Impact and implementation of simulation-based training for safety

Simulation-based education for teaching aggression management skills to healthcare providers in acute healthcare settings: A systematic review

BACKGROUND

Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills.

OBJECTIVE

The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings.

METHODS

The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses.

RESULTS

Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes.

CONCLUSIONS

Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes.

REGISTRATION

PROSPERO Registration Number CRD42020151002.

TWEETABLE ABSTRACT

Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Training the public health emergency response workforce: a mixed-methods approach to evaluating the virtual reality modality

OBJECTIVES

To produce and evaluate a novel virtual reality (VR) training for public health emergency responders.

DESIGN

Following a VR training designed to test key public health emergency responder competencies, a prospective cohort of participants completed surveys rating self-assessed skill levels and perceptions of training methods.

SETTING

The VR training sessions were administered in a quiet room at the US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

PARTICIPANTS

All participants volunteered from a list of CDC emergency international surge responders.

OUTCOME MEASURES

Perceived impact of the training on responder skills was self-reported via a Likert 5-point scale questionnaire. Assessments were modelled according to the Expanded Technology Acceptance Model measuring participant perceived usefulness of and intention to use the new technology. Inductive coding of qualitative feedback resulted in the identification of central themes.

RESULTS

From November 2019 to January 2020, 61 participants were enrolled. Most (98%) participants self-rated above neutral for all skills (mean 4.3; range 1.21-5.00). Regression modelling showed that the perceived ease of use of the VR and ability to produce demonstrable results as likely drivers of further use. Participants agreed that others would benefit from the training (97%), it was representative of actual response scenarios (72%) and they would use lessons learnt in the field (71%). Open-response feedback highlighted feeling being immersed in the training and its utility for public health responders.

CONCLUSIONS

At a time when a trained emergency public health workforce is a critical need, VR may be an option for addressing this gap. Participants' impressions and feedback, in the setting of their high skill level and experience, highlighted the utility and benefit of using VR to deliver training. Further research is needed to determine skill acquisition through VR training among a pool of future responders with limited to no response experience.

Virtual aids and students' performance with haptic simulation in implantology

OBJETIVES

This study aims to validate that haptic simulator assistance could improve drilling ability in implantology and that the repetition of training session could highlight a learning curve.

METHODS

This work was carried out with 88 first-year dental students. After randomization, students were divided into two groups. Group 1 was assigned to prepare an implant site for a left first mandibular molar (36) on haptic simulator with assistance provided by simulator. Group 2 had to perform the same exercise without assistance. Whatever the group, the maximum time for each reparation was restricted to 5 min. An interval of 1 week was done between each session. For each test, different objective parameters provided by the simulator were recorded and analyzed.

RESULTS

This study showed that the presence of virtual aids led to quickly obtain better results, and the training led to gradually acquire sufficient competence to do without virtual aids.

CONCLUSION

By associating virtual assistance and repetition, the student will acquire more quickly the skills allowing to carry out his clinical gestures in real conditions.

Simulation-based assessments of fire emergency preparedness and response in virtual reality

The current study aimed at evaluating the prospects of a three-dimensional gas power plant (GPP) simulation in an immersive virtual reality (IVR) environment for fire emergency preparedness and response (EPR). To achieve this aim, the study assessed the possibility of safety situational awareness, evacuation drills and hazard mitigation exercises during a fire emergency simulation scenario. The study likewise evaluated the safety and ergonomics of the environment while addressing this aim. We employed the virtual reality accident causation model (VR-ACM) for the assessment with 54 participants individually in IVR. Participants were grouped into two according to whether they had work experience in engineering or not. The obtained results suggested that IVR can be realistic and safe, with the potential for presenting hazardous scenarios necessary for fire EPR. Furthermore, the results indicated that there were no statistically significant differences in the perceptions of both groups regarding the prospects of IVR towards EPR.

Implementation of Crisis-Resource-Management-based Team Training in Lower Austria

Objective

Sequelae of medical errors are a significant problem in acute care. Human-factor-based events are frequent but avoidable causes. Thus, non-technical skills are crucial. In 2008, crisis-resource-management (CRM)-based simulation training was established for the medical staff of the Lower Austria Regional Hospitals, one of the largest hospital operators in Europe.

Methods

Implementation and development of simulation training from 2008 until today are described, costs and performance data retrospectively analysed over a 10-year period. The applied methodology and organisational aspects of CRM training are highlighted. To complete the picture, activities triggered through CRM training throughout the hospitals with potential to further improve patient safety are shown.

Results

With an initial funding of €100,000 by the Landeskliniken Holding and course rates of €350 to €500, a simulation programme was established for approximately 1,900 co-workers in the acute care setting. In the past 10 years, more than 2,300 doctors and nurses took part in one of the courses, held by 14 qualified trainers. Training was held in the simulation centre as well as in hospitals. Over the time, simulation facilities have been expanded to 8 different manikins, high-fidelity ventilation and monitoring simulation. In addition, a variety of patient safety activities like implementation of critical incident reporting, OR checklists and anaesthesia briefing was accompanied by the trainer team. The total cost of the project was just under €20, 00,000.

Conclusion

Simulation-based CRM training was successfully introduced and sustainably institutionalised at the NOE LKH group of hospitals. The demand for and acceptance of the training were both excellent. The previous costs of training were relatively low; the organisational model of an independent, non-profit registered association allowed the training activities to be implemented without reducing the availability of the instructors in their clinical roles.

Exposing medical students to various difficulty levels of simulated endotracheal intubations improves success rate: a randomised non-blinded trial

Objective

Simulation training of endotracheal intubation (ETI) has proven to be an effective training tool. We used an adjustable airway mannequin that allows the achievement of various difficulty levels of laryngoscopy to train inexperienced medical students. The purpose of this study was to evaluate the effect of training using this novel airway mannequin on ETI success rates of medical students.

Methods

This was a randomised non-blinded trial conducted at the Steinberg Centre for Simulation and Interactive Learning. Twenty recruited medical students were randomly allocated to two different training groups. During training, the mixed training group was asked to perform successful intubations in three levels of difficulty; the standard training group was asked to perform the same number of successful intubations in one level of difficulty. After training, all participants were asked to perform intubations using both the adjustable airway mannequin and a standard mannequin. Success rates and airway surface area visualised were compared between the two groups.

Results

Students in the mixed training group had a significantly higher success rate both in the adjustable airway mannequin (p=0.01) and in the standard mannequin (p=0.02). Students in the mixed group had 51%, 59% and 47% significantly more visual area surface than students in the standard group during standard and difficult setup of the adjustable airway mannequin and the standard airway mannequin, respectively.

Conclusions

The use of an adjustable airway mannequin to train medical students leads to superior ETI success rates and better glottis visualisation.

Chest Tube Insertion Among Surgical and Nonsurgical Trainees: How Skilled Are Our Residents?

BACKGROUND

Competency-based medical education has renewed focus on the attainment and evaluation of resident skill. Proper evaluation is crucial to inform educational interventions and identify residents in need of increased training and supervision. Currently, there is a paucity of studies rigorously evaluating resident chest tube insertion skill.

MATERIALS AND METHODS

Residents of all training levels before their intensive care unit rotation or currently rotating through the intensive care unit were invited to participate. Trainees inserted a thoracostomy tube on a high-fidelity simulator. Their performances were recorded and scored by blinded raters using the validated TUBE-iCOMPT rubric. Surgical and nonsurgical residents were compared.

RESULTS

Forty-nine residents participated; 30 from nonsurgical and 19 from surgical training programs. Overall, trainees were most deficient in the "preprocedural checks" and "patient positioning and local anesthetic" domains. Surgical trainees demonstrated higher chest tube insertion skill than their nonsurgical peers (median total score 88 [interquartile range, 74-90] versus 75 [interquartile range, 66-85], respectively, P = 0.01), particularly in the "patient positioning" and "blunt dissection" domains (P = 0.01 and P = 0.03, respectively). These differences were no longer significant when controlled for experience and Advanced Trauma Life Support certification.

CONCLUSIONS

Overall, surgical residents were more skilled than nonsurgical residents in tube thoracostomy placement. Relative skill deficits within the domains of chest tube insertion have also been identified among residents of different specialties. These areas can be targeted with educational interventions to improve resident performance, and ultimately, patient safety.

The HOTSHOT taxonomy and a signature pedagogy framework for operating department practice: The juxtaposition to the academic apartheid surrounding higher order thinking

Bloom's insistence on using verbs and Anderson and Karthwohl's juxtaposition with nouns creates an academic apartheid, where there is only black and white with no grey when addressing the parts of speech used to define Higher Order Thinking. This paper embraces the grey and by draining the conceptual swamp surrounding traditional perceptions of Higher Order Thinking, creates fertile new ground which in turn feeds emergent notions, and allows pioneering characterisation of Higher Order Thinking to propagate.

Effects of ECMO Simulations and Protocols on Patient Safety

The use of extracorporeal membrane oxygenation (ECMO) has greatly increased over the years; however, the survival rate is only above 56%. There has been a drastic increase in ECMO centers and cases. ECMO has become a popular therapy route for patients with respiratory and cardiac complications; however, patient safety is a major concern. Perfusion and non-perfusion students from the University of Nebraska Medical Center were recruited to participate in three simulation trials. The trials consisted of five different tasks that are required for managing or preventing catastrophic events on ECMO. Students were evaluated for the time it took to complete each task, number of errors made, and protocol referencing. The data indicated that there was a decrease in time for the 1st vs. 2nd trial (p = .02) for perfusion students and a decrease from the 1st to 3rd trial (p = .001) for the circuit set-up simulation. There was a decrease in priming time from the 1st to 3rd trial (p = .02) and for the pump change (p = .0098) for the perfusion students as well. The non-perfusion students had a significant decrease in time for the circuit set-up in the 1st vs. 2nd (p = .004) and 1st vs. 3rd trial (p = .002). There was a decrease in time for priming (.004), pump change (p = .002), tubing change (p = .0098), and errors during the tubing change (p = .02) in the non-perfusion students. Both groups felt more confident after the simulations and the non-perfusion students specifically felt like they were more familiar with the purpose of ECMO after the simulation. ECMO simulations and protocols may improve patient safety by strengthening the skills needed for rapid management, fewer errors, and higher levels of confidence during the management of ECMO and catastrophic events.

An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams

Errors in thinking contribute to harm, delays in diagnosis, incorrect treatments, or failures to recognize clinical changes. Models of cognition are useful in understanding error occurrence and avoidance. Intra-team conflict can represent failures in joint cognitive processing. The authors developed training focused on recognizing and managing cognitive bias and resolving conflicts. The program provides context and introduces models of cognition, concepts of bias, team cognition, conflict resolution, and 2 tools. "IDEA" incorporates 4 de-biasing strategies: Identify assumptions; Don't assume correctness; Explore expectations; Assess alternatives. "TLA" presents strategies for resolving conflicts: Tell your thoughts; Listen actively, and Ask questions. A total of 4941 care providers participated in training using didactic presentations, group discussion, and simulation. Learners rated training effectiveness at 4.68 on a scale of 1 to 5 (5 as optimum) and perceived improvement in recognizing or managing errors. Nonphysician caregivers reported greatest improvement. Training to improve critical thinking is feasible, well received, and effective.

Education in neuroanesthesia and neurocritical care: trends, challenges and advancements

PURPOSE OF REVIEW

We summarize the latest evidence in neuroanesthesia and neurocritical care (NCC) training. In addition, we describe the newer advancements that clinical educators face in these subspecialties. Lastly, we highlight educational approaches that may lead to an enhanced learning experience and development of necessary skills for neurosciences trainees.

RECENT FINDINGS

Current neuroanesthesia and NCC training requires acquisition of specific skills for increasing complex surgical cases, specialized neurosurgical practice and new perioperative technologies. Furthermore, there is increasing international interest for standardization and accreditation of neuroanesthesia fellowship programs. Recent evidence has demonstrated that well structured training using high-fidelity simulation improves cognitive and technical skills in acute neurological crises.

SUMMARY

High-fidelity simulation in perioperative care of neurosurgical patients can be part of formal neuroanesthesia and NCC curricula, and potentially impact trainees' proficiency. A research agenda is needed to validate the assessment of most effective educational interventions in neurosciences trainees with diverse medical backgrounds. Creative combinations of cost-effective interventions including traditional teaching, specific technical skills workshops, low and high-fidelity simulation deserve to be assessed in future studies.

Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula

Substance abuse is a growing public health concern in the USA (US), especially now that the US faces a national drug overdose epidemic. Over the past decade, the number of drug overdose deaths has rapidly grown, largely driven by increases in prescription opioid-related overdoses. In recent years, increased heroin and illicitly manufactured fentanyl overdoses have substantially contributed to the rise of overdose deaths. Given the role of physicians in interacting with patients who are at risk for or currently abusing opioids and heroin, it is essential that physicians are aware of this issue and know how to respond. Unfortunately, medical school curricula do not devote substantial time to addiction education and many physicians lack knowledge regarding assessment and management of opioid addiction. While some schools have modified curricula to include content related to opioid prescription techniques and pain management, an added emphasis about the growing role of heroin and fentanyl is needed to adequately address the epidemic. By adapting curricula to address the rising opioid and heroin epidemic, medical schools have the potential to ensure that our future physicians can effectively recognize the signs, symptoms, and risks of opioid/heroin abuse and improve patient outcomes. This article proposes ways to include heroin and fentanyl education into medical school curricula and highlights the potential of simulation-based medical education to enable students to develop the skillset and emotional intelligence necessary to work with patients struggling with opioid and heroin addiction. This will result in future doctors who are better prepared to both prevent and recognize opioid and heroin addiction in patients, an important step in helping reduce the number of addicted patients and address the drug overdose epidemic.

A low cost dural closure simulation model for tomorrow's spinal neurosurgeons

Introduction: We present a low cost model that can be used to improve a trainee's skills in spinal dural closure. Development of microsurgical skills in a simulated environment provides a safe environment in which patients are protected. We argue that this is likely to improve the quality of dural closure, especially for surgeons early in their training and may lead to a commensurate reduction in post-operative CSF leak. Method: In our model, two consultant spine surgeons assessed the ability of participants to close the spinal dura. Participants were scored both quantitatively (time taken to complete the task) and qualitatively under the category of "surgical performance"- assessed by video and inspection of the closed dural substitute. Results: The cohort under assessment included senior and newly appointed consultants, clinical fellows and thirteen specialty trainees. 10 trainees were assessed a second time and a significant majority improved on both domains: 8 (80%) were faster on their second attempt; surgical performance scores also improved in the majority of trainees (90%). Conclusion: Our results, albeit with small numbers, show that a large proportion of trainees improve with practice with a reduction in overall task time and an improvement in surgical performance. Our model is cost-effective and easy to reproduce: simulation need not be an expensive exercise. This study further validates the use of simulation in modern neurosurgical training.

Echocardiography for Intraoperative Decision Making in Mitral Valve Surgery-A Pilot Simulation-Based Training Module

Echocardiographic assessment of the repaired or replaced mitral valve intraoperatively involves making a high-impact joint decision with the surgeon, in a time-sensitive manner, in a dynamic clinical situation. These decisions have to take into account the degree of imperfection if any, the likelihood of obtaining a better result, the underlying condition of the patient, and the impact of a longer cardiopulmonary bypass period if the decision is made to reintervene. Traditional echocardiography teaching is limited in its ability to provide this training. The authors report the development and implementation of a training module simulating the dynamic clinical environment of a mitral valve surgery in progress and the critical echo-based intraoperative decision making involved in the assessment of the acceptability of the surgical result.

Surgeon Training in Telerobotic Surgery via a Hardware-in-the-Loop Simulator

This work presents a software and hardware framework for a telerobotic surgery safety and motor skill training simulator. The aims are at providing trainees a comprehensive simulator for acquiring essential skills to perform telerobotic surgery. Existing commercial robotic surgery simulators lack features for safety training and optimal motion planning, which are critical factors in ensuring patient safety and efficiency in operation. In this work, we propose a hardware-in-the-loop simulator directly introducing these two features. The proposed simulator is built upon the Raven-II™ open source surgical robot, integrated with a physics engine and a safety hazard injection engine. Also, a Fast Marching Tree-based motion planning algorithm is used to help trainee learn the optimal instrument motion patterns. The main contributions of this work are (1) reproducing safety hazards events, related to da Vinci™ system, reported to the FDA MAUDE database, with a novel haptic feedback strategy to provide feedback to the operator when the underlying dynamics differ from the real robot's states so that the operator will be aware and can mitigate the negative impact of the safety-critical events, and (2) using motion planner to generate semioptimal path in an interactive robotic surgery training environment.

The Role of Simulation in Planning Intraoperative Magnetic Resonance Imaging-Guided Neurosurgical Procedures: A Case Report

Simulation of the actual procedure is a simple and yet effective method of increasing patient safety and reducing the rate of unexpected adverse effects. We present our experience with 2 cases of preprocedural simulation on healthy volunteers that were performed in the intraoperative magnetic resonance imaging suite. During one of the cases, we also simulated a scenario of sudden cardiac arrest. Such an approach helped us to refine the procedures and coordinate the work of different teams within the intraoperative magnetic resonance imaging suite as well as improve the quality of patient management.

The Electronic Portfolio as a Teaching Complement for Technical Skills in Health Sciences

The portfolio has gathered pace in recent years, being a useful tool for teaching and assessment. The main goal is to improve learning through student reflection and continuous feedback of evaluations. The implantation of information technology has facilitated the introduction of the electronic portfolio (e-portfolio). Based on previous experience with portfolios, it was decided to implement it in some subjects within Medicine and Dentistry in the Department. The objectives of the study (2009-2013) have been assessing the response to its introduction, assess student satisfaction and determine the extra load imposed on the teaching process. The topic has focused on clinical skills of students, using the e-portfolio Mahara®, installed on the Virtual Campus of Barcelona University. There have been 1241 e-portfolios and 1611 email exchanges between teachers and students. All assessment is carried out on-line (average response time 48 hours, 40 minutes /portfolio). Satisfaction surveys show a high level of acceptance by the students. This allows one to conclude that the e-portfolio has proven to be a good teaching tool, presenting a high degree of compliance and satisfaction among students, encouraging student-teacher relationships.

Relative contribution of haptic technology to assessment and training in implantology

Background. The teaching of implant surgery, as in other medical disciplines, is currently undergoing a particular evolution. Aim of the Study. To assess the usefulness of haptic device, a simulator for learning and training to accomplish basic acts in implant surgery. Materials and Methods. A total of 60 people including 40 third-year dental students without knowledge in implantology (divided into 2 groups: 20 beginners and 20 experiencing a simulator training course) and 20 experienced practitioners (experience in implantology >15 implants) participated in this study. A basic exercise drill was proposed to the three groups to assess their gestural abilities. Results. The results of the group training with the simulator tended to be significantly close to those of the experienced operators. Conclusion. Haptic simulator brings a real benefit in training for implant surgery. Long-term benefit and more complex exercises should be evaluated.