Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We?

The utility of virtual reality and manikin crisis scenario simulations for anaesthesia trainee education: a randomised crossover pilot study

Simulation education for anaesthesia trainees is essential to build clinical skills and virtual reality can provide a reproducible, high-fidelity intra-operative training environment. Compared to in-situ manikin-based simulation, this modality has yet to be thoroughly evaluated. Twenty-six second post-graduate year anaesthesiology residents were randomly divided into two groups and participated in both virtual reality and manikin crisis scenarios at sessions six months apart. The exposure order was group A virtual reality followed by manikin and group B manikin followed by virtual reality. Clinical assessments were performed using a standardised checklist. Knowledge assessments were conducted. National Aeronautics and Space Administration Task Load Index and System Usability Scale scores were collected immediately after participation. Clinical scores between groups A and B were not significantly different. Group A had improved post-simulation knowledge scores after both sessions. Task load index scores were lower in mental demand for virtual reality. System usability scores showed less ease of use and more need for support in virtual reality.

Comparison of human cadaver and blue phantom for teaching ultrasound-guided regional anesthesia to novice postgraduate students of anesthesiology: A randomized controlled trial

Background and Aims

Simulation is increasingly used in medical teaching. Various studies have evaluated different simulation models for training of regional anesthesia (RA). We compared the use of human cadaver and blue phantom models for training of regional anesthesia to novice postgraduate students of anesthesiology.

Material and Methods

Fifty students were taught knobology of the ultrasonography (USG) machine. They were divided into two equal groups by computer-generated random number table, and the groups assigned were kept in sealed envelopes. In group BP, students were trained on a blue phantom model, and in group HC, students were trained on human cadaver. After training, a didactic video of sonoanatomy of the supraclavicular block was shown to all participants. The block performance was then judged on patients requiring supraclavicular block. The primary objective of the study was to compare the block performance time, and secondary objectives were the quality of image acquired, orientation of transducer to the target, identification of ultrasound artifacts, errors committed, complications, and success rate.

Results

The mean block performance time was shorter in group HC compared to group BP (451.96 ± 50.25 and 526.48 ± 43.486 s, respectively; P < 0.001). The image quality score, transducer orientation to the target, and identification of USG artifacts were better in group HC compared to group BP, with lesser number of needle passes.

Conclusion

Cadaver-based training produced better results compared to blue phantom simulator model for teaching of ultrasound-guided RA to novice postgraduate trainees of anesthesiology.

Role of simulation-based training in thoracic anaesthesia

Simulation-based training (SBT) aims to acquire technical and non-technical skills in a simulated fashion without harming the patient. Simulation helps the anaesthesiologist acquire procedural competence and non-technical abilities. In thoracic anaesthesia, various simulators are available with varying degrees of fidelity and costs. Apart from improving bronchoscopy-related skills, other potential applications of SBT include the practice of lung isolation in normal and difficult airway scenarios, troubleshooting complications during surgeries, and certification of the proficiency of anaesthesiologists. A pragmatic approach is required for choosing the simulator based on its availability, cost, and benefits. Although the literature supports SBT to improve procedural skills, retention of the skills and their translation into improving clinical outcomes remain largely unproven. Randomised, controlled studies targeting the effect of SBT on the improvement of clinical outcomes of patients are needed to prove their worth.

Simulation in Anesthesia for Perioperative Neuroscience: Present and Future

The brain's sensitivity to fluctuations in physiological parameters demands precise control of anesthesia during neurosurgery, which, combined with the complex nature of neurosurgical procedures and potential for adverse outcomes, makes neuroanesthesia challenging. Neuroanesthesiologists, as perioperative physicians, work closely with neurosurgeons, neurologists, neurointensivists, and neuroradiologists to provide care for patients with complex neurological diseases, often dealing with life-threatening conditions such as traumatic brain injuries, brain tumors, cerebral aneurysms, and spinal cord injuries. The use of simulation to practice emergency scenarios may have potential for enhancing competency and skill acquisition amongst neuroanesthesiologists. Simulation models, including high-fidelity manikins, virtual reality, and computer-based simulations, can replicate physiological responses, anatomical structures, and complications associated with neurosurgical procedures. The use of high-fidelity simulation can act as a valuable complement to real-life clinical exposure and training in neuroanesthesia.

Perioperative crisis resource management simulation training in anaesthesia

Simulation-based education is now recognised to be a valuable tool to impart both technical and non-technical skills to healthcare professionals of all levels. Simulation is an well accepted educational tool for cultivating teamwork skills among residents globally. Simulation-based education encompasses diverse modalities, ranging from task trainers and simulated patients to sophisticated high-fidelity patient simulators. Notably, anaesthesiologists globally were early advocates of integrating simulation into education, particularly to instruct anaesthesia residents about the intricacies of perioperative crisis resource management and collaborative interdisciplinary teamwork. Given the inherent high-risk nature of anaesthesia, where effective teamwork is pivotal to averting adverse patient outcomes, and also to improve overall outcome of the patient, simulation training becomes imperative. This narrative review delves into the contemporary landscape of simulation training in perioperative anaesthesia management, examining the pedagogical approaches, simulators, techniques and technologies employed to facilitate this training.

Simulation-Based Outreach Program Improves Rural Hospitals’ Team Confidence in Neonatal Resuscitation

Introduction: Neonatal resuscitation is a high acuity, low occurrence event (HALO), and in rural community hospitals, low birth rates prevent providers from regular opportunities to maintain essential resuscitation skills. Simulation is an effective training modality for medical education, although resources for simulation are often limited in rural hospitals. Our primary objective was to test the hypothesis that in situ neonatal resuscitation simulation training improves rural hospitals' delivery room team confidence in performing key Neonatal Resuscitation Program^® (NRP^®) skills. Our secondary objective was to compare confidence to performance as measured by adherence to NRP® guidelines.

Methods: We conducted a quasi-experimental pre-training survey and post-training survey of delivery room team confidence in NRP^® skills at five level one delivery hospitals before and after an in situ simulation training program. Participants included rural hospitals’ usual delivery room team members. Participants rated their confidence on a five-point Likert scale. Simulations were analyzed using an adapted version of a validated scoring tool for NRP^® adherence and presented as overall percentage scores.

Results: Our data demonstrate a significant improvement in self-assessed confidence levels pre- and post-simulation training in key areas of neonatal resuscitation. Participants reported higher confidence in airway management (4 vs. 3, p=0.003), emergency intravenous access (3 vs. 2, p=0.007), and the ability to manage a code in the delivery room (4 vs. 3, p=0.013) and the operating room (4 vs. 3, p=0.028). Improvements were also noted in their team member’s knowledge and skills to perform neonatal resuscitation. While improvements were appreciated in confidence, the performance of skills (NRP^® adherence scores) was often in the sub-optimal performance range.

Conclusions: An in situ-based neonatal resuscitation outreach simulation program improves self-confidence among rural delivery room teams. Additional research is needed to understand how to translate improved confidence into actual improved performance. 

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees. Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice. Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students. Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.

Simulation in Perioperative Liver Transplant Anesthesia: A Systematic Review

Due to the complexity of liver transplant patients and the variability in exposure to transplantation by anesthesia trainees, simulation is often required as an adjunct to clinical experience. This systematic review identifies current simulation models in the literature that pertain to perioperative liver transplant anesthesia.

Data were collected by performing an electronic search of the PubMed and Scopus databases for articles describing simulation in transplant anesthesia. Abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 16 abstracts found in the search and agreed upon articles that met the inclusion criteria for the systematic review.

A total of five publications met the inclusion criteria; they could be grouped as cognitive skills and technical skills simulators. Cognitive skills simulators utilized high-fidelity mannequins and animal models combined with traditional educational material to enhance pattern recognition of critical complications during liver transplantation. One manuscript focused on a technical skills acquisition by utilizing transesophageal echocardiography (TEE) to identify intraoperative pathologies.

There is a heterogeneity in the exposure to liver transplant care during anesthesia training. Simulation provides low-stakes exposure to the high-stakes skills required in the operating room. Hence, it can be used as an adjunct to improve both cognitive and technical skill acquisition for perioperative transplant anesthesia. The goal of these simulation programs is to improve patient outcomes and produce more capable anesthesiologists.

Characteristics of Simulation-Based Point-of-Care Ultrasound Education: A Systematic Review of MedEdPORTAL Curricula

Point-of-care ultrasonography (POCUS) is increasingly recognized as a safe, efficacious, and cost-effective diagnostic and procedural tool used by many medical disciplines. Although standardized POCUS curricula are lacking, simulation represents an effective modality to teach the fundamentals of POCUS in medical education. We sought to characterize POCUS simulation cases available within MedEdPORTAL, the primary repository of learning resources for health professions, to highlight areas for future curricular development and study. This systematic review was performed based on a comprehensive search of MedEdPORTAL. Identified simulations were categorized and contrasted with respect to their target audiences, settings, pathologies, required materials and equipment, and POCUS techniques tested. A total of eight curricula were identified. The majority (6/8) were targeted at trainees in acute care specialties. Pathologies included in most simulations involved cardiac or pericardial disease, although obstetric and medical diseases were also tested in isolated cases. While half (4/8) of the identified simulation curricula incorporated diagnostic POCUS interpretation, only a few (2/8) allowed for high-fidelity ultrasound simulation. While self-reported learner satisfaction appeared to be generally high, most (7/8) identified curricula did not include objective assessments of learning outcomes. A small number of simulation-based POCUS curricula have been published within MedEdPORTAL. The widespread use of simulation for POCUS may be limited by the financial costs of high-fidelity training equipment. While simulation provides a highly promising solution to the need for greater instruction in POCUS, there is a need for comprehensive, standardized, and cost-effective curricula that can be adapted to varied educational environments.

Utilizing High-fidelity Simulators in Improving Trainee Confidence and Competency in Code Management

Simulation training is central in preparing practitioners for code management that is free from patient harm.¹ The purpose of this study was to determine if using a high-fidelity simulator in pediatric code education would improve trainee confidence and competency compared with the use of a traditional mannequin in the same setting.

Use of simulation to teach in the operating room: don't Let the COVID-19 pandemic to interrupt education an observational clinical trial

Background

Simulation-based education has become the most important part of resident training in anesthesiology, especially during the pandemic. It allows learning the skills and the management of different situations without putting residents in risk of contamination, considering COVID-19 is highly contagious. The hypothesis was that simulation is still associated with improvement of knowledge acquisitions despite the context of the COVID-19 pandemic.

Methods

Residents of anesthesiology and intensive care subjected to an anaphylaxis simulation scenario. Their knowledge levels were assessed by true/false questions before and one month after the simulation session. The STAI test was used to measure anxiety levels before and after the scenario. Data were analyzed statistically using Wilcoxon and McNemar tests.

Results

Junior residents (< 2 years) received significantly higher scores in post-training theoretical tests compared to their pre-training scores (79.2 ± 9.6, 84.5 ± 8.2, p = 0.002, n = 21). There was no difference between pre- and post-test scores of seniors (80.2 ± 9, 81.8 ± 10.4, p = 0.3). Pre- and post-anxiety inventory scores were nearly the same and both were in the moderate group (39.8 ± 10.1, 39.3 ± 12.1, p = 0.8).

Conclusion

Simulation-based education improved the knowledge levels of the residents without raising anxiety levels. Thus, simulation-based training showed its value as an important tool of education during the pandemic, which needs to be further popularized for training at all institutions. Enlightening medical educators about this accomplished teaching method may lead to improved quality of medical education in developing countries and reshape how tomorrow's doctors are trained during pandemics.

Synchronous Screen-Based Simulation in Anesthesia Distance Education

PURPOSE

The aim of the present study was to evaluate the feasibility, acceptability, and utility of synchronous online screen-based simulation (SBS) in anesthesia education.

METHODS

The investigational cohort consisted of 12 second-year nurse anesthesia students enrolled in a Doctor of Nursing Practice (DNP) program. Pairs of students worked with a single instructor online using the same SBS employing a cloud-based peer-to-peer platform and high-fidelity software involving a graphical avatar. During each session, the instructor initially manipulated the avatar through the software scenario with educational pauses to communicate learning content. Thereafter, students proceeded through the same SBS by stating their desired actions, which were then implemented by the instructor. At the conclusion of each session, students were evaluated by an integrated software scoring system, and thereafter they completed a questionnaire rating their distance SBS experience.

RESULTS

Synchronous online SBS was performed in this manner without difficulty; it was accepted by students as a valuable adjunct to their in-person mannequin-based simulation (MBS) training; and it was perceived as a useful addition to their anesthesia education. Students identified significant value in the isolation of the cognitive component of learning by this teaching methodology. Lack of haptic learning, however, also was seen as a disadvantage of SBS compared to MBS. Students' criticisms of SBS were largely unrelated to use of this technique with synchronous online education, but rather related to general limitations associated with SBS technology. There was a positive correlation between the students' mean post-SBS rating and the automated SBS score (r = 0.832).

CONCLUSION

Synchronous online SBS can effectively supplement MBS in an anesthesia training program. Its major perceived advantage appears to be an ability to isolate and reinforce appropriate cognitive skills related to intraoperative care including crisis management. Students who had higher mean post-SBS ratings also had higher automated SBS scores.

The evolution of a national, advanced airway management simulation-based course for anaesthesia trainees

BACKGROUND

Needs analyses involving patient complaints and anaesthesiologists' confidence levels in difficult airway management procedures in Denmark have shown a need for training in both technical and non-technical skills.

OBJECTIVE

To provide an example of how to design, implement and evaluate a national simulation-based course in advanced airway management for trainees within a compulsory, national specialist training programme.

DESIGN AND RESULTS

A national working group, established by the Danish Society for Anaesthesiology and Intensive Care Medicine, designed a standardised simulation course in advanced airway management for anaesthesiology trainees based on the six-step approach. Learning objectives are grounded in the curriculum and analyses-of-needs (in terms of knowledge, skills and attitudes, including non-technical skills, which encompass the cognitive skills and social skills, necessary for safe and effective performance). A total of 28 courses for 800 trainees have been conducted. Evaluation has been positive and pre and posttests have indicated a positive effect on learning.

CONCLUSION

The course was successfully designed and implemented within the national training programme for trainees. Important factors for success were involvement of all stakeholders, thorough planning, selection of the most important learning objectives, the use of interactive educational methods and training of the facilitators.

Experiential learning in simulated parapharyngeal abscess in breathing cadavers

Purpose

Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways.

Methods

Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements—the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models.

Results

The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%).

Conclusions

Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02904-0.

Toward interprofessional team training for surgeons and anesthesiologists using virtual reality

Purpose

In this work, a virtual environment for interprofessional team training in laparoscopic surgery is proposed. Our objective is to provide a tool to train and improve intraoperative communication between anesthesiologists and surgeons during laparoscopic procedures.

Methods

An anesthesia simulation software and laparoscopic simulation software are combined within a multi-user virtual reality (VR) environment. Furthermore, two medical training scenarios for communication training between anesthesiologists and surgeons are proposed and evaluated. Testing was conducted and social presence was measured. In addition, clinical feedback from experts was collected by following a think-aloud protocol and through structured interviews.

Results

Our prototype is assessed as a reasonable basis for training and extensive clinical evaluation. Furthermore, the results of testing revealed a high degree of exhilaration and social presence of the involved physicians. Valuable insights were gained from the interviews and the think-aloud protocol with the experts of anesthesia and surgery that showed the feasibility of team training in VR, the usefulness of the system for medical training, and current limitations.

Conclusion

The proposed VR prototype provides a new basis for interprofessional team training in surgery. It engages the training of problem-based communication during surgery and might open new directions for operating room training.

Electronic supplementary material

The online version of this article (10.1007/s11548-020-02276-y) contains supplementary material, which is available to authorized users.

[Room of horrors: A low-fidelity simulation practice for patient safety-relevant hazards of hospitalization]

INTRODUCTION

Even in well-developed healthcare systems, raising awareness for undesirable dangers and risks of modern healthcare services among the clinical staff is a continuous and methodical challenge. The concept of the so-called "Room of Horrors" is both an innovative and a low-fidelity simulation approach for team-based training of patient safety-relevant hazards. The purpose of this evaluation study is to report on practicability and acceptance of such a low-threshold simulation training.

METHOD

A fictitious patient room including a patient manikin (lying in bed) was set up in the hospital to simulate the Room of Horrors. Additional artifacts such as a side table, medication and the medical record completed the simulation, in which 12 typical errors or latent risks related to patient safety were hidden. After a short briefing, individuals or groups (2-5 participants) should enter the room and try to find as many errors as possible. The error detection rate was evaluated immediately followed by a debriefing. The participants were then asked to answer a short structured questionnaire to provide content-related feedback about the patient safety simulation.

RESULTS

Within three days, the Room of Horrors was visited by a total of 89 participants (27 teams and 6 individuals). Average error detection rate was 8.54 out of 12 hidden errors (71%), whereby the teams showed a slightly better result. All the surveyed participants found the simulation to be educational and beneficial. The importance of team discussion was particularly emphasized by a majority of participants. 91% of the participants found the wrong patient identification wristband and in spite of a documented lactose intolerance a yogurt on the side table. 88% of the participants recognized the bell which was out of the patients reach. Few participants found the missing indication of a permanent catheter (24%) and a doubled prescription of paracetamol (42%).

DISCUSSION

A comparison of several international studies about so-called Rooms of Horrors shows that the present study has a relatively high average detection rate (71%), although a significant percentage of the participants are not engaged in medical or nursing services. Not surprisingly, the average detection of errors of the teams were higher than individuals. This strengthens the theory that a discursive discussion and exchange of dialogue among the clinical staff in a patient's room increases patient safety or at least strengthens situational awareness for clinical risks. The consistently positive feedback coincides with the evaluation results of other clinics and thus demonstrates the acceptance of simulation-based on-site training. The organizational and financial effort to execute the simulation training remained very low (apart from the resulting costs incurred due to the participants missing from their regular hospital duties). Hence, the evaluation study proves practicability and acceptance of this simulation method.

CONCLUSION

The study provides no information about the extent to which the simulation actually influences the behavior and situational awareness of the participants. At least the awareness of the participants for real risks, hazards and errors of modern patient care was raised temporarily. The Room of Horrors can be easily adapted to different learning goals and settings. It is a flexible and practical learning arrangement. In comparison to the organizational and financial efforts involved, the implementation can be recommended without exception.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Design and Evaluation of a Low-Cost Bronchoscopy-Guided Percutaneous Dilatational Tracheostomy Simulator

Supplemental digital content is available in the text.

Introduction

Bronchoscopy-guided percutaneous dilatational tracheostomy (BG-PDT) is an invasive procedure regularly performed in the intensive care unit. Risk of serious complications have been estimated in up to 5%, focused during the learning phase. We have not found any published formal training protocols, and commercial simulators are costly and not widely available in some countries. The objective of this study was to present the design and simulator performance of a low-cost BG-PDT simulator.

Methods

A simulator was designed with materials available in a hardware store, synthetic skin pads, ex vivo bovine tracheas, and a pipe inspection camera. The simulator was tested in 8 experts and 9 novices. Sessions were video recorded, and participants were equipped with the Imperial College Surgical Device, a hand motion–tracking device. Performance was evaluated with a multimodal approach, including first attempt success rate, global success rate, total procedural time, Imperial College Surgical Device–derived proficiency parameters, and global rating scale applied blindly by 2 expert observers. A satisfaction survey was applied after the procedure.

Results

A simulator was successfully constructed, allowing multiple iterations per assembly, with a fixed cost of US $30 and $4 per use. Experts had greater global and first attempt success rate, performed the procedure faster, and with greater proficiency. It presented high user satisfaction and fidelity.

Conclusions

A low-cost BG-PDT simulator was successfully constructed, with the ability to discriminate between experts and novices, and with high fidelity. Considering its ease of construction and cost, it can be replicated in almost any intensive care unit.

Expectations, training and evaluation of intensive care staff to an interprofessional simulation course in Germany - Development of a relevant training concept

Objective: Increasingly, intensive care units (ICU) are operated by teams of physicians and nurses with specialist training in anaesthesia and intensive care. The aims of our study were to evaluate any prior experience, expectations and the requisites for interprofessional ICU simulation-based training (SBT), and to evaluate a newly designed training course incorporating these findings. Methods: The study was laid out as a cross-sectional study and is projected in three steps. First, questionnaires were sent out to ICU nurses and physicians from 15 different hospitals in a greater metropolitan area (> million citizens). Based upon this survey a one-day ICU simulator course designed for 12 participants (6 nurses and 6 physicians) was developed, with evaluation data from four subsequent courses being analysed. Results: In the survey 40% of nurses and 57% of the physicians had had prior exposure to SBT. Various course formats were explored with respect to duration, day of the week, and group composition. After completing the course, the majority deemed a full working day in interprofessional setting to be most appropriate (p<0.001). The scenarios were considered relevant and had a positive impact on communication, workflow and coping with stress. Conclusion: Currently SBT is not a mainstream tool used by German ICU teams for further education, and this lack of familiarity must be taken into consideration when preparing SBT courses for them. We developed a nontechnical skills training course for ICU teams which was undertaken in the setting of simulated clinical scenarios (pertinent to their work environment). The participants found the course's content to be relevant for their daily work, rated the course's impact on their workplace practices as being good and advocated for longer training sessions.

Expert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist

Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. To optimize care and improve access for patients with valvular heart disease the Expert Consensus Systems of Care Document by Nishimura et al.¹ was recently published. The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.

Design and Development of a Novel Invasive Blood Pressure Simulator for Patient's Monitor Testing

This paper presents a newly-designed and realized Invasive Blood Pressure (IBP) device for the simulation on patient’s monitors. This device shows improvements and presents extended features with respect to a first prototype presented by the authors and similar systems available in the state-of-the-art. A peculiarity of the presented device is that all implemented features can be customized from the developer and from the point of view of the end user. The realized device has been tested, and its performances in terms of accuracy and of the back-loop measurement of the output for the blood pressure regulation utilization have been described. In particular, an accuracy of ±1 mmHg at 25 °C, on a range from −30 to 300 mmHg, was evaluated under different test conditions. The designed device is an ideal tool for testing IBP modules, for zero setting, and for calibrations. The implemented extended features, like the generation of custom waveforms and the Universal Serial Bus (USB) connectivity, allow use of this device in a wide range of applications, from research to equipment maintenance in clinical environments to educational purposes. Moreover, the presented device represents an innovation, both in terms of technology and methodologies: It allows quick and efficient tests to verify the proper functioning of IBP module of patients’ monitors. With this innovative device, tests can be performed directly in the field and faster procedures can be implemented by the clinical maintenance personnel. This device is an open source project and all materials, hardware, and software are fully available for interested developers or researchers.

Comparison of a Novel Cadaver Model (Fix for Life) With the Formalin-Fixed Cadaver and Manikin Model for Suitability and Realism in Airway Management Training

BACKGROUND

Manikins are widely used in airway management training; however, simulation of realism and interpatient variability remains a challenge. We investigated whether cadavers embalmed with the novel Fix for Life (F4L) embalmment method are a suitable and realistic model for teaching 3 basic airway skills: facemask ventilation, tracheal intubation, and laryngeal mask insertion compared to a manikin (SimMan 3G) and formalin-fixed cadavers.

METHODS

Thirty anesthesiologists and experienced residents ("operators") were instructed to perform the 3 airway techniques in 10 F4L, 10 formalin-fixed cadavers, and 1 manikin. The order of the model type was randomized per operator. Primary outcomes were the operators' ranking of each model type as a teaching model (total rank), ranking of the model types per technique, and an operator's average verbal rating score for suitability and realism of learning the technique on the model. Secondary outcomes were the percentages of successfully performed procedures per technique and per model (success rates in completing the respective airway maneuvers). For each of the airway techniques, the Friedman analysis of variance was used to compare the 3 models on mean operator ranking and mean verbal rating scores.

RESULTS

Twenty-seven of 30 operators (90%) performed all airway techniques on all of the available models, whereas 3 operators performed the majority but not all of the airway maneuvers on all models for logistical reasons. The total number of attempts for each technique was 30 on the manikin, 292 in the F4L, and 282 on the formalin-fixed cadavers. The operators' median total ranking of each model type as a teaching model was 1 for F4L, 2 for the manikin and, 3 for the formalin-fixed cadavers (P < .001). F4L was considered the best model for mask ventilation (P = .029) and had a higher mean verbal rating score for realism in laryngeal mask airway insertion (P = .043). The F4L and manikin did not differ significantly in other scores for suitability and realism. The formalin-fixed cadaver was ranked last and received lowest scores in all procedures (all P < .001). Success rates of the procedures were highest in the manikin.

CONCLUSIONS

F4L cadavers were ranked highest for mask ventilation and were considered the most realistic model for training laryngeal mask insertion. Formalin-fixed cadavers are inappropriate for airway management training.

Advancing Simulation-Based Education in Pain Medicine

Background

The Accreditation Council for Graduate Medical Education (ACGME) has recently implemented milestones and competencies as a framework for training fellows in Pain Medicine, but individual programs are left to create educational platforms and assessment tools that meet ACGME standards.

Objectives

In this article, we discuss the concept of milestone-based competencies and the inherent challenges for implementation in pain medicine. We consider simulation-based education (SBE) as a potential tool for the field to meet ACGME goals through advancing novel learning opportunities, engaging in clinically relevant scenarios, and mastering technical and nontechnical skills.

Results

The sparse literature on SBE in pain medicine is highlighted, and we describe our pilot experience, which exemplifies a nascent effort that encountered early difficulties in implementing and refining an SBE program.

Conclusions

The many complexities in offering a sophisticated simulated pain curriculum that is valid, reliable, feasible, and acceptable to learners and teachers may only be overcome with coordinated and collaborative efforts among pain medicine training programs and governing institutions.

Exploring assessment of medical students' competencies in pain medicine-A review

Supplemental Digital Content is Available in the Text.

Introduction:

Considering the continuing high prevalence and public health burden of pain, it is critical that medical students are equipped with competencies in the field of pain medicine. Robust assessment of student expertise is integral for effective implementation of competency-based medical education.

Objective:

The aim of this review was to describe the literature regarding methods for assessing pain medicine competencies in medical students.

Method:

PubMed, Medline, EMBASE, ERIC, and Google Scholar, and BEME data bases were searched for empirical studies primarily focusing on assessment of any domain of pain medicine competencies in medical students published between January 1997 and December 2016.

Results:

A total of 41 studies met the inclusion criteria. Most assessments were performed for low-stakes summative purposes and did not reflect contemporary theories of assessment. Assessments were predominantly undertaken using written tests or clinical simulation methods. The most common pain medicine education topics assessed were pain pharmacology and the management of cancer and low-back pain. Most studies focussed on assessment of cognitive levels of learning as opposed to more challenging domains of demonstrating skills and attitudes or developing and implementing pain management plans.

Conclusion:

This review highlights the need for more robust assessment tools that effectively measure the abilities of medical students to integrate pain-related competencies into clinical practice. A Pain Medicine Assessment Framework has been developed to encourage systematic planning of pain medicine assessment at medical schools internationally and to promote continuous multidimensional assessments in a variety of clinical contexts based on well-defined pain medicine competencies.

Anaesthetizing children-From a nurse anaesthetist's perspective-A qualitative study

AIM

The aim of this study was to describe nurse anaesthetists' experiences of encountering and caring for children in connection to anaesthesia.

DESIGN

Qualitative design.

METHODS

Sixteen written narratives based on eight nurse anaesthetists' experiences of meeting children was analysed using qualitative content analysis.

RESULTS

The overarching theme was: "anaesthetizing children is a complex caring situation, including interactions with the child and parents as well as ensuring patient safety, affected by the perioperative team and organizational prerequisites". The nurses stated that in their interaction with the family, their goal was to ensure that children and parents felt secure and calm. "Striving to work in confidence" underlined the team and organizational influences. Encountering children involves more than knowledge about technical equipment, procedures and drugs. Knowledge about children's development and fears and parents' needs are essential for an optimal caring situation. Organizations need to realize that extra time, skills and resources are needed to safely anaesthetize children.

Integration of simulation in postgraduate studies in Saudi Arabia: The current practice in anesthesia training program

The educational programs in the Saudi Commission for Health Specialties are developing rapidly in the fields of technical development. Such development is witnessed, particularly in the scientific areas related to what is commonly known as evidence-based medicine. This review highlights the critical need and importance of integrating simulation into anesthesia training and assessment. Furthermore, it describes the current utilization of simulation in anesthesia and critical care assessment process.

[Full-scale simulation in German medical schools and anesthesia residency programs : Status quo]

BACKGROUND

Simulation has been increasingly used in medicine. In 2003 German university departments of anesthesiology were provided with a full-scale patient simulator, designated for use with medical students. Meanwhile simulation courses are also offered to physicians and nurses. Currently, the national model curriculum for residency programs in anesthesiology is being revised, possibly to include mandatory simulation training.

OBJECTIVES

To assess the status quo of full-scale simulation training for medical school, residency and continuing medical education in German anesthesiology.

METHODS

All 38 German university chairs for anesthesiology as well as five arbitrarily chosen non-university facilities were invited to complete an online questionnaire regarding their centers' infrastructure and courses held between 2010 and 2012.

RESULTS

The overall return rate was 86 %. In university simulation centers seven non-student staff members, mainly physicians, were involved, adding up to a full-time equivalent of 1.2. All hours of work were paid by 61 % of the centers. The median center size was 100 m² (range 20-500 m²), equipped with three patient simulators (1-32). Simulators of high or very high fidelity are available at 80 % of the centers. Scripted scenarios were used by 91 %, video debriefing by 69 %. Of the participating university centers, 97 % offered courses for medical students, 81 % for the department's employees, 43 % for other departments of their hospital, and 61 % for external participants. In 2012 the median center reached 46 % of eligible students (0-100), 39 % of the department's physicians (8-96) and 16 % of its nurses (0-56) once. For physicians and nurses from these departments that equals one simulation-based training every 2.6 and 6 years, respectively. 31 % made simulation training mandatory for their residents, 29 % for their nurses and 24 % for their attending physicians. The overall rates of staff ever exposed to simulation were 45 % of residents (8-90), and 30 % each of nurses (10-80) and attendings (0-100). Including external courses the average center trained 59 (4-271) professionals overall in 2012. No clear trend could be observed over the three years polled. The results for the non-university centers were comparable.

CONCLUSIONS

Important first steps have been taken to implement full-scale simulation in Germany. In addition to programs for medical students courses for physicians and nurses are available today. To reach everyone clinically involved in German anesthesiology on a regular basis the current capacities need to be dramatically increased. The basis for that to happen will be new concepts for funding, possibly supported by external requirements such as the national model curriculum for residency in anesthesiology.

[The basis for well-founded simulations]

In medical education, simulation is gaining increasing importance for teaching a variety of subjects. A well-founded educational approach is necessary for effective use. In addition to material aspects, simulation environment, curriculum, learning environment, and methods of debriefing have to be considered. The role of a competent instructor should be emphasized and the importance of an elaborate change management process to implement a good concept should not be underestimated.

Neck stoma patients: is vital information displayed at the bedside?

Tracheostomies are common procedures in head and neck and critical care practice, with 50% of airway-related deaths attributable to complications such as occlusion or displacement. The National Tracheostomy Safety Project (NTSP) published guidance regarding emergency management of neck stoma patients. A prospective multicentre regional audit of all neck stoma inpatients (ward and intensive care unit (ICU) settings) was conducted. Bed spaces were assessed for tracheostomy care bundles and essential stoma information, as recommended by the NTSP guidelines. The results demonstrate inadequate ward compliance across all three trusts, with ICU compliance greater in comparison to a ward environment. Of note, crucial information regarding the nature of stoma and whom to contact in the event of an emergency, was not displayed in the majority of cases. A greater awareness of the NTSP guidance and implementation of vital information is a necessity across all disciplines in order to reduce stoma complication-related morbidity and mortality.