Impact of Virtual Reality Simulation on New Nurses' Assessment of Pediatric Respiratory Distress

BACKGROUND

Children often experience respiratory illnesses requiring bedside nurses skilled in recognizing respiratory decompensation. Historically, recognizing respiratory distress has relied on teaching during direct patient care. Virtual reality simulation may accelerate such recognition among novice nurses.

OBJECTIVE

To determine whether a virtual reality curriculum improved new nurses' recognition of respiratory distress and impending respiratory failure in pediatric patients based on assessment of physical examination findings and appropriate escalation of care.

METHODS

New nurses (n = 168) were randomly assigned to complete either an immersive virtual reality curriculum on recognition of respiratory distress (intervention) or the usual orientation curriculum (control). Group differences and changes from 3 months to 6 months after the intervention were examined.

RESULTS

Nurses in the intervention group were significantly more likely to correctly recognize impending respiratory failure at both 3 months (23.4% vs 3.0%, P < .001) and 6 months (31.9% vs 2.6%, P < .001), identify respiratory distress without impending respiratory failure at 3 months (57.8% vs 29.6%, P = .002) and 6 months (57.9% vs 17.8%, P < .001), and recognize patients' altered mental status at 3 months (51.4% vs 18.2%, P < .001) and 6 months (46.8% vs 18.4%, P = .006).

CONCLUSIONS

Implementation of a virtual reality-based training curriculum was associated with improved recognition of pediatric respiratory distress, impending respiratory failure, and altered mental status at 3 and 6 months compared with standard training approaches. Virtual reality may offer a new approach to nurse orientation to enhance training in pediatrics-specific assessment skills.

Multiuser immersive virtual reality simulation for interprofessional sepsis recognition and management

INTRODUCTION

Sepsis is a leading cause of pediatric mortality. While there has been significant effort toward improving adherence to evidence-based care, gaps remain. Immersive multiuser virtual reality (MUVR) simulation may be an approach to enhance provider clinical competency and situation awareness for sepsis.

METHODS

A prospective, observational pilot of an interprofessional MUVR simulation assessing a decompensating patient from sepsis was conducted from January to June 2021. The study objective was to establish validity and acceptability evidence for the platform by assessing differences in sepsis recognition between experienced and novice participants. Interprofessional teams assessed and managed a patient together in the same VR experience with the primary outcome of time to recognition of sepsis utilizing the Situation Awareness Global Assessment Technique analyzed using a logistic regression model. Secondary outcomes were perceived clinical accuracy, relevancy to practice, and side effects experienced.

RESULTS

Seventy-two simulations included 144 participants. The cumulative odds ratio of recognizing sepsis at 2 min into the simulation in comparison to later time points by experienced versus novice providers were significantly higher with a cumulative odds ratio of 3.70 (95% confidence interval: 1.15-9.07, p = .004). Participants agreed that the simulation was clinically accurate (98.6%) and will impact their practice (81.1%), with a high degree of immersion (95.7%-99.3%), and the majority of side effects were perceived as mild (70.4%-81.4%).

CONCLUSIONS

Our novel MUVR simulation demonstrated significant differences in sepsis recognition between experienced and novice participants. This validity evidence along with the data on the simulation's acceptability supports expanded use in training and assessment.

Tolerability and Acceptability of Autonomous Immersive Virtual Reality Incorporating Digital Twin Technology for Mass Training in Healthcare

INTRODUCTION

As part of onboarding and systems testing for a clinical expansion, immersive virtual reality (VR) incorporating digital twin technology was used. While digital twin technology has been leveraged by industry, its use in health care has been limited with no prior application for onboarding or training. The tolerability and acceptability of immersive VR for use by a large population of healthcare staff were unknown.

METHODS

A prospective, observational study of an autonomous immersive VR onboarding experience to a new clinical space was conducted from May to September 2021. Participants were healthcare staff from several critical care and acute care units. Primary outcomes were tolerance and acceptability measured by reported adverse effects and degree of immersion. Secondary outcomes were attitudes toward the efficacy of VR compared with standard onboarding experiences.

RESULTS

A total of 1522 healthcare staff participated. Rates of adverse effects were low and those with prior VR experience were more likely to report no adverse effects. Odds of reporting immersion were high across all demographic groups, though decreased with increasing age. The preference for VR over low-fidelity methods was high across all demographics; however, preferences were mixed when compared with traditional simulation and real-time clinical care.

CONCLUSIONS

Large-scale VR onboarding is feasible, tolerable, and acceptable to a diverse population of healthcare staff when using digital twin technology. This study also represents the largest VR onboarding experience to date and may address preconceived notions that VR-based training in health care is not ready for widespread adoption.

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit

BACKGROUND

Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU.

OBJECTIVE

To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness.

DESIGN, SETTINGS, AND PARTICIPANTS

A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation.

INTERVENTION

Improved and updated communication devices and bedside mitigation plans.

MAIN OUTCOME AND MEASURES

Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition.

RESULTS

When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.

Just-in-Time, Just-in-Place Virtual Training in the Pediatric Emergency Department: A Novel Approach to Impact the Perfusion Exam

Background

Early identification of shock is vital in decreasing morbidity and mortality in the pediatric population. Although residents are taught the perfusion portion of the rapid cardiopulmonary assessment at our institution, they perform it at the bedside with 8.4% completing 1 part of the assessment and 9.7% verbalizing their findings. Newer technologies, including virtual reality (VR), offer immersive training to close this clinical gap.

Objective

To assess senior pediatric residents' performance of a perfusion exam and verbalization of their perfusion assessment following VR-based Just-in-Time/Just-in-Place (JITP) training compared to video-based JITP training. We hypothesized that JITP media training was feasible, and VR JITP was more effective than video-based training.

Methods

Residents were randomized to VR or video-based training during shifts in the emergency department. Clinical performance was assessed by review of a video-recorded patient encounter using a standardized assessment tool and by an in-person, two question shock assessment. Residents completed a survey assessing attitudes toward their intervention at the time of training.

Results

Eighty-five senior pediatric residents were enrolled; 84 completed training. Sixty-four (76%) residents had a patient encounter available for video review (VR 33; Video 31). Fourteen residents in the VR group (42.4%, 95% CI 25.5% to 60.8%) and 13 residents in the video group (41.9%, 95% CI 24.6% to 60.9%) completed a perfusion exam AND verbalized an assessment during their next clinical encounter (X2 p-value 1.00). Fifty-one of 64 residents (79.7%) completed the two-step shock assessment; 50 (98%) agreed with supervising physician's assessment. VR was rated more effective than reading, low-fidelity manikin, standardized patient encounters, traditional didactic teaching, and online learning. Video was rated more effective than online learning, traditional didactic teaching, and reading.

Conclusion

Novel video and VR JITP perfusion exam and assessment trainings are impactful and well-received by senior pediatric residents.

Virtual Reality to Assess Resident Recognition of Impending Respiratory Failure During COVID-19

OBJECTIVES

To assess the performance of pediatric residents in recognizing a decompensating patient with impending respiratory failure and appropriately escalating care using a virtual reality (VR) simulated case of an infant with bronchiolitis after an extended period of decreased clinical volumes during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Sixty-two pediatric residents at a single academic pediatric referral center engaged in a 30-minute VR simulation on respiratory failure in a 3-month-old admitted to the pediatric hospital medicine service with bronchiolitis. This occurred in a socially distant manner across the Zoom platform during the COVID-19 pandemic (January-April 2021). Residents were assessed on their ability to (1) recognize altered mental status (AMS), (2) designate clinical status as "(impending) respiratory failure," and (3) escalate care. Statistical differences between and across postgraduate year (PGY) levels were examined using χ2 or Fisher's exact test, followed by pairwise comparison and posthoc multiple testing using the Hochberg test.

RESULTS

Among all residents, 53% successfully recognized AMS, 16% identified respiratory failure, and 23% escalated care. No significant differences were seen across PGY levels for recognizing AMS or identifying respiratory failure. PGY3+ residents were more likely to escalate care than PGY2 residents (P = .05).

CONCLUSIONS

In the setting of an extended period with decreased clinical volumes during the COVID-19 pandemic, pediatric residents across all PGY levels demonstrated challenges with identifying (impending) respiratory failure and appropriately escalating care during VR simulations. Though limited, VR simulation may serve as a safe adjunct for clinical training and assessment during times of decreased clinical exposure.

Impact of a Remote Virtual Reality Curriculum Pilot on Clinician Conflict Communication Skills

OBJECTIVES

Conflict management skills are essential for interprofessional team functioning, however existing trainings are time and resource intensive. We hypothesized that a curriculum incorporating virtual reality (VR) simulations would enhance providers' interprofessional conflict communication skills and increase self-efficacy.

METHODS

We conducted a randomized controlled pilot study of the Conflict Instruction through Virtual Immersive Cases (CIVIC) curriculum among inpatient clinicians at a pediatric satellite campus. Participants viewed a 30-minute didactic presentation on conflict management and subsequently completed CIVIC (intervention group) or an alternative VR curriculum on vaccine counseling (control group), both of which allowed for verbal interactions with screen-based avatars. Three months following VR training, all clinicians participated in a unique VR simulation focused on conflict management that was recorded and scored using a rubric of observable conflict management behaviors and a Global Entrustment Scale (GES). Differences between groups were evaluated using generalized linear models. Self-efficacy was also assessed immediately pre, post, and 3 months postcurriculum. Differences within and between groups were assessed with paired independent and 2-sample t-tests, respectively.

RESULTS

Forty of 51 participants (78%) completed this study. The intervention group (n = 17) demonstrated better performance on the GES (P = .003) and specific evidence-based conflict management behaviors, including summarizing team member's concerns (P = .02) and checking for acceptance of the plan (P = .02), as well as statistical improvements in 5 self-efficacy measures compared with controls.

CONCLUSIONS

Participants exposed to CIVIC demonstrated enhanced conflict communication skills and reported increased self-efficacy compared with controls. VR may be an effective method of conflict communication training.

Using Technology to Overcome Vaccine Hesitancy

Technology holds great potential to address many vaccine hesitancy determinants and support vaccine uptake given its ability to amplify positive messages, support knowledge, and enhance providers' recommendations. Modalities previously implemented with variable success have included automated reminder systems, decision support for clinicians, online education programs, social media campaigns, and virtual reality curricula. Further research is needed to identify the optimal uses of technology at the patient/parent and provider levels to overcome vaccine hesitancy. The most effective interventions will likely be multipronged providing patients, parents, and providers with information related to vaccine status.

Development and Implementation of Augmented Reality Enhanced High-Fidelity Simulation for Recognition of Patient Decompensation

INTRODUCTION

Simulation is a core aspect of training and assessment; however, simulation laboratories are limited in their ability to visually represent mental, respiratory, and perfusion status. Augmented reality (AR) represents a potential adjunct to address this gap.

METHODS

A prospective, observational pilot of interprofessional simulation assessing a decompensating patient was conducted from April to June 2019. Teams completed 2 simulations: (1) traditional training (TT) using a manikin (Laerdal SimJunior) and (2) AR-enhanced training (ART) using a manikin plus an AR patient. The primary outcome was self-assessed effectiveness at the assessment of patient decompensation. Secondary outcomes were attitudes toward and adverse effects during the AR training.

RESULTS

Twenty-one simulation sessions included 84 participants in headsets. Participants reported improved ability to assess the patient's mental status, respiratory status, and perfusion status (all P < 0.0001) during ART in comparison to TT. Similar findings were noted for recognition of hypoxemia, shock, apnea, and decompensation (all P ≤ 0.0003) but not for recognition of cardiac arrest (P = 0.06). Most participants agreed or strongly agreed that ART accurately depicted a decompensating patient (89%), reinforced key components of the patient assessment (88%), and will impact how they care for patients (68%). Augmented reality-enhanced training was rated more effective than manikin training and standardized patients and equally as effective as bedside teaching.

CONCLUSIONS

This novel application of AR to enhance the realism of manikin simulation demonstrated improvement in self-assessed recognition of patient decompensation. Augmented reality may represent a viable modality for increasing the clinical impact of training.

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

BACKGROUND

The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED).

METHODS

This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria.

RESULTS

Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively.

CONCLUSIONS

We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.

Establishing Objective Measures of Clinical Competence in Undergraduate Medical Education Through Immersive Virtual Reality

OBJECTIVE

The Association of American Medical Colleges defines recognition of the need for urgent or emergent escalation of care as a key Entrustable Professional Activity (EPA) for entering residency (EPA#10). This study pilots the use of an immersive virtual reality (VR) platform for defining objective observable behaviors as standards for evaluation of medical student recognition of impending respiratory failure.

METHODS

A cross-sectional observational study was conducted from July 2018 to December 2019, evaluating student performance during a VR scenario of an infant in impending respiratory failure using the OculusRift VR platform. Video recordings were rated by 2 pair of physician reviewers blinded to student identity. One pair provided a consensus global assessment of performance (not competent, borderline, or competent) while the other used a checklist of observable behaviors to rate performance. Binary discriminant analysis was used to identify the observable behaviors that predicted the global assessment rating.

RESULTS

Twenty-six fourth year medical students participated. Student performance of 8 observable behaviors was found to be most predictive of a rating of competent, with a 91% probability. Correctly stating that the patient required an escalation of care had the largest contribution toward predicting a rating of competent, followed by commenting on the patient's increased heart rate, low oxygen saturation, increased respiratory rate, and stating that the patient was in respiratory distress.

CONCLUSIONS

This study demonstrates that VR can be used to establish objective and observable performance standards for assessment of EPA attainment - a key step in moving towards competency based medical education.

Increasing PCP and Hospital Medicine Physician Verbal Communication During Hospital Admissions

OBJECTIVES

During hospital admission, communication between primary care physicians (PCPs) and hospital medicine (HM) physicians provides an opportunity for collaboration. Two-way communication facilitates collaboration by allowing the receiver to ask and respond to questions. At our institution, most HM-to-PCP communication occurred by telephone call after discharge. Our specific aim was to increase the percentage of patients for whom a telephone conversation occurred between HM and PCPs during hospital admission from 40% to >80%.

METHODS

An improvement team that included PCPs and HM physicians redesigned the process for communication with PCPs to emphasize collaboration during hospitalization. Interventions were used to target key drivers of information transparency, PCP and HM provider buy-in, the value of early call initiation, process standardization, accommodating provider availability, and preoccupation with failure. We used improvement-science methods and run charts to measure our progress and attain our goal.

RESULTS

The median weekly percentage of patients with a phone call completed during hospitalization increased from 40% to 85% at the satellite campus and 40% to 80% at the main campus. In addition to the standardized use of a telephone operator system to route calls and follow-up on unplaced calls, critical interventions included feedback on PCP call preferences to providers and the provider script for calls.

CONCLUSIONS

PCPs and HM physicians applied quality-improvement methodology to ensure reliable HM-PCP communication during hospital admission. Interventions to facilitate communication between providers and learners (who may otherwise have limited interaction), such as the scripting of phone calls and feedback from PCPs to HM physicians, were important for success.

Objective Assessment of Resident Teaching Competency Through a Longitudinal, Clinically Integrated, Resident-as-Teacher Curriculum

OBJECTIVE

Competency-based training should be paired with objective assessments. To date, there has been limited objective assessment of resident-as-teacher curricula (RATC). We sought to assess the impact of a longitudinal RATC on postgraduate year-1 (PGY1) resident teaching competency using Observed Structured Teaching Encounters (OSTEs) for the skills of 1) brief didactic teaching [DT], 2) feedback [FB], and 3) precepting [PR].

METHODS

A controlled, prospective, educational study was conducted from May 2015 to June 2016. The RATC consisted of a workshop series with reinforcement of key skills (DT, FB) during clinical rotations. Intervention residents participated in the RATC and completed OSTEs at the beginning and end of the academic year. A control group, PGY1 residents that matriculated the year previously, completed the OSTEs before starting their PGY2 year. OSTEs were reviewed by 2 blinded study personnel. We assessed reliability between raters via intraclass correlation coefficients and differences in OSTE scores via least squared mean differences (LSMD).

RESULTS

In total, 92.5% (n = 37) of eligible control and 100% (n = 41) of eligible intervention residents participated. The OSTEs demonstrated excellent agreement between reviewers (DT: 0.99, FB: 0.89, PR: 0.98). A significant pre-post difference was demonstrated in the intervention group for DT (LSMD [95% confidence interval], 3.14 [2.49-3.79], P < .0001), FB (0.93 [0.49-1.37], P < .0001), and PR (0.64 [0.09-1.18], P < .022). A significant difference between the control and intervention groups was demonstrated for DT (3.00 [2.05-3.96], P < .0001).

CONCLUSIONS

Skill-based OSTEs can be used to detect changes in residents' teaching competency and may represent a potential component of programmatic evaluation of resident-as-teacher curricula.

Enhancing Educational Scholarship Through Conceptual Frameworks: A Challenge and Roadmap for Medical Educators

Historically, health sciences education has been guided by tradition and teacher preferences rather than by the application of practices supported by rigorous evidence of effectiveness. Although often underutilized, conceptual frameworks-theories that describe the complexities of educational and social phenomenon-are essential foundations for scholarly work in education. Conceptual frameworks provide a lens through which educators can develop research questions, design research studies and educational interventions, assess outcomes, and evaluate the impact of their work. Given this vital role, conceptual frameworks should be considered at the onset of an educational initiative. Use of different conceptual frameworks to address the same topic in medical education may provide distinctive approaches. Exploration of educational issues by employing differing, theory-based approaches advances the field through the identification of the most effective educational methods. Dissemination of sound educational research based on theory is similarly essential to spark future innovation. Ultimately, this rigorous approach to medical education scholarship is necessary to allow us to establish how our educational interventions impact the health and well-being of our patients.

An overarching approach for acute care delivery: extension of the acute care model to the entire inpatient admission

The acute care model has been proposed as a framework for quality improvement in emergency care to improve care delivery and patient flow. There is currently an absence of an overarching model inclusive of other relevant care settings, such as the inpatient ward or the intensive care unit (ICU), involved in the care of an acute illness episode. This gap limits our ability to optimize patient outcomes, improve flow, and reduce waste through all stages of acute illness. We propose that a unified approach to improve quality of care for acute illness may be achieved by extending the acute care model to the inpatient care setting.