diagnose and treat obstructive pathology of the salivary glands in a risk-free environment guaranteeing the reproducibility of the technique in conditions similar to those of normal practice.

Use of clinical simulation to train healthcare teams in conflict management: a scoping review

OBJECTIVE

To assess and analyze the impact of clinical simulation as a training tool in healthcare teams ability to resolve and manage conflicts, through an exploratory systematic review.

METHODS

A structured literature review was performed with the terms clinical simulation OR patientsimulation OR simulation training OR high fidelity simulation training AND conflict OR conflict resolution in the following databases: MEDLINE, LILACS, Cochrane, Scielo, PubMed, CINHAL, ScienceDirect, MEDES, IBECS and DOCUMED. Articles were considered if they involved clinical simulation oriented to training of healthcare professionals or trainees in conflict management, using clinical scenarios, and excluding those studies older than 20 years. Absence of debriefing was not considered an exclusion criterion, neither the use of simulation along with other methodologies. A quantitative analysis was performed.

RESULTS

10 articles were retrieved, mostly with quasi-experimental designs, in which clinical simulation was designed as an interprofessional training and was used with multiple other methodologies like roleplay, reflexive practice and audiovisual aids, strategy that suggest an increase its effectivity. Different scenarios have been recreated, like decision-making divergences and management of medical errors, in order to apply the competences of mediation, communication, emotional skills among others, and followed by debriefing. The use of validated scales and conventional assessment methods reveal a positive impact on satisfaction, perception and learning of students, as well as transfer to clinical practice and decrease in errors.

CONCLUSION

Multiple studies describe and support the use of clinical simulation for training in management and resolution of conflicts among healthcare professionals. Simulation is accepted by participants, developing transfer of skills and competences and impact at the organizational level. Nonetheless, studies are recent and limited in number, making this area a developing field that promotes future research.

TeamSTEPPS online simulation: expanding access to teamwork training for medical students

Background

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) programme is an evidence-based approach to teamwork training. In-person education is not always feasible for medical student education. The aim of this study was to evaluate the impact of online, interactive TeamSTEPPS simulation versus an in-person simulation on medical students’ TeamSTEPPS knowledge and attitudes.

Methods

Fourth-year medical students self-selected into an in-person or online training designed to teach and evaluate teamwork skills. In-person participants received didactic sessions, team-based medical simulations and facilitated debriefing sessions. The online group received an equivalent online didactic session and participated in an interactive software-based simulation with immediate, personalised performance-based feedback and scripted debriefing. Both trainings used three iterations of a case of septic shock, each with increasing medical complexity. Participants completed a demographic survey, a preintervention/postintervention TeamSTEPPS Benchmarks test and a retrospective preintervention/postintervention TeamSTEPPS teamwork attitudes questionnaire. Data were analysed using descriptive statistics and repeated measures analysis of variance.

Results

Thirty-one students (18 in-person, 13 online) completed preintervention/postintervention surveys, tests and questionnaires. Gender, age and exposure to interprofessional education, teamwork training and games were similar between groups. There were no statistical differences in preintervention knowledge or teamwork attitude scores between in-person and online groups. Postintervention knowledge scores increased significantly from baseline (+2.0% p=0.047), and these gains did not differ significantly based on whether participants received in-person versus online training (+1.5% vs +2.9%; p=0.49). Teamwork attitudes scores also showed a statistically significant increase with training (+0.9, p<0.01) with no difference in the effect of training by group (+0.8 vs +1.0; p=0.64).

Conclusions

Graduating medical students who received in-person and online teamwork training showed similar increases in TeamSTEPPS knowledge and attitudes. Online simulations may be used to teach and reinforce team communication skills when in-person, interprofessional simulations are not feasible.

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.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

BACKGROUND

Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.

OBJECTIVES

To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.

SEARCH METHODS

The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.

MAIN RESULTS

We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).

AUTHORS' CONCLUSIONS

Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

Optimizing Multidisciplinary Simulation in Medical School for Larger Groups: Role Assignment by Lottery and Guided Learning

PURPOSE

Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups.

PATIENTS AND METHODS

We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session.

RESULTS

Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method.

CONCLUSION

We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

Research on simulation in radiography education: a scoping review protocol

BACKGROUND

Today, there are fewer opportunities for health care students and staff for skills training through direct patient contact. The World Health Organization therefore recommends learning about patient safety through hands-on experience and simulation. Simulation has the potential to improve skills through training in a controlled environment, and simulation has a positive effect on knowledge and skills, and even patient-related outcomes. Reviews addressing the use of simulation across the different radiography specialties are lacking. Further knowledge on simulation in radiography education is needed to inform curriculum design and future research. The purpose of this scoping review is to explore, map, and summarize the extent, range, and nature of published research on simulation in radiography education.

METHODS

We will follow the methodological framework for scoping reviews originally described by Arksey and O'Malley. We will search the MEDLINE, Embase, Epistemonikos, The Cochrane Library, ERIC, Scopus, and sources of grey literature. A comprehensive search strategy for Ovid MEDLINE was developed in collaboration with a research librarian. An example of a full electronic search from the Ovid MEDLINE (1641 articles records, January 9, 2020) is provided and will be used to adapt the search strategy to each database. Two independent review authors will screen all abstracts and titles, and full-text publications during a second stage. Next, they will extract data from each included study using a data extraction form informed by the aim of the study. A narrative account of all studies included will be presented. We will present a simple numerical analysis related to the extent, nature, and distribution of studies, and we will use content analysis to map the different simulation interventions and learning design elements reported. Any type of simulation intervention within all types of radiography specializations will be included. Our search strategy is not limited by language or date of publication.

DISCUSSION

An overview of publications on simulation in radiography education across all radiography specialties will help to inform future research and will be useful for stakeholders within radiography education using simulation, both in the academic and clinical settings.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (OSF). Submitted on October 18, 2020.

Emergency airway training: "Who are you going to FONA?"

OBJECTIVES

To demonstrate face and content validity of a home-made simulation model as a training tool for front of neck access (FONA) procedures.

DESIGN

This was a prospective evaluation study, in which experienced otolaryngologists and trainees were recruited to complete 3 tasks using our FONA model.

SETTING

The study was completed during regular simulation training days and international conferences.

PARTICIPANTS

A total of 52 participants completed the questionnaire and were included in the study; 25 were experts and 27 were trainees.

MAIN OUTCOME MEASURES

All participants completed a validated 15-item questionnaire using a 5-point likert scale to assess the model across 4 domains: face validity (FV), global content (GC), task-specific content (TSC) and curriculum applicability (CTR).

RESULTS

There were no statistically significant differences between the groups ratings for FV, GC, TSC or CTR (P = .76, .13, .4 and .67, respectively). The model achieved a median FV of 4 (IQR 4-5) with the agreement of experienced and trainee groups (68.9% and 92%, respectively). The median GC validity score was 5 (IQR 4-5) with the agreement of 87.6% and 98.4% in respected groups. The model achieved a median TSC of 4.8 (IQR 4-5) with the agreement of 54.5% and 99% in respected groups. The median CTR score was 5 (IQR 4-5) with the agreement of 54.4% and 100% in respected groups.

CONCLUSION

Our home-made FONA model achieved face and content validity for training and is safe and affordable for teaching basic front of neck access skills to otolaryngology trainees.

Teaching surgery novices and trainees advanced laparoscopic suturing: a trial and tribulations

INTRODUCTION

The benefits of minimally invasive surgery are numerous; however, considerable variability exists in its application and there is a lack of standardized training for important advanced skills. Our goal was to determine whether participation in an advanced laparoscopic curriculum (ALC) results in improved laparoscopic suturing skills.

METHODS AND PROCEDURES

Study design was a prospective, randomized controlled trial. Surgery novices and trainees underwent baseline FLS training and were pre-tested on bench models. Participants were stratified by pre-test score and randomized to undergo either further FLS training (control group) or ALC training (intervention group). All were post-tested on the same bench model. Tests for differences between post-test scores of cohorts were performed using least squared means. Multivariable regression identified predictors of post-test score, and Wilcoxon rank sum test assessed for differences in confidence improvement in laparoscopic suturing ability between groups.

RESULTS

Between November 2018 and May 2019, 25 participants completed the study (16 females; 9 males). After adjustment for relevant variables, participants randomized to the ALC group had significantly higher post-test scores than those undergoing FLS training alone (mean score 90.50 versus 82.99, p = 0.001). The only demographic or other variables found to predict post-test score include level of training (p = 0.049) and reported years of video gaming (p = 0.034). There was no difference in confidence improvement between groups.

CONCLUSIONS

Training using the ALC as opposed to basic laparoscopic skills training only is associated with superior advanced laparoscopic suturing performance without affecting improvement in reported confidence levels. Performance on advanced laparoscopic suturing tasks may be predicted by lifetime cumulative video gaming history and year of training but does not appear to be associated with other factors previously studied in relation to basic laparoscopic skills, such as surgical career aspiration or musical ability.

Assessing competency using simulation: the SimZones approach

Introduction

Competency-based medical education (CBME) is a system of medical training that focuses on a structured approach to developing the clinical abilities of medical education graduates and practicing physicians. CBME requires a robust and multifaceted system of assessment in order to both measure and guide the progress of learners toward pre-established goals. Simulation has been proposed as one method for assessing competency in healthcare workers. However, a longitudinal framework for assessing competency using simulation has not been developed.

Methods

Conjecture mapping methodology was used to map Miller's framework for competency assessment-'knows', 'knows how', 'shows how', and 'does'-to the five SimZones described by Roussin and Weinstock. The SimZones describe a system of organising the development and delivery of simulation-based education and offer a foundation for both guiding and organising assessment in a simulation context.

Results

A conceptualised alignment of the SimZones with Miller's pyramid of assessment was developed, as well as a detailed conjecture map. SimZone 0 (auto-feedback) and SimZone 1 (foundational instruction) mapped to 'knows' and 'knows how'. SimZone 2 (acute care instruction) mapped to 'shows how'. SimZone 3 (team and system development) mapped to 'shows how'. SimZone 4 (real-life debriefing and development) mapped to 'does'.

Conclusion

The SimZones system of competency assessment offers a robust, flexible, and multifaceted system to guide both formative and summative assessment in CBME. The SimZones approach adds to the many methods of competency assessment available to educators. Adding SimZones to the vocabulary of CBME may be helpful for the full deployment of CBME.

Recent Advances in Simulation for Pediatric Critical Care Medicine

PURPOSE OF REVIEW

This review highlights the emerging fields of simulation research by tying innovation into principles of learning and process improvement.

RECENT FINDINGS

Advances have been made in both educational simulation and simulation for quality improvement, allowing this versatile modality to be more broadly applied to healthcare and systems.

SUMMARY

Simulation in pediatric critical care medicine continues to evolve. Although the majority of simulation is focused on learner education, emerging research has broadened to focus on patient- and system-centered outcomes, leading to improvement in the quality of care delivered in the ICU.

[Simulation as a tool to facilitate change in healthcare organisations]

OBJECTIVE

To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain.

METHODS

A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results.

RESULTS

The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology.

CONCLUSIONS

Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.