Simulation-based training and assessment of non-technical skills in the Norwegian Helicopter Emergency Medical Services: a cross-sectional survey

The Royal Flying Doctor Service Initiation of Helicopter Video Simulation Orientation Training for Air Medical Crews in Western Australia: A Pilot Study

OBJECTIVE

In May 2022, the Royal Flying Doctor Service Western Operations in Western Australia pioneered the introduction of the first organizational helicopter emergency service with 2 Eurocopter EC145 helicopters. This article describes the pilot study undertaken, assessing the implementation and flight crew confidence outcomes of the supplementation of video simulation training to standard clinical training for helicopter air medical retrieval.

METHODS

Survey assessments using a 5-point Likert scale provided anonymous demographic data with summarized results of the means and standard deviations. Nonparametric tests were used to compare responses between the control and experimental groups from pretraining to postintervention to postpractical.

RESULTS

The findings showed an increase in confidence rates after a classroom session and further increases after a practical session in the control group. The intervention group showed a small rise in overall confidence levels after being shown video simulations following the completion of their classroom session before commencing their practical session. This study established that regardless of the airframe, clinical staff, often with significant experience in air medical retrieval and critical care medicine, do not automatically have confidence in performing critical care procedures in a new aircraft type to which they have not previously been oriented. The results display a statistically significant increase in confidence levels in procedural performance after the classroom session compared with the pretraining questionnaire, with a subtle further rise when video simulations are included in the classroom session. When a classroom session is subsequently supplemented with a practical simulation session, confidence levels continue to rise.

CONCLUSION

Implementing a comprehensive educational strategy including classroom and practical elements for clinical staff in their orientation to new aircraft improves their confidence in performing critical care procedures if required in flight. The addition of in-flight prerecorded videos demonstrating these critical care procedures is a useful adjunct to simulation training for flight crew in air medical retrieval, and further analytical studies may indeed show a statistically significant improvement in staff confidence.

Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance

Background

Advanced prehospital airway management includes complex procedures carried out in challenging environments, necessitating a high level of technical and non-technical skills. We aimed to describe Norwegian Air Ambulance-crews’ performance in a difficult airway scenario simulation, ending with a “cannot intubate, cannot oxygenate”-situation.

Methods

The study describes Air Ambulance crews’ management of a simulated difficult airway scenario. We used video-observation to assess time expenditure according to pre-defined time intervals and technical and non-technical performance was evaluated according to a structured evaluation-form.

Results

Thirty-six crews successfully completed the emergency cricothyroidotomy with mean procedural time 118 (SD: ±70) seconds. There was variation among the crews in terms of completed procedural steps, including preparation of equipment, patient- monitoring and management. The participants demonstrated uniform and appropriate situational awareness, and effective communication and resource utilization within the crews was evident.

Conclusions

We found that Norwegian Air Ambulance crews managed a prehospital “cannot intubate, cannot oxygenate”-situation with an emergency cricothyroidotomy under stressful conditions with effective communication and resource utilization, and within a reasonable timeframe. Some discrepancies between standard operating procedures and performance are observed. Further studies to assess the impact of check lists on procedural aspects of airway management in the prehospital environment are warranted.

High-Fidelity Simulation Training for Helicopter Emergency Medical Services Flight Nurses: A Report From the First Italian Experience

OBJECTIVE

Simulation-based training has a significant effect in enhancing professionals' skills in the helicopter emergency medical service (HEMS) setting and is reported to be more effective than other learning strategies. The main objective of this study was to assess the efficacy of a specific high-fidelity simulation (HFS) training course for HEMS nurses before entering into operational service.

METHODS

This report describes the first Italian experience of a specifically designed HFS training program for HEMS nurses held in Bologna, Italy, in a dedicated scenario with a mock-up helicopter and an advanced mannequin.

RESULTS

A total of 14 nurses participated in the SAFE2019 (Simulazione ad Alta Fedeltà per l'Elisoccorso-High-Fidelity Simulation for HEMS) courses. The aspects considered most useful and effective were related to team working, communication issues, and nontechnical skills (NTS) development. Moreover, participants suggested implementing a series of scheduled HFS retraining sessions.

CONCLUSION

HFS in a dedicated HEMS scenario during the orientation period has contributed to enhanced technical competencies and NTS, increasing comfort and situational awareness for new entrant flight nurses. Simulation may represent a valuable resource to assess and maintain competencies through periodic retraining sessions for full HEMS teams or when new devices are adopted.

Game Experience and Learning Effects of a Scoring-Based Mechanic for Logistical Aspects of Pediatric Emergency Medicine: Development and Feasibility Study

Background

Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals.

Objective

This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure.

Methods

First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment.

Results

A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR² of 0.796 (F1_4,31=2725.49, P<.001) for the board version and 0.702 (F2_4,31=2635.31, P<.001) for the multiplayer online version after the learning engagement attributes.

Conclusions

The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used.

The role of non-technical skills in community pharmacy practice: an exploratory review of the literature

BACKGROUND

Non-technical skills (NTS) are the cognitive and social skills that complement technical skills in safe and efficient practice, and include leadership, teamwork, task management, decision-making and situation awareness. Other areas within healthcare have heavily invested in producing taxonomies to aid training and assessment of NTS within their disciplines, and have found them to be essential for improving patient safety. In pharmacy, no validated taxonomy has been produced, nor has the existing literature been appraised to aid the future development of a validated taxonomy.

OBJECTIVE(S)

To examine the literature on NTS within a community pharmacy setting and establish the research conducted thus far on each NTS and how they are applied by community pharmacists.

METHODS

A literature search of six electronic databases (EMBASE, PsychINFO, Medline, SCOPUS, CINAHL Plus and HMIC) using the generic list of NTS identified in previous studies. Only empirical studies were included. Examples of behaviours or skills were extracted and categorised within each NTS.

KEY FINDINGS

Seventeen studies were identified that contained one or more examples of NTS specific to community pharmacy practice. Altogether, 16 elements were extracted. Four elements were identified within leadership and task management. A further three were identified within situation awareness and decision-making, and a final two within teamwork and communication.

CONCLUSION

A framework consisting of the skills and how they're applied has been presented which describe the NTS required by community pharmacists from the published literature. This framework can provide a foundation for further investigation into NTS use within pharmacy practice.

Usefulness of a Simulated Helicopter Transport Experience for Medical Resident Training

OBJECTIVE

This study evaluated the usefulness of a medical transport simulation to increase residents' understanding of medical transport.

METHODS

Twenty-four medical residents participated in an intensive half-day medical transport simulation experience. Two questionnaires were administered, a pre/postsimulation questionnaire containing 11 questions that assessed the impact of the simulation training and a questionnaire that assessed realism of the flight simulator.

RESULTS

There were statistically significant differences between the pre/postsimulation questions assessing perceived level of knowledge, experience, and training of transferring a patient in a helicopter with a mean change of 25 points on a 0 to 100 scale (P ≤ .001) and awareness of obstacles to treating patients during air transport exhibiting a mean change of 28 (P ≤ .001). The mean stress level for all participants increased from 32 (0-100 scale) before the start of the simulation to 47 during the simulation and decreased to 31 after the simulation (F_2,46 = 20.67, P ≤ .001).

CONCLUSION

The findings from this study provide evidence that the air medical simulation experience increases residents' perceived awareness of the context and difficulties of transferring a patient by helicopter and that the experience would influence their medical decision making in their future practice related to patient transfers.

Training and assessment of non-technical skills in Norwegian helicopter emergency services: a cross-sectional and longitudinal study

Background

Deficient non-technical skills (NTS) among providers of critical care in helicopter emergency medical services (HEMS) is a threat to patient and operational safety. Skills can be improved through simulation-based training and assessment. A previous study indicated that physicians underwent less frequent training compared to pilots and HEMS crew members (HCM) and that all professional groups in Norwegian HEMS received limited training in how to cope with fatigue. Since then, training initiatives and a fatigue risk management project has been initiated. Our study aimed to explore if the frequency of simulation-based training and assessment of NTS in Norwegian HEMS has changed since 2011 following these measures.

Methods

A cross-sectional web-based survey from October through December 2016, of physicians, HCM and pilots from all civilian Norwegian HEMS-bases reporting the overall extent of simulation-based training and assessment of NTS.

Results

Of 214 invited, 109 responses were eligible for analysis. The frequency of simulation-based training and assessment of NTS has increased significantly for all professional groups in Norwegian HEMS, most prominently for the physicians. For all groups, the frequency of assessment is generally lower than the frequency of training.

Conclusions

Physicians in Norwegian HEMS seem to have adjusted to the NTS training culture of the other crew member groups. This might be a consequence of improved NTS training programs. The use of behavioural marker systems systematically in HEMS should be emphasized.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0583-1) contains supplementary material, which is available to authorized users.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services

BACKGROUND

Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation.

METHOD

A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence.

RESULTS

The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training.

CONCLUSION

HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Air Medical Simulation Training: A Retrospective Review of Cost and Effectiveness

OBJECTIVE

Simulation training is an integral part of the training of medical personnel. However, there are limited data on the use of simulation in the training of helicopter emergency medical services (HEMS).

METHODS

In this study, we retrospectively compared the number of orientation flights needed to be released to a full crewmember and the cost of training in an air medical flight academy before and after implementation of a high-fidelity air medical simulator. A total of 13 participants in the air medical services flight academy were analyzed. Four of these participants went through the standard academy. Nine participants went through the standard academy but had additional training using the simulator.

RESULTS

There was no statistical difference in the number of orientation flights before release from training (P = .35). Also, although there was a trend that the simulator decreased the overall cost of training, there was no significant difference between the groups (P = .16).

CONCLUSION

This study found that the use of a high-fidelity simulator when training HEMS personnel does not significantly reduce the number of orientation flights needed to become a full crewmember. There was a trend toward a significant reduction in the total cost of training.

"Hand-it-on": an innovative simulation on the relation of non-technical skills to healthcare

Non-technical skills (NTS) are an integral part of the abilities healthcare professionals need to optimally care for patients. Integrating NTS into the already complex tasks of healthcare can be a challenge for clinicians. Integrating NTS into simulation-based training increases the demands for simulation instructors with regard to scenario design, conduct, and debriefing. We introduce a simulation game, Hand-it-on, that can trigger discussions on how NTS can influence work processes. Hand-it-on aims to help clinicians and simulation instructors alike to improve their understanding of NTS concepts and where they can apply them in their work. It complements existing approaches to teaching NTS by limiting the complexity of the game and by removing medical content, allowing learners to concentrate on NTS. Hand-it-on is relevant for groups and teams working across the range of different healthcare contexts. During Hand-it-on, participants stand in a circle and hand on everyday objects to each other according to simple rules, resulting in many events that can be debriefed in relation to safe patient care. We describe both the conduct of Hand-it-on and ideas on how to debrief participants. We provide variations that can be used in different contexts, focusing the exercise on different learning goals. We also offer the theoretical rationale for using an out-of-context simulation in combination with other forms of teaching. Although we did not evaluate Hand-it-on formally, oral feedback from participants and the replication of Hand-it-on by many simulation teams support its value.

Simulation-Based Training in Mountain Helicopter Emergency Medical Service: A Multidisciplinary Team Training Concept

OBJECTIVE

Mountain helicopter rescue operations often confront crews with unique challenges in which even minor errors can result in dangerous situations. Simulation training provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal errors and increasing the safety for both the patient and the helicopter emergency medical service (HEMS) crew.

METHODS

A simulation-based training, dedicated to mountain helicopter emergency medicine service, was developed and executed. We evaluated the impact of this training by the means of a pre- and posttraining self-assessment of 40 HEMS crewmembers.

RESULTS

Multidisciplinary simulation-based educational training in HEMS is feasible. There was a significant increase in self-assessed competence in safety-related items of human factors and team resource management. The highest gain of competence was demonstrated by a trend in the domain of structured decision making.

CONCLUSIONS

Interprofessional simulation-based team training could have the potential to impact patient outcomes and improve rescuer safety. Simulation trainings lead to a subjective increase of self-assuredness in the management of complex situations in a difficult working environment.

Non-technical skills evaluation in the critical care air ambulance environment: introduction of an adapted rating instrument--an observational study

BACKGROUND

In the isolated and dynamic health-care setting of critical care air ambulance transport, the quality of clinical care is strongly influenced by non-technical skills such as anticipating, recognising and understanding, decision making, and teamwork. However there are no published reports identifying or applying a non-technical skills framework specific to an intensive care air ambulance setting. The objective of this study was to adapt and evaluate a non-technical skills rating framework for the air ambulance clinical environment.

METHODS

In the first phase of the project the anaesthetists' non-technical skills (ANTS) framework was adapted to the air ambulance setting, using data collected directly from clinician groups, published literature, and field observation. In the second phase experienced and inexperienced inter-hospital transport clinicians completed a simulated critical care air transport scenario, and their non-technical skills performance was independently rated by two blinded assessors. Observed and self-rated general clinical performance ratings were also collected. Rank-based statistical tests were used to examine differences in the performance of experienced and inexperienced clinicians, and relationships between different assessment approaches and assessors.

RESULTS

The framework developed during phase one was referred to as an aeromedical non-technical skills framework, or AeroNOTS. During phase two 16 physicians from speciality training programmes in intensive care, emergency medicine and anaesthesia took part in the clinical simulation study. Clinicians with inter-hospital transport experience performed more highly than those without experience, according to both AeroNOTS non-technical skills ratings (p = 0.001) and general performance ratings (p = 0.003). Self-ratings did not distinguish experienced from inexperienced transport clinicians (p = 0.32) and were not strongly associated with either observed general performance (r(s) = 0.4, p = 0.11) or observed non-technical skills performance (r(s) = 0.4, p = 0.1).

DISCUSSION

This study describes a framework which characterises the non-technical skills required by critical care air ambulance clinicians, and distinguishes higher and lower levels of performance.

CONCLUSION

The AeroNOTS framework could be used to facilitate education and training in non-technical skills for air ambulance clinicians, and further evaluation of this rating system is merited.

Prehospital response model and time to CT scan in blunt trauma patients; an exploratory analysis of data from the head injury retrieval trial

Background

It has been suggested that prehospital care teams that can provide advanced prehospital interventions may decrease the transit time through the ED to CT scan and subsequent surgery. This study is an exploratory analysis of data from the Head Injury Retrieval Trial (HIRT) examining the relationship between prehospital team type and time intervals during the prehospital and ED phases of management.

Methods

Three prehospital care models were compared; road paramedics, and two physician staffed Helicopter Emergency Medical Services (HEMS) - HIRT HEMS and the Greater Sydney Area (GSA) HEMS. Data on prehospital and ED time intervals for patients who were randomised into the HIRT were extracted from the trial database. Additionally, data on interventions at the scene and in the ED, plus prehospital entrapment rate was also extracted. Subgroups of patients that were not trapped or who were intubated at the scene were also specifically examined.

Results

A total of 3125 incidents were randomised in the trial yielding 505 cases with significant injury that were treated by road paramedics, 302 patients treated by the HIRT HEMS and 45 patients treated by GSA HEMS. The total time from emergency call to CT scan was non-significantly faster in the HIRT HEMS group compared with road paramedics (medians of 1.9 hours vs. 2.1 hours P = 0.43) but the rate of prehospital intubation was 41% higher in the HIRT HEMS group (46.4% vs. 5.3% P < 0.001). Most time intervals for the GSA HEMS were significantly longer with a regression analysis indicating that GSA HEMS scene times were 13 (95% CI, 7–18) minutes longer than the HIRT HEMS independent of injury severity, entrapment or interventions performed on scene.

Conclusion

This study suggests that well-rehearsed and efficient interventions carried out on-scene, by a highly trained physician and paramedic team can allow earlier critical care treatment of severely injured patients without increasing the time elapsed between injury and hospital-based intervention. There is also indication that role specialisation improves time intervals in physician staffed HEMS which should be confirmed with purpose designed trials.