Impact of levels of simulation fidelity on training of interns in ACLS

Efficacy of high-fidelity simulation in advanced life support training: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Simulation is an increasingly used novel method for the education of medical professionals. This study aimed to systematically review the efficacy of high-fidelity (HF) simulation compared with low-fidelity (LF) simulation or no simulation in advanced life support (ALS) training.

METHODS

A comprehensive search of the PubMed, Chinese Biomedicine Database, Embase, CENTRAL, ISI, and China Knowledge Resource Integrated Database was performed to identify randomized controlled trials (RCTs) that evaluated the use of HF simulation in ALS training. Quality assessment was based on the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1. The primary outcome was the improvement of knowledge and skill performance. The secondary outcomes included the participants' confidence and satisfaction at the course conclusion, skill performance at one year, skill performance in actual resuscitation, and patient outcomes. Data were synthesized using the RevMan 5.4 software.

RESULTS

Altogether, 25 RCTs with a total of 1,987 trainees were included in the meta-analysis. In the intervention group, 998 participants used HF manikins, whereas 989 participants received LF simulation-based or traditional training (classical training without simulation). Pooled data from the RCTs demonstrated a benefit in improvement of knowledge [standardized mean difference (SMD) = 0.38; 95% confidence interval (CI): 0.18-0.59, P = 0.0003, I2 = 70%] and skill performance (SMD = 0.63; 95% CI: 0.21-1.04, P = 0.003, I2 = 92%) for HF simulation when compared with LF simulation and traditional training. The subgroup analysis revealed a greater benefit in knowledge with HF simulation compared with traditional training at the course conclusion (SMD = 0.51; 95% CI: 0.20-0.83, P = 0.003, I2 = 61%). Studies measuring knowledge at three months, skill performance at one year, teamwork behaviors, participants' satisfaction and confidence demonstrated no significant benefit for HF simulation.

CONCLUSIONS

Learners using HF simulation more significantly benefited from the ALS training in terms of knowledge and skill performance at the course conclusion. However, further research is necessary to enhance long-term retention of knowledge and skill in actual resuscitation and patient's outcomes.

The effect of interprofessional simulations on pharmacy and physician assistant students' learning of advanced cardiac life support concepts

BACKGROUND

The Interprofessional Education Collaborative (IPEC) defined core competencies for IPE in 2011, and use of simulation in interprofessional education (IPE) continues to be developed in prelicensure health education programs.

INTERPROFESSIONAL EDUCATION ACTIVITY

In this prospective, observational study, interprofessional student teams addressed reversible causes of cardiac arrest in weekly simulations during an Emergency Medicine course. Each simulation was followed by sequential team debriefs, first regarding the IPEC core competencies of interprofessional communication, teamwork, and roles and responsibilities, and second regarding the patient-related content of the case.

DISCUSSION

Twenty-eight pharmacy students and 60 physician assistant students completed the course. A didactic knowledge exam was administered before, immediately after, and 150 days after the course. Both disciplines' exam scores significantly increased from baseline to the end of the course and from baseline to the 150-day follow-up. Students also completed the validated Interprofessional Perceptions Survey before and after the course. Both disciplines demonstrated significant increases in Team Value, Efficiency and Interprofessional Accommodation components.

IMPLICATIONS

Participation in this simulation-based course resulted in 150-day retention of advanced cardiovascular life support knowledge and improved interprofessional perceptions in both pharmacy and physician assistant students.

The effect of simulator fidelity on procedure skill training: a literature review

OBJECTIVES

To evaluate the effect of simulator fidelity on procedure skill training through a review of existing studies.

METHODS

MEDLINE, OVID and EMBASE databases were searched between January 1990 and January 2019. Search terms included "simulator fidelity and comparison" and "low fidelity" and "high fidelity" and "comparison" and "simulator". Author classification of low- and high-fidelity was used for non-laparoscopic procedures. Laparoscopic simulators are classified using a proposed schema. All included studies used a randomized methodology with two or more groups and were written in English. Data was abstracted to a standard data sheet and critically appraised from 17 eligible full papers.

RESULTS

Of 17 studies, eight were for laparoscopic and nine for other skill training. Studies employed evaluation methodologies, including subjective and objective measures. The evaluation was conducted once in 13/17 studies and before-after in 4/17. Didactic training only or control groups were used in 5/17 studies, while 10/17 studies included two groups only. Skill acquisition and simulator fidelity were different for the level of training in 1/17 studies. Simulation training was followed by clinical evaluation or a live animal evaluation in 3/17 studies. Low-fidelity training was not inferior to training with a high-fidelity simulator in 15/17 studies.

CONCLUSIONS

Procedure skill after training with low fidelity simulators was not inferior to skill after training with high fidelity simulators in 15/17 studies. Some data suggest that the effectiveness of different fidelity simulators depends on the level of training of participants and requires further study.

Observing the stages of bystander intervention in virtual reality simulation

BACKGROUND

Understanding bystander reactions to an emergency is an important component of effective training. Four stages of bystander intervention (BI) have been previously described: noticing the situation as a problem, interpreting when it is appropriate to intervene, recognizing personal responsibility to intervene, and knowing how to intervene. Using virtual reality (VR) to simulate emergencies such as sudden cardiac arrest (SCA) can be used to study these stages.

METHODS

In a secondary analysis of an observational cohort study, we analyzed bystander self-efficacy for stages of BI before and after simulated SCA. Each subject participated in a single-player, immersive, VR SCA scenario. Subjects interacted with simulated bystanders through voice commands ("call 911", "get an AED"). Actions taken in scenario, like performing CPR, were documented. Scenario BI actions were compared based on dichotomized comfort/discomfort.

RESULTS

From June 2016 to June 2017, 119 subjects participated. Average age was 37±14 years, 44% were female and 46% reported CPR training within 2 years. During the scenario, 98% "noticed the event" and "interpreted it as a problem", 78% "took responsibility", and 54% "possessed the necessary skills". Self-efficacy increased from pre- to post-scenario: noticing the event increased from 80% to 96%; interpreting as a problem increased from 86% to 97%; taking responsibility increased from 56% to 93%; possessing necessary skills increased from 47% to 63% (P<0.001).

CONCLUSION

Self-efficacy to respond to an SCA event increased pre- to post-scenario. Bystanders who reported feeling comfortable "taking responsibility to intervene" during an emergency were more likely to take action during a simulated emergency.

Comparing bystander response to a sudden cardiac arrest using a virtual reality CPR training mobile app versus a standard CPR training mobile app

BACKGROUND

Using a mobile virtual reality (VR) platform to heighten realism for cardiopulmonary resuscitation (CPR) training has the potential to improve bystander response.

OBJECTIVES

We examined whether using a VR mobile application (mApp) for CPR training would improve bystander response compared with a standard mApp CPR training.

METHODS

We randomized lay bystanders to either our intervention arm (VR mApp) or our control arm (mApp). During a post-intervention skills test, we collected bystander response data (call 911, perform CPR, ask for an automated external defibrillator (AED)), along with CPR quality (chest compression (CC) rate and depth). Wilcox rank sum was used to analyze CC rate and CC depth as they were not normally distributed; Pearson's Chi-square was used to analyze Chain of Survival variables.

RESULTS

Between 3/2018 and 9/2018, 105 subjects were enrolled: 52 VR mApp and 53 mApp. Mean age was 46 ± 16 years, 34% were female, 59% were Black, and 17% were currently CPR trained (≤2 years). Bystander response was significantly higher in the VR mApp arm: called 911 (82% vs 58%, p = 0.007) and asked for an AED (57% vs 28%, p = 0.003). However there was no difference in CPR performed (98% vs 98%, p = NS) and the application of the AED (90% vs 93%, p = NS). When comparing the VR mApp to the mApp, mean CC rate was 104 ± 42 cpm vs 112 ± 30 cpm (p = NS), and mean CC depth was 38 ± 15 mm vs 44 ± 13 mm (p = 0.05).

CONCLUSION

The use of the VR mApp significantly increased the likelihood of calling 911 and asking for an AED, however, CC depth was decreased.

High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students

BACKGROUND

Simulation has become integral to the training of both undergraduate medical students and medical professionals. Due to the increasing degree of realism and range of features, the latest mannequins are referred to as high-fidelity simulators. Whether increased realism leads to a general improvement in trainees' outcomes is currently controversial and there are few data on the effects of these simulators on participants' personal confidence and self-assessment.

METHODS

One-hundred-and-thirty-five fourth-year medical students were randomly allocated to participate in either a high- or a low-fidelity simulated Advanced Life Support training session. Theoretical knowledge and self-assessment pre- and post-tests were completed. Students' performance in simulated scenarios was recorded and rated by experts.

RESULTS

Participants in both groups showed a significant improvement in theoretical knowledge in the post-test as compared to the pre-test, without significant intergroup differences. Performance, as assessed by video analysis, was comparable between groups, but, unexpectedly, the low-fidelity group had significantly better results in several sub-items. Irrespective of the findings, participants of the high-fidelity group considered themselves to be advantaged, solely based on their group allocation, compared with those in the low-fidelity group, at both pre- and post-self-assessments. Self-rated confidence regarding their individual performance was also significantly overrated.

CONCLUSION

The use of high-fidelity simulation led to equal or even worse performance and growth in knowledge as compared to low-fidelity simulation, while also inducing undesirable effects such as overconfidence. Hence, in this study, it was not beneficial compared to low-fidelity, but rather proved to be an adverse learning tool.

Randomized Controlled Trial of Simulation vs. Standard Training for Teaching Medical Students High-quality Cardiopulmonary Resuscitation

INTRODUCTION

Most medical schools teach cardiopulmonary resuscitation (CPR) during the final year in course curriculum to prepare students to manage the first minutes of clinical emergencies. Little is known regarding the optimal method of instruction for this critical skill. Simulation has been shown in similar settings to enhance performance and knowledge. We evaluated the comparative effectiveness of high-fidelity simulation training vs. standard manikin training for teaching medical students the American Heart Association (AHA) guidelines for high-quality CPR.

METHODS

This was a prospective, randomized, parallel-arm study of 70 fourth-year medical students to either simulation (SIM) or standard training (STD) over an eight-month period. SIM group learned the AHA guidelines for high-quality CPR via an hour session that included a PowerPoint lecture with training on a high-fidelity simulator. STD group learned identical content using a low-fidelity Resusci Anne® CPR manikin. All students managed a simulated cardiac arrest scenario with primary outcome based on the AHA guidelines definition of high-quality CPR (specifies metrics for compression rate, depth, recoil, and compression fraction). Secondary outcome was time to emergency medical services (EMS) activation. We analyzed data via Kruskal-Wallis rank sum test. Outcomes were performed on a simulated cardiac arrest case adapted from the AHA Advanced Cardiac Life Support (ACLS) SimMan® Scenario manual.

RESULTS

Students in the SIM group performed CPR that more closely adhered to the AHA guidelines of compression depth and compression fraction. Mean compression depth was 4.57 centimeters (cm) (95% confidence interval [CI] [4.30-4.82]) for SIM and 3.89 cm (95% CI [3.50-4.27]) for STD, p=0.02. Mean compression fraction was 0.724 (95% CI [0.699-0.751]) for SIM group and 0.679 (95% CI [0.655-0.702]) for STD, p=0.01. There was no difference for compression rate or recoil between groups. Time to EMS activation was 24.7 seconds (s) (95% CI [15.7-40.8]) for SIM group and 79.5 s (95% CI [44.8-119.6]) for STD group, p=0.007.

CONCLUSION

High-fidelity simulation training is superior to low-fidelity CPR manikin training for teaching fourth-year medical students implementation of high-quality CPR for chest compression depth and compression fraction.

Impact of an Advanced Cardiac Life Support Simulation Laboratory Experience on Pharmacy Student Confidence and Knowledge

Objective. To assess the impact of an advanced cardiac life support (ACLS) simulation on pharmacy student confidence and knowledge. Design. Third-year pharmacy students participated in a simulation experience that consisted of team roles training, high-fidelity ACLS simulations, and debriefing. Students completed a pre/postsimulation confidence and knowledge assessment. Assessment. Overall, student knowledge assessment scores and student confidence scores improved significantly. Student confidence and knowledge changes from baseline were not significantly correlated. Conversely, a significant, weak positive correlation between presimulation studying and both presimulation confidence and presimulation knowledge was discovered. Conclusions. Overall, student confidence and knowledge assessment scores in ACLS significantly improved from baseline; however, student confidence and knowledge were not significantly correlated.