Development of a simulation and skills centre in East Africa: a Rwandan-Canadian partnership

Effectiveness of simulation-based cesarean section education on improving non-physician clinician midwife's competency in performing cesarean section in Ethiopia: a quasi-experimental study

BACKGROUND

Simulation-based education enhances fundamental and clinical knowledge, procedural abilities, teamwork, and communication skills, as well as quality of care and patient safety. Due to excessive clinical loads and a lack of physicians, even classic teaching methods like bedside instruction are constrained in low-income settings. Thus, this study aimed to ascertain if simulation-based cesarean section education successfully raises non-physician clinician midwives' competency in Ethiopia.

METHODS

A quasi-experimental study design triangulated with a qualitative design was implemented. Sixty Masters Clinical Midwifery students (29 intervention and 31 control) were taken in 5 universities. Three questionnaires (knowledge, confidence levels, and skills) were used. Qualitative data was also collected from 14 participants. The data were analyzed using SPSS version 25. Descriptive and inferential analyses were conducted. P < 0.05 was used for statistical significance. A difference-in-difference with a 95% confidence level was employed to control the potential confounders for knowledge and self-confidence. Multiple linear regression was fitted to identify the independent effect of simulation-based education interventions while controlling for other variables. Thematic analysis was performed using MAXQDA 2020.

RESULT

The age of the respondents varies from 24 to 34 years, with the control group's mean age being 28.8 (± 2.3) years and the intervention group's mean age being 27.2 (± 2.01) years. The intervention and control groups' pre-intervention and post-intervention knowledge scores showed a statistically significant difference. There was a substantial increase in self-confidence mean scores in both the intervention and control groups and between the pre-intervention and post-intervention periods in both the intervention and control groups. Furthermore, there was a substantial improvement in cesarean section skills in the intervention group as compared to the control group (59.6 (3.3) vs. 51.5 (4.8). The qualitative findings supported these.

CONCLUSIONS

The study showed that simulation-based education improved students' procedural knowledge, self-confidence, and skills. As a result, professional care teams can create simulation-based teaching packages to help students prepare for their residency.

Developing a Surgical Simulation Curriculum for the Rwandan Context

OBJECTIVE

We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda.

DESIGN

This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students.

SETTING

University of Global Health Equity, a new medical school located in Butaro, Rwanda.

PARTICIPANTS

Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship.

RESULTS

The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options.

CONCLUSIONS

Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.

Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial

INTRODUCTION

Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with "cross-suturing" would improve suturing performance.

METHODS

We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests.

RESULTS

A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29).

CONCLUSIONS

The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

AMPATH surgical app: Low-cost simulator for the open appendectomy

BACKGROUND

Due to a shortage and maldistribution of surgeons within Kenya, doctors with limited formal surgical training often perform emergency surgical procedures such as appendectomy. This lack of training can compromise patient outcomes and complicate care delivery. Our aim was to develop a low-cost simulator and skills curriculum to effectively teach open appendectomy.

METHODS

Surgeons from 4 countries participated in semi-structured interviews to define the steps and technique of open appendectomy using cognitive task analysis. Using this input, our Academic Model Providing Access to Healthcare surgical team developed a curriculum, including a simulator and feedback mechanism. Surgeons and surgical trainees from Kenya and the United States tested the simulator prototype and provided feedback for its refinement based on clarity, utility, and realism.

RESULTS

Instructions for a self-constructed simulator were developed at the cost of 70 Kenyan shillings (0.64 US dollars). Fifteen surgeons and surgical residents gave feedback on the simulator and curriculum, and each was presented with an updated version based on feedback. Overall, the curriculum was clear, with each sub-step receiving a median score of ≥83.5 out of 100 for clarity; however, through iterative design, the utility of sub-steps on the simulator improved.

CONCLUSION

A comprehensive open appendectomy curriculum, including a low-cost appendectomy simulator model, was developed and refined using surgeon feedback. Such curricula may benefit trainees in low-resource settings who may otherwise have limited access to quality training material.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

Virtual Faculty Development in Simulation in Sub-Saharan Africa: A Pilot Training for Pediatricians in Kisumu, Kenya

INTRODUCTION

Simulation is an effective educational tool increasingly being utilized in medical education globally and across East Africa. Globally, pediatric patients often present with low frequency, high acuity disease and simulation-based training in pediatric emergencies can equip physicians with the skills to recognize and intervene. Northwestern University (NU) in Chicago, IL, USA, and Maseno University (MU), in Kisumu, Kenya launched a predominantly virtual partnership in 2020 to utilize the Jaramogi Oginga Odinga Teaching & Referral Hospital (JOOTRH) simulation center for MU faculty development in simulation based medical education (SBME) for medical students.

MATERIALS AND METHODS

Educational goals, learning objectives, and educational content were collaboratively developed between MU and NU faculty. Virtual sessions were held for didactic education on simulation pedagogy, case development, and debriefing. Mixed educational methods were used including virtual mentored sessions for deliberate practice, piloted case facilitation with medical students, and mentored development of MU identified cases. Trained faculty had the summative experience of an intensive simulation facilitation with graduating MU students. MU faculty and students were surveyed on their experiences with SBME and MU faculty were scored on facilitation technique with a validated tool.

RESULTS

There were four didactic sessions during the training. Seven cases were developed to reflect targeted educational content for MU students. Six virtually mentored sessions were held to pilot SBME with MU students. In July 2021, fifty students participated in a week-long SBME course led by the MU trained faculty with virtual observation and mentorship from NU faculty. MU faculty reported positive experience with the SBME training and demonstrated improvement in debriefing skills after the training. The overwhelming majority of MU students reported positive experiences with SBME and endorsed desire for earlier and additional sessions.

DISCUSSION AND CONCLUSIONS

This medical education partnership, developed through virtual sessions, culminated in the implementation of an independently run simulation course by three trained MU faculty. SBME is an important educational tool and faculty in a resource constrained setting were successfully, virtually trained in its implementation and through collaborative planning, became a unique tool to address gaps for medical students.

Nursing students' experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study

AIMS AND OBJECTIVES

This study introduced simulation-based education in nurse education programs in Tanzania and Madagascar and explored nursing students' experiences with this pedagogic method as a mode of learning.

BACKGROUND

Simulation-based education has barely been introduced to education programs in resource-constrained settings. The study was conducted in two nurse education programs: one in rural Tanzania and the other in the mid-land of Madagascar. Both institutions offer diploma programs in nursing. Simulation-based education has not been included in the teaching methods used in these nursing programs.

DESIGN

A descriptive and convergent mixed method design was employed.

METHODS

Ninety-nine nursing students were included in the study. Simulation sessions followed by data collection took place once in 2017 and twice in 2018. Data were collected by means of several questionnaires and six focus groups. The data were analyzed using descriptive statistics and qualitative content analysis. The Standards for Reporting Qualitative Research (SRQR) was used to report the results.

RESULTS

The quantitative data revealed that the students rated all the questions related to the simulation design elements, educational practices, and students' satisfaction and self-confidence in learning with scores of above four on a 5-point Likert scale. The qualitative data from the first theme, building competence and confidence, further emphasized and outlined the quantitative results. Additionally, the qualitative data revealed a second theme, improving through encouragement and corrections. The students clearly expressed that they wanted to be aware of their weaknesses to be able to improve; however, the provision of feedback should be carried out in an encouraging way.

CONCLUSION

The findings indicated that the nursing students were satisfied with simulation as a pedagogic method, as it improved their competence and prepared them for professional practice. Further research is necessary to explore whether the students are able to transfer their knowledge into clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Simulation as a pedagogic method is valuable for the learning of clinical skills and preparation for clinical practice.

Medical student satisfaction and confidence in simulation-based learning in Rwanda - Pre and post-simulation survey research

INTRODUCTION

Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, comfort with undertaking taught tasks, inter-professional communication, teamwork and teaching skills. This study aimed to evaluate Rwandan medical students' attitudes, satisfaction and confidence level with SBL.

METHODS

Fifth year medical students at the University of Rwanda were given a short course on paediatric acute care using simulation. The simulation sessions were locally developed cases based on the pRRAPID materials, developed at the University of Leeds (UK). Equipment included low fidelity infant mannequins, basic airway devices, IV access, and monitoring. A four-part, Likert-scale questionnaire was distributed to medical students before and after their four-week simulation program.

RESULTS

57 pre-simulation and 49 post-simulation questionnaires were completed. Confidence in skills increased in all fifteen domains of the questionnaire with the total skill confidence score rising from 44.0 (±12.3) to 56.2 (±8.8) after the simulation-based intervention (p < 0.001). Satisfaction and attitudes towards simulation-based learning in this setting were very positive.

CONCLUSION

The simulation-based intervention was well received by students in this setting. Satisfaction was high and the simulation exercise increased the students' confidence. Previous research has demonstrated that SBL is effective and the results of this study now demonstrate that it is well received in our setting. As we move from knowledge-based education to a competency-based education culture, faculties in this setting should invest in providing SBL opportunities throughout the medical school curriculum.

A Novel University of North Carolina Laparoscopic Ventral Hernia Repair Simulator

Background: Simulation plays an important role in surgical training. We developed a simulator for laparoscopic ventral hernia repair (LVHR) surgery based on porcine tissue, characterized by low cost and high reality. Methods: Our LVHR model is based on porcine tissue mounted in a human mannequin. The anterior abdominal wall is constructed to allow laparoscopic training. Training sessions are conducted in a simulated operating room environment. Results: During preliminary tests, the LVHR simulator was found to be highly realistic in terms of tissue feedback, instrumentation usage, and performing the key steps of the LVHR procedure. The model was evaluated as a very useful tool for residents' training allowing to gain laparoscopic skills, learn the key steps of LVHR, and practice team work. Conclusions: Our simulator, based on porcine tissue mounted in a mannequin, offers a very realistic and cost-effective model for simulating LVHR surgery.

The Utility of an Open-Access Surgical Simulator to Enhance Surgeon Training

BACKGROUND

Smile Train, an international children's charity committed to improving cleft care around the world, empowers local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. As part of their sustainable model, Smile Train developed a web-based, interactive virtual simulator to improve surgical training of cleft procedures for surgeons around the world, replicating the anatomical and technical steps involved in cleft surgery. This study evaluated the simulator as a tool for enhancing surgical training.

METHODS

A pre-test and questionnaire addressing cleft care, surgical knowledge, and confidence level was administered to surgeons-in-training at an academic institution. Participants completed 3 simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels.

RESULTS

Sixteen surgeons-in-training participated in this study. The mean score on the knowledge examination increased after reviewing the modules for both junior residents (33.1%-64.4%) and senior residents (46.9%-70.8%). Reviewing the modules increased participants' confidence in the knowledge of cleft anatomy, understanding of surgical procedures, and ability to follow along meaningfully while assisting in operations.

CONCLUSIONS

The Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons-in-training. Virtual simulation is a valuable resource for improving understanding and competence of the craniofacial surgeon while serving as an educational resource to other members of the comprehensive cleft care team, patients, and families.

General Thoracic Surgery in Rwanda: An Assessment of Surgical Volume and of Workforce and Material Resource Deficits

BACKGROUND

Benchmarking operative volume and resources is necessary to understand current efforts addressing thoracic surgical need. Our objective was to examine the impact on thoracic surgery volume and patient access in Rwanda following a comprehensive capacity building program, the Human Resources for Health (HRH) Program, and thoracic simulation training.

METHODS

A retrospective cohort study was conducted of operating room registries between 2011 and 2016 at three Rwandan referral centers: University Teaching Hospital of Kigali, University Teaching Hospital of Butare, and King Faisal Hospital. A facility-based needs assessment of essential surgical and thoracic resources was performed concurrently using modified World Health Organization forms. Baseline patient characteristics at each site were compared using a Pearson Chi-squared test or Kruskal-Wallis test. Comparisons of operative volume were performed using paired parametric statistical methods.

RESULTS

Of 14,130 observed general surgery procedures, 248 (1.76%) major thoracic cases were identified. The most common indications were infection (45.9%), anatomic abnormalities (34.4%), masses (13.7%), and trauma (6%). The proportion of thoracic cases did not increase during the HRH program (2.07 vs 1.78%, respectively, p = 0.22) or following thoracic simulation training (1.95 2013 vs 1.44% 2015; p = 0.15). Both university hospitals suffer from inadequate thoracic surgery supplies and essential anesthetic equipment. The private hospital performed the highest percentage of major thoracic procedures consistent with greater workforce and thoracic-specific material resources (0.89% CHUK, 0.67% CHUB, and 5.42% KFH; p < 0.01).

CONCLUSIONS AND RELEVANCE

Lack of specialist providers and material resources limits thoracic surgical volume in Rwanda despite current interventions. A targeted approach addressing barriers described is necessary for sustainable progress in thoracic surgical care.

An Evaluation of the Role of Simulation Training for Teaching Surgical Skills in Sub-Saharan Africa

Background

An estimated 5 billion people worldwide lack access to any surgical care, whilst surgical conditions account for 11–30% of the global burden of disease. Maximizing the effectiveness of surgical training is imperative to improve access to safe and essential surgical care on a global scale. Innovative methods of surgical training have been used in sub-Saharan Africa to attempt to improve the efficiency of training healthcare workers in surgery. Simulation training may have an important role in up-scaling and improving the efficiency of surgical training and has been widely used in SSA. Though not intended to be a systematic review, the role of simulation for teaching surgical skills in Sub-Saharan Africa was reviewed to assess the evidence for use and outcomes.

Methods

A systematic search strategy was used to retrieve relevant studies from electronic databases PubMed, Ovid, Medline for pertinent articles published until August 2016. Studies that reported the use of simulation-based training for surgery in Africa were included.

Results

In all, 19 articles were included. A variety of innovative surgical training methods using simulation techniques were identified. Few studies reported any outcome data. Compared to the volume of surgical training initiatives that are known to take place in SSA, there is very limited good quality published evidence for the use of simulation training in this context.

Conclusions

Simulation training presents an excellent modality to enhance and improve both volume and access to high quality surgical skills training, alongside other learning domains. There is a desperate need to meticulously evaluate the appropriateness and effectiveness of simulation training in SSA, where simulation training could have a large potential beneficial impact. Training programs should attempt to assess and report learner outcomes.

Anaesthesia in austere environments: literature review and considerations for future space exploration missions

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda

BACKGROUND

The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty.

METHODS

Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website <http://thoracicsurgeryeducation.com> was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants' responses.

RESULTS

Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45).

CONCLUSIONS

General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

Implementing simulation in a nursing education programme: a case report from Tanzania

This paper presents a description of, and some reflections around, the experience of implementing simulation-based education within a nursing education programme in a low-income context. The students in the nursing education programme found the simulation sessions to be useful, motivating and a realistic learning method. Our experience may provide useful insight for other nursing education programmes in low-income contexts. It looks like a deeper knowledge about the feasibility of simulation-based education from both the teacher and student perspective is necessary.

Nursing education challenges and solutions in Sub Saharan Africa: an integrative review

BACKGROUND

The Lancet Commission and the Global Health Workforce Alliance reported that professional education has generally not kept up the pace of health care challenges. Sub Saharan Africa needs an effective and efficient nursing education system to build an adequate, competent and relevant nursing workforce necessary for the achievement of Sustainable Development Goals. The Plan of Action for Scaling up Quality Nursing and Midwifery Education and Practice for the African Region 2012 - 2022 provided a framework for scale up of nurses and midwives. This integrative review examined literature on nursing education challenges and solutions in Sub Saharan Africa to inform development of a model for improving the quality, quantity and relevance of nursing education at local level.

METHODS

A search of PubMed, Medline on EBCSOhost and Google Scholar was conducted using key words: nursing education, challenges, solutions and/ or Africa. Published works from 2012 to 2016 were reviewed to explore reports about challenges and solution in nursing education in Sub Saharan Africa. Full texts of relevant studies were retrieved after reading the tittles and abstracts. Critical appraisal was undertaken and the findings of the relevant studies were analysed using thematic analysis.

RESULTS

Twenty articles and five grey sources were included. Findings of the review generally supports World Health Organisation framework for transformative and scale up of health professions education. Six themes emerged; curriculum reforms, profession regulation, transformative teaching strategies, collaboration and partnership, capacity building and infrastructure and resources. Challenges and solutions in nursing education are common within countries. The review shows that massive investment by development partners is resulting in positive development of nursing education in Sub Saharan Africa. However, strategic leadership, networking and partnership to share expertise and best practices are critical.

CONCLUSION

Sub Saharan Africa needs more reforms to increase capacity of educators and mentors, responsiveness of curricula, strongly regulatory frameworks, and availability of infrastructure and resources. The review adds to the body of knowledge to enhance efforts of stakeholders in the improvement of the quality, quantity and relevance of nursing education in Sub Saharan Africa.

Health Care Simulation in Developing Countries and Low-Resource Situations

INTRODUCTION

Health care simulation, as a complement to traditional learning, has spread widely and seems to benefit both students and patients. The teaching methods involved in health care simulation require substantial human, logistical, and financial investments that might preclude their spread in developing countries. The aim of this study was to analyze the health care simulation experiences in developing countries.

METHODS

A comprehensive literature search was performed from January 2000 to December 2016. Articles reporting studies on educational health care simulation in developing countries were included.

RESULTS

In total, 1161 publications were retrieved, of which 156 were considered eligible based on title and abstract screening. Thirty articles satisfied our predefined selection criteria. Most of the studies were case series; 76.7% (23/30) were prospective and comparative, and five were randomized trials. The development of dedicated task trainers and telesimulation were the primary techniques assessed. The retrieved studies showed encouraging trends in terms of trainee satisfaction with improvement after training, but the improvements were mainly tested on the training tool itself. Two of the tools have been proven to be construct valid with clinical impact.

CONCLUSION

Health care simulation in developing countries seems feasible with encouraging results. Higher-quality studies are required to assess the educational value and promote the development of health care simulation programs.

Low-Cost Simulation to Teach Anesthetists' Non-Technical Skills in Rwanda

BACKGROUND

Safe anesthesia care is challenging in developing countries where there are shortages of personnel, drugs, equipment, and training. Anesthetists' Non-technical Skills (ANTS)-task management, team working, situation awareness, and decision making-are difficult to practice well in this context. Cesarean delivery is the most common surgical procedure in sub-Saharan Africa. This pilot study investigates whether a low-cost simulation model, with good psychological fidelity, can be used effectively to teach ANTS during cesarean delivery in Rwanda.

METHODS

Study participants were anesthesia providers working in a tertiary referral hospital in Rwanda. Baseline observations were conducted for 20 anesthesia providers during cesarean delivery using the established ANTS framework. After the first observation set was complete, participants were randomly assigned to either simulation intervention or control groups. The simulation intervention group underwent ANTS training using low-cost high psychological fidelity simulation with debriefing. No training was offered to the control group. Postintervention observations were then conducted in the same manner as the baseline observations.

RESULTS

The primary outcome was the overall ANTS score (maximum, 16). The median (range) ANTS score of the simulation group was 13.5 (11-16). The ANTS score of the control group was 8 (8-9), with a statistically significant difference (P = .002). Simulation participants showed statistically significant improvement in subcategories and in the overall ANTS score compared with ANTS score before simulation exposure.

CONCLUSIONS

Rwandan anesthesia providers show improvement in ANTS practice during cesarean delivery after 1 teaching session using a low-cost high psychological fidelity simulation model with debriefing.

Lessons from the Design and Implementation of a Pediatric Critical Care and Emergency Medicine Training Program in a Low Resource Country-The South American Experience

For more than 60 years, the world has recognized the need for pediatric critical care (PCC). Today, most low- and middle-income countries (LMICs) still lack access to pediatric intensive care units (PICUs) and specialists, resulting in high rates of morbidity and mortality. These disparities result from several infrastructure and socioeconomic factors, chief among them being the lack of trained PCC and emergency medicine (PCCEM) frontline providers. In this article, we describe a continuing medical education model to increase frontline PCC capacity in Ecuador. The Laude in PCCEM is a program created by a team of Ecuadorian physicians at the University San Francisco de Quito School of Medicine. The program is aimed at providers with no formal training in PCC and who, nonetheless, care for critically ill children. The program resulted in stronger, more cohesive PICU teams with improved resuscitation times and coordination during simulation rounds. In hospitals that implemented the program, we saw decreased PICU mortality rates. Our aim is to identify the opportunities and challenges learned and to offer lessons for other countries that use similar models to cope with the lack of local resource availability.

Simulation in the operating room

Simulation has become a significant training tool in the operating room (OR). It can be used in both simple task training and complex scenarios. The challenge for simulation in the OR is how to translate that which is learned, and perceived to beneficial, into behavioral change and improved patient outcomes. Simulation in the developing world is progressing, but is still hampered by a shortage of material, personnel funding.