National growth in simulation training within emergency medicine residency programs, 2003-2008

SimZones: An Organizational Innovation for Simulation Programs and Centers

The complexity and volume of simulation-based learning programs have increased dramatically over the last decade, presenting several major challenges for those who lead and manage simulation programs and centers. The authors present five major issues affecting the organization of simulation programs: (1) supporting both single- and double-loop learning experiences; (2) managing the training of simulation teaching faculty; (3) optimizing the participant mix, including individuals, professional groups, teams, and other role-players, to ensure learning; (4) balancing in situ, node-based, and center-based simulation delivery; and (5) organizing simulation research and measuring value. They then introduce the SimZones innovation, a system of organization for simulation-based learning, and explain how it can alleviate the problems associated with these five issues.Simulations are divided into four zones (Zones 0-3). Zone 0 simulations include autofeedback exercises typically practiced by solitary learners, often using virtual simulation technology. Zone 1 simulations include hands-on instruction of foundational clinical skills. Zone 2 simulations include acute situational instruction, such as clinical mock codes. Zone 3 simulations involve authentic, native teams of participants and facilitate team and system development.The authors also discuss the translation of debriefing methods from Zone 3 simulations to real patient care settings (Zone 4), and they illustrate how the SimZones approach can enable the development of longitudinal learning systems in both teaching and nonteaching hospitals. The SimZones approach was initially developed in the context of the Boston Children's Hospital Simulator Program, which the authors use to illustrate this innovation in action.

Individualised Expert Feedback is Not Essential for Improving Basic Clinical Skills Performance in Novice Learners: A Randomized Trial

OBJECTIVE

To determine whether unsupervised video feedback (UVF) is as effective as direct expert feedback (DEF) in improving clinical skills performance for medical students learning basic surgical skills-intravenous cannulation, catheterization, and suturing.

BACKGROUND

Feedback is a vital component of the learning process, yet great variation persists in its quality, quantity, and methods of delivery. The use of video technology to assist in the provision of feedback has been adopted increasingly.

METHODS

A prospective, blinded randomized trial comparing DEF, an expert reviewing students' performances with subsequent improvement suggestions, and UVF, students reviewing their own performance with an expert teaching video, was carried out. Medical students received an initial teaching lecture on intravenous cannulation, catheterization, and suturing and were then recorded performing the task. They subsequently received either DEF or UVF before reperforming the task. Students' recordings were additionally scored by 2 blinded experts using a validated proforma.

RESULTS

A total of 71 medical students were recruited. Cannulation scores improved 4.3% with DEF and 9.5% with UVF (p = 0.044), catheterization scores improved 8.7% with DEF and 8.9% with UVF (p = 0.96), and suturing improved 15.6% with DEF and 13.2% with UVF (p = 0.54). Improvement from baseline scores was significant in all cases (p < 0.05).

CONCLUSION

Video-assisted feedback allows a significant improvement in clinical skills for novices. No significant additional benefit was demonstrated from DEF, and a similar improvement can be obtained using a generic expert video and allowing students to review their own performance. This could have significant implications for the design and delivery of such training.

Use of simulation-based medical training in Swiss pediatric hospitals: a national survey

BACKGROUND

Simulation-based medical training (SBMT) is a powerful tool for continuing medical education. In contrast to the Anglo-Saxon medical education community, up until recently, SBMT was scarce in continental Europe's pediatric health care education: In 2009, only 3 Swiss pediatric health care institutions used SBMT. The Swiss catalogue of objectives in Pediatrics does not acknowledge SBMT. The aim of this survey is to describe and analyze the current state of SBMT in Swiss pediatric hospitals and health care departments.

METHODS

A survey was carried out with medical education representatives of every institution. SBMT was defined as any kind of training with a mannequin excluding national and/or international standardized courses. The survey reference day was May 31st 2015.

RESULTS

Thirty Swiss pediatric hospitals and health care departments answered our survey (response rate 96.8%) with 66.6% (20 out of 30) offering SBMT. Four of the 20 hospitals offering SMBT had two independently operating training simulation units, resulting in 24 educational units as the basis for our SBMT analysis. More than 90% of the educational units offering SBMT (22 out of 24 units) were conducting in-situ training and 62.5% (15 out of 24) were using high-technology mannequins. Technical skills, communication and leadership ranked among the top training priorities. All institutions catered to inter-professional participants. The vast majority conducted training that was neither embedded within a larger educational curriculum (19 out of 24: 79.2%) nor evaluated (16 out of 24: 66.6%) by its participants. Only 5 institutions (20.8%) extended their training to at least two thirds of their hospital staff.

CONCLUSIONS

Two thirds of the Swiss pediatric hospitals and health care departments are offering SBMT. Swiss pediatric SBMT is inter-professional, mainly in-situ based, covering technical as well as non-technical skills, and often employing high-technology mannequins. The absence of a systematic approach and reaching only a small number of healthcare employees were identified as shortcomings that need to be addressed.

Simulation in Canadian postgraduate emergency medicine training – a national survey

Objectives

Simulation-based education (SBE) is an important training strategy in emergency medicine (EM) postgraduate programs. This study sought to characterize the use of simulation in FRCPC-EM residency programs across Canada.

Methods

A national survey was administered to residents and knowledgeable program representatives (PRs) at all Canadian FRCPC-EM programs. Survey question themes included simulation program characteristics, the frequency of resident participation, the location and administration of SBE, institutional barriers, interprofessional involvement, content, assessment strategies, and attitudes about SBE.

Results

Resident and PR response rates were 63% (203/321) and 100% (16/16), respectively. Residents reported a median of 20 (range 0–150) hours of annual simulation training, with 52% of residents indicating that the time dedicated to simulation training met their needs. PRs reported the frequency of SBE sessions ranging from weekly to every 6 months, with 15 (94%) programs having an established simulation curriculum. Two (13%) of the programs used simulation for resident assessment, although 15 (94%) of PRs indicated that they would be comfortable with simulation-based assessment. The most common PR-identified barriers to administering simulation were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Interprofessional involvement in simulation was strongly valued by both residents and PRs.

Conclusions

SBE is frequently used by Canadian FRCPC-EM residency programs. However, there exists considerable variability in the structure, frequency, and timing of simulation-based activities. As programs transition to competency-based medical education, national organizations and collaborations should consider the variability in how SBE is administered.

An evaluation of the emergency care training workshops in the province of KwaZulu-Natal, South Africa

BACKGROUND

Emergency care in South Africa is both complex and complicated which is further compromised by inadequately trained healthcare workers. Academic disciplines at the University of KwaZulu-Natal have run emergency care workshops for doctors and nurses providing primary emergency care, in the province for the last 14 years. This delivery of such training has evolved over time.

OBJECTIVES

The aim of this study was to evaluate the feedback and knowledge of participants attending the last nine workshops.

METHODS

An evaluation questionnaire asked participants to assess the workshops held in the province and to rate their perceived improvement in knowledge. A multiple choice questionnaire was conducted in the last few workshops and was administered pre- and postworkshop. The data were extracted onto an Excel spreadsheet and analysed in Stata version 13. Outcome measures were generated using percentages. A paired t-test was used to compare knowledge scores. Open-ended questions were also used to identify areas for future improvement.

RESULTS

The majority (89.4%) of the participants worked in the primary emergency care setting. All participants found the quality of training, the facilitators and the training material good or excellent. Participants' perceived improvement in knowledge and skills and the objective measure of knowledge improved significantly (p &lt; 0.001).

CONCLUSION

Emergency care education using a combination of inter-professional simulation and lecture-based teaching has the potential of contributing towards better educational outputs in both undergraduate and postgraduate curricula.

A competency-based simulation curriculum for surgical resident trauma resuscitation skills

Background:

Evidence-based curricula for nonprocedural simulation training in general surgery are lacking. Residency programs are required to implement simulation training despite this shortcoming. The goal of this project was the development of a simulation curriculum that measurably improves milestone performance and replaces traditional experienced-based training with a competency-based model.

Materials and Methods:

SimMan 3G^® (Laerdal Medical, Wappingers Falls, NY, USA) was utilized for simulation. Needs assessment targeted trauma and shock resuscitation. Scenario design applied deliberate practice methodology. Learner performance data included items such as identification of shock physiology, resuscitation products used, volume delivered, use of resuscitation end-points, and knowledge of massive transfusion. Characteristics essential for a successful program were tabulated.

Results:

Forty-eight residents in postgraduate year (PGY) 2–5 participated representing 100% of the 48 eligible for the training. Senior residents (PGY 4 and 5) demonstrated near universal improvement. Junior residents (PGY 2 and 3) improved in some areas but showed more skill decay between sessions. Overall, milestone performance improved with each training session, and resident feedback was universally positive.

Conclusions:

This prototype curriculum improved surgical resident competency in shock resuscitation in a simulated patient care environment. It can be modified to accommodate centers with fewer resources and can be implemented by clinical faculty. The essential characteristics of a successful program are identified.

A Novel Approach to Simulation-Based Education for Veterinary Medical Communication Training Over Eight Consecutive Pre-Clinical Quarters

Experiential learning through the use of standardized patients (SPs) is the primary way by which human medical schools teach clinical communication. The profession of veterinary medicine has followed suit in response to new graduates' and their employers' concerns that veterinary interpersonal skills are weak and unsatisfactory. As a result, standardized clients (SCs) are increasingly relied upon as invaluable teaching tools within veterinary curricula to advance relationship-centered care in the context of a clinical scenario. However, there is little to no uniformity in the approach that various colleges of veterinary medicine take when designing simulation-based education (SBE). A further complication is that programs with pre-conceived curricula must now make room for training in clinical communication. Curricular time constraints challenge veterinary colleges to individually decide how best to utilize SCs in what time is available. Because it is a new program, Midwestern University College of Veterinary Medicine (MWU CVM) has had the flexibility and the freedom to prioritize an innovative approach to SBE. The author discusses the SBE that is currently underway at MWU CVM, which incorporates 27 standardized client encounters over eight consecutive pre-clinical quarters. Prior to entering clinical rotations, MWU CVM students are exposed to a variety of simulation formats, species, clients, settings, presenting complaints, and communication tasks. These represent key learning opportunities for students to practice clinical communication, develop self-awareness, and strategize their approach to future clinical experiences.

Efficient and Effective Use of Peer Teaching for Medical Student Simulation

INTRODUCTION

Simulation is increasingly used in medical education, promoting active learning and retention; however, increasing use also requires considerable instructor resources. Simulation may provide a safe environment for students to teach each other, which many will need to do when they enter residency. Along with reinforcing learning and increasing retention, peer teaching could decrease instructor demands. Our objective was to determine the effectiveness of peer-taught simulation compared to physician-led simulation. We hypothesized that peer-taught simulation would lead to equivalent knowledge acquisition when compared to physician-taught sessions and would be viewed positively by participants.

METHOD

This was a quasi-experimental study in an emergency medicine clerkship. The control group was faculty taught. In the peer-taught intervention group, students were assigned to teach one of the three simulation-based medical emergency cases. Each student was instructed to master their topic and teach it to their peers using the provided objectives and resource materials. The students were assigned to groups of three, with all three cases represented; students took turns leading their case. Three groups ran simultaneously. During the intervention sessions, one physician was present to monitor the accuracy of learning and to answer questions, while three physicians were required for the control groups. Outcomes compared pre-test and post-test knowledge and student reaction between control and intervention groups.

RESULTS

Both methods led to equally improved knowledge; mean score for the post-test was 75% for both groups (p=0.6) and were viewed positively. Students in the intervention group agreed that peer-directed learning was an effective way to learn. However, students in the control group scored their simulation experience more favorably.

CONCLUSION

In general, students' response to peer teaching was positive, students learned equally well, and found peer-taught sessions to be interactive and beneficial.

A simulation-based curriculum to introduce key teamwork principles to entering medical students

BACKGROUND

Failures of teamwork and interpersonal communication have been cited as a major patient safety issue. Although healthcare is increasingly being provided in interdisciplinary teams, medical school curricula have traditionally not explicitly included the specific knowledge, skills, attitudes, and behaviors required to function effectively as part of such teams.

METHODS

As part of a new "Foundations" core course for beginning medical students that provided a two-week introduction to the most important themes in modern healthcare, a multidisciplinary team, in collaboration with the Center for Experiential Learning and Assessment, was asked to create an experiential introduction to teamwork and interpersonal communication. We designed and implemented a novel, all-day course to teach second-week medical students basic teamwork and interpersonal principles and skills using immersive simulation methods. Students' anonymous comprehensive course evaluations were collected at the end of the day. Through four years of iterative refinement based on students' course evaluations, faculty reflection, and debriefing, the course changed and matured.

RESULTS

Four hundred twenty evaluations were collected. Course evaluations were positive with almost all questions having means and medians greater than 5 out of 7 across all 4 years. Sequential year comparisons were of greatest interest for examining the effects of year-to-year curricular improvements. Differences were not detected among any of the course evaluation questions between 2007 and 2008 except that more students in 2008 felt that the course further developed their "Decision Making Abilities" (OR 1.69, 95% CI 1.07-2.67). With extensive changes to the syllabus and debriefer selection/assignment, concomitant improvements were observed in these aspects between 2008 and 2009 (OR = 2.11, 95% CI: 1.28-3.50). Substantive improvements in specific exercises also yielded significant improvements in the evaluations of those exercises.

CONCLUSIONS

This curriculum could be valuable to other medical schools seeking to inculcate teamwork foundations in their medical school's preclinical curricula. Moreover, this curriculum can be used to facilitate teamwork principles important to inter-disciplinary, as well as uni-disciplinary, collaboration.

Development of an Emergency Medicine Simulation Fellowship Consensus Curriculum: Initiative of the Society for Academic Emergency Medicine Simulation Academy

OBJECTIVES

There is currently no consolidated list of existing simulation fellowship programs in emergency medicine (EM). In addition, there are no universally accepted or expected standards for core curricular content. The objective of this project is to develop consensus-based core content for EM simulation fellowships to help frame the critical components of such training programs.

METHODS

This paper delineates the process used to develop consensus curriculum content for EM simulation fellowships. EM simulation fellowship curricula were collected. Curricular content was reviewed and compiled by simulation experts and validated utilizing survey methodology, and consensus was obtained using a modified Delphi methodology.

RESULTS

Fifteen EM simulation fellowship curricula were obtained and analyzed. Two rounds of a modified Delphi survey were conducted. The final proposed core curriculum content contains 47 elements in nine domains with 14 optional elements.

CONCLUSION

The proposed consensus content will provide current and future fellowships a foundation on which to build their own specific and detailed fellowship curricula. Such standardization will ultimately increase the transparency of training programs for future trainees and potential employers.

Why Isn't There More High-fidelity Simulation Training in Diagnostic Radiology? Results of a Survey of Academic Radiologists

RATIONALE AND OBJECTIVES

Despite its increasing use in training other medical specialties, high-fidelity simulation to prepare diagnostic radiology residents for call remains an underused educational resource. To attempt to characterize the barriers toward adoption of this technology, we conducted a survey of academic radiologists and radiology trainees.

MATERIALS AND METHODS

An Institutional Review Board-approved survey was distributed to the Association of University Radiologists members via e-mail. Survey results were collected electronically, tabulated, and analyzed.

RESULTS

A total of 68 survey responses representing 51 programs were received from program directors, department chairs, chief residents, and program administrators. The most common form of educational activity for resident call preparation was lectures. Faculty supervised "baby call" was also widely reported. Actual simulated call environments were quite rare with only three programs reporting this type of educational activity. Barriers to the use of simulation include lack of faculty time, lack of faculty expertise, and lack of perceived need.

CONCLUSIONS

High-fidelity simulation can be used to mimic the high-stress, high-stakes independent call environment that the typical radiology resident encounters during the second year of training, and can provide objective data for program directors to assess the Accreditation Council of Graduate Medical Education milestones. We predict that this technology will begin to supplement traditional diagnostic radiology teaching methods and to improve patient care and safety in the next decade.

An Equivalence Trial Comparing Instructor-Regulated With Directed Self-Regulated Mastery Learning of Advanced Cardiac Life Support Skills

INTRODUCTION

Instructor-led simulation-based mastery learning of advanced cardiac life support (ACLS) skills is an effective and focused approach to competency-based education. Directed self-regulated learning (DSRL) may be an effective and less resource-intensive way to teach ACLS skills.

METHODS

Forty first-year internal medicine residents were randomized to either simulation-based DSRL or simulation-based instructor-regulated learning (IRL) of ACLS skills using a mastery learning model. Residents in each intervention completed pretest, posttest, and retention test of their performance in leading an ACLS response to a simulated scenario. Performance tests were assessed using a standardized checklist. Residents in the DSRL intervention were provided assessment instruments, a debriefing guide, and scenario-specific teaching points, and they were permitted to access relevant online resources. Residents in the IRL intervention had access to the same materials; however, the teaching and debriefing were instructor led.

RESULTS

Skills of both the IRL and DSRL interventions showed significant improvement after the intervention, with an average improvement on the posttest of 21.7%. After controlling for pretest score, there was no difference between intervention arms on the posttest [F(1,37) = 0.02, P = 0.94] and retention tests [F(1,17) = 1.43, P = 0.25]. Cost savings were realized in the DSRL intervention after the fourth group (16 residents) had completed each intervention, with an ongoing savings of $80 per resident.

CONCLUSIONS

Using a simulation-based mastery learning model, we observed equivalence in learning of ACLS skills for the DSRL and IRL conditions, whereas DSRL was more cost effective.

Characteristics and Core Curricular Elements of Medical Simulation Fellowships in North America

Background In the past few years, there has been rapid growth in the number of simulation fellowships for physicians in the United States and Canada, with the objective of producing faculty with expertise and leadership training in medical simulation. Relatively little is known about the collective content and structure of these new fellowship opportunities. Objective We sought to identify a common set of core curricular elements among existing simulation fellowships and to obtain demographic background information on participants and leadership. Methods We designed a web-based survey and circulated it to simulation fellowship directors in the United States and Canada. The questions explored aspects of the fellowship curriculum. A grounded theory approach was used to qualitatively analyze fellowship goals and objectives. Results Of the 29 program directors surveyed, 23 responded (79%). The most commonly listed goals and objectives were to increase skills in simulation curriculum development, simulation operations and training environment setup, research, educational theory, administration, and debriefing. The majority of the responding fellowship directors (17 of 22, 77%) indicated that a set of consensus national guidelines would benefit their fellowship program. Conclusions Simulation fellowships are experiencing a period of rapid growth. Development of a common set of program guidelines is a widely shared objective among fellowship directors.

Stress levels during emergency care: A comparison between reality and simulated scenarios

PURPOSE

Medical simulation is fast becoming a standard of health care training throughout undergraduate, postgraduate and continuing medical education. Our aim was to evaluate if simulated scenarios have a high psychological fidelity and induce stress levels similarly to real emergency medical situations.

MATERIALS AND METHODS

Medical residents had their stress levels measured during emergency care (real-life and simulation) in baseline (T1) and immediately post-emergencies (T2). Parameters measuring acute stress were: heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary interleukin-1β, and State-Trait Anxiety Inventory score.

RESULTS

Twenty-eight internal medicine residents participated in 32 emergency situations (16 real-life and 16 simulated emergencies). In the real-life group, all parameters increased significantly (P < .05) between T1 and T2. In the simulation group, only heart rate and interleukin-1β increased significantly after emergencies. The comparison between groups demonstrates that acute stress response (T2 - T1) and State-Trait Anxiety Inventory score (in T2) did not differ between groups.

CONCLUSIONS

Acute stress response did not differ between both groups. Our results indicate that emergency medicine simulation may create a high psychological fidelity environment similarly to what is observed in a real emergency room.

Training clinicians to care for children in emergency departments

Children account for 22% of presentations to Emergency Departments in Australia, the majority presenting to mixed departments. A diverse group of clinicians looks after these children. In this review, we examine the different techniques and approaches to implementing education curricula and professional development within these emergency departments with a particular focus on bedside teaching, professional coaching, skills maintenance, e-learning and simulation.

A simulation-based resident-as-teacher program: The impact on teachers and learners

BACKGROUND

Residency training is charged with improving resident teaching skills. Utilizing simulation in teacher training has unique advantages such as providing a controlled learning environment and opportunities for deliberate practice.

OBJECTIVE

We assessed the impact of a simulation-based resident-as-teacher (RaT) program.

DESIGN

A RaT program was embedded in an existing 8-case simulation curriculum for 52 internal medicine (IM) interns. Residents participated in a workshop, then served as facilitators in the curriculum and received feedback from faculty.

METHODS

Residents' teaching and feed back skills were measured using a pre- and post-program self-assessment and post-session and post-curriculum evaluations by intern learners.

SETTING/PARTICIPANTS

Forty-one second- and third-year residents participated in the study August 2013 to October 2013 at a single center.

RESULTS

Pre- and post-program teaching skills were assessed for 34 of 41 resident facilitators (83%) participating in 3.9 sessions on average. Partaking in the program led to improvements in resident facilitators' self-reported teaching and feedback skills across all domains. The most significant improvement was in teaching in a simulated environment (2.81 to 4.16, P < 0.001). Interns rated the curriculum highly (81% "excellent," 19% "good") and reported that resident facilitators frequently utilized debriefing techniques covered in the RaT program.

CONCLUSIONS

Our simulation-based RaT program offered a unique opportunity for deliberate practice of teaching skills in a controlled environment and led to improvements in resident facilitators' teaching and feed back skills. The simulation curriculum, facilitated by residents, was well received by the intern learners. Our program design may serve as a model for the development of simulation curricula and RaT programs within IM residencies.

Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country

Introduction

Increasingly, pediatric and emergency medicine (EM) residents are pursuing clinical rotations in low-income countries. Optimal pre-departure preparation for such rotations has not yet been established. High-fidelity simulation represents a potentially effective modality for such preparation. This study was designed to assess whether a pre-departure high-fidelity medical simulation curriculum is effective in helping to prepare residents for clinical rotations in a low-income country.

Methods

43 pediatric and EM residents planning clinical rotations in Liberia, West Africa, participated in a simulation-based curriculum focused on severe pediatric malaria and malnutrition and were then assessed by survey at three time points: pre-simulation, post-simulation, and after returning from work abroad.

Results

Prior to simulation, 1/43 (2%) participants reported they were comfortable with the diagnosis and management of severe malnutrition; this increased to 30/42 (71%) after simulation and 24/31 (77%) after working abroad. Prior to simulation, 1/43 (2%) of residents reported comfort with the diagnosis and management of severe malaria; this increased to 26/42 (62%) after simulation and 28/31 (90%) after working abroad; 36/42 (86%) of residents agreed that a simulation-based global health curriculum is more useful than a didactic curriculum alone, and 41/42 (98%) felt a simulator-based curriculum should be offered to all residents planning a clinical trip to a low-income country.

Conclusion

High-fidelity simulation is effective in increasing residents’ self-rated comfort in management of pediatric malaria and malnutrition and a majority of participating residents feel it should be included as a component of pre-departure training for all residents rotating clinically to low-income countries.

The Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim): a tool for systematic simulation scenario design

Simulation-based training (SBT) affords practice opportunities for improving the quality of clinicians' technical and nontechnical skills. However, the development of practice scenarios is a process plagued by a set of challenges that must be addressed for the full learning potential of SBT to be realized. Scenario templates are useful tools for assisting with SBT and navigating its inherent challenges. This article describes existing SBT templates, explores considerations in choosing an appropriate template, and introduces the Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim) as a tool for facilitating the formation of practice scenarios in accordance with an established evidence-based simulation design methodology. TEACH Sim's unique contributions are situated within the landscape of previously existing templates, and each of its component sections is explained in detail.

"A short trauma course for physicians in a resource-limited setting: Is low-cost simulation effective?"

INTRODUCTION

Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios.

MATERIALS AND METHODS

A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics.

RESULTS

A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively.

CONCLUSIONS

A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries.

Simulation in Pediatric Emergency Medicine Fellowships

BACKGROUND AND OBJECTIVES

Graduate medical education faces challenges as programs transition to the next accreditation system. Evidence supports the effectiveness of simulation for training and assessment. This study aims to describe the current use of simulation and barriers to its implementation in pediatric emergency medicine (PEM) fellowship programs.

METHODS

A survey was developed by consensus methods and distributed to PEM program directors via an anonymous online survey.

RESULTS

Sixty-nine (95%) fellowship programs responded. Simulation-based training is provided by 97% of PEM fellowship programs; the remainder plan to within 2 years. Thirty-seven percent incorporate >20 simulation hours per year. Barriers include the following: lack of faculty time (49%) and faculty simulation experience (39%); limited support for learner attendance (35%); and lack of established curricula (32%). Of those with written simulation curricula, most focus on resuscitation (71%), procedures (63%), and teamwork/communication (38%). Thirty-seven percent use simulation to evaluate procedural competency and resuscitation management. PEM fellows use simulation to teach (77%) and have conducted simulation-based research (33%). Thirty percent participate in a fellows' "boot camp"; however, finances (27%) and availability (15%) limit attendance. Programs receive simulation funding from hospitals (47%), academic institutions (22%), and PEM revenue (17%), with 22% reporting no direct simulation funding.

CONCLUSIONS

PEM fellowships have rapidly integrated simulation into their curricula over the past 5 years. Current limitations primarily involve faculty and funding, with equipment and dedicated space less significant than previously reported. Shared curricula and assessment tools, increased faculty and financial support, and regionalization could ameliorate barriers to incorporating simulation into PEM fellowships.

Development and evaluation of a simulation-based resuscitation scenario assessment tool for emergency medicine residents

Objective:

We sought to develop and validate a three-station simulation-based Objective Structured Clinical Examination (OSCE) tool to assess emergency medicine resident competency in resuscitation scenarios.

Methods:

An expert panel of emergency physicians developed three scenarios for use with high-fidelity mannequins. For each scenario, a corresponding assessment tool was developed with an essential actions (EA) checklist and a global assessment score (GAS). The scenarios were (1) unstable ventricular tachycardia, (2) respiratory failure, and (3) ST elevation myocardial infarction. Emergency medicine residents were videotaped completing the OSCE, and three clinician experts independently evaluated the videotapes using the assessment tool.

Results:

Twenty-one residents completed the OSCE (nine residents in the College of Family Physicians of Canada– Emergency Medicine [CCFP-EM] program, six junior residents in the Fellow of the Royal College of Physicians of Canada–Emergency Medicine [FRCP-EM] program, six senior residents in the FRCP-EM). Interrater reliability for the EA scores was good but varied between scenarios (Spearman rho 5 [1] 0.68, [2] 0.81, [3] 0.41). Interrater reliability for the GAS was also good, with less variability (rho 5 [1] 0.64, [2] 0.56, [3] 0.62). When comparing GAS scores, senior FRCP residents outperformed CCFP-EM residents in all scenarios and junior residents in two of three scenarios (p , 0.001 to 0.01). Based on EA scores, senior FRCP residents outperformed CCFP-EM residents, but junior residents outperformed senior FRCP residents in scenario 1 and CCFPEM residents in all scenarios (p 5 0.006 to 0.04).

Conclusions:

This study outlines the creation of a high-fidelity simulation assessment tool for trainees in emergency medicine. A single-point GAS demonstrated stronger relational validity and more consistent reliability in comparison with an EA checklist. This preliminary work will provide a foundation for ongoing future development of simulationbased assessment tools.

Heart rate, anxiety and performance of residents during a simulated critical clinical encounter: a pilot study

BACKGROUND

High-fidelity patient simulation has been praised for its ability to recreate lifelike training conditions. The degree to which high fidelity simulation elicits acute emotional and physiologic stress among participants - and the influence of acute stress on clinical performance in the simulation setting - remain areas of active exploration. We examined the relationship between residents' self-reported anxiety and a proxy of physiologic stress (heart rate) as well as their clinical performance in a simulation exam using a validated assessment of non-technical skills, the Ottawa Crisis Resource Management Global Rating Scale (Ottawa GRS).

METHODS

This was a prospective observational cohort study of emergency medicine residents at a single academic center. Participants managed a simulated clinical encounter. Anxiety was assessed using a pre- and post-simulation survey, and continuous cardiac monitoring was performed on each participant during the scenario. Performance in the simulation scenario was graded by faculty raters using a critical actions checklist and the Ottawa GRS instrument.

RESULTS

Data collection occurred during the 2011 academic year. Of 40 eligible residents, 34 were included in the analysis. The median baseline heart rate for participants was 70 beats per minute (IQR: 62 - 78). During the simulation, the median maximum heart rate was 140 beats per minute (IQR: 137 - 151). The median minimum heart rate during simulation was 81 beats per minute (IQR: 72 - 92), and mean heart rate was 117 beats per minute (95% CI: 111 - 123). Pre- and post-simulation anxiety scores were equal (mean 3.3, IQR: 3 to 4). The minimum and maximum Overall Ottawa GRS scores were 2.33 and 6.67, respectively. The median Overall score was 5.63 (IQR: 5.0 to 6.0). Of the candidate predictors of Overall performance in a multivariate logistic regression model, only PGY status showed statistical significance (P = 0.02).

CONCLUSIONS

Simulation is associated with physiologic stress, and heart rate elevation alone correlates poorly with both perceived stress and performance. Non-technical performance in the simulation setting may be more closely tied to one's level of clinical experience than to perceived or actual stress.

How we implemented a resident-led medical simulation curriculum in a large internal medicine residency program

Mannequin-based simulation in graduate medical education has gained widespread acceptance. Its use in non-procedural training within internal medicine (IM) remains scant, possibly due to the logistical barriers to implementation of simulation curricula in large residency programs. We report the Massachusetts General Hospital Department of Medicine's scale-up of a voluntary pilot program to a mandatory longitudinal simulation curriculum in a large IM residency program (n = 54). We utilized an eight-case curriculum implemented over the first four months of the academic year. An intensive care unit curriculum was piloted in the spring. In order to administer a comprehensive curriculum in a large residency program where faculty resources are limited, thirty second-year and third-year residents served as session facilitators and two senior residents served as chairpersons of the program. Post-session anonymous survey revealed high learner satisfaction scores for the mandatory program, similar to those of the voluntary pilot program. Most interns believed the sessions should continue to be mandatory. Utilizing residents as volunteer facilitators and program leaders allowed the implementation of a well-received mandatory simulation program in a large IM residency program and facilitated program sustainability.

High-fidelity simulation enhances pediatric residents' retention, knowledge, procedural proficiency, group resuscitation performance, and experience in pediatric resuscitation

OBJECTIVE

The goal of this study was to assess the effect of high-fidelity simulation (HFS) pediatric resuscitation training on resident performance and self-reported experience compared with historical controls.

METHODS

In this case-control study, pediatric residents at a tertiary academic children's hospital participated in a 16-hour HFS resuscitation curriculum. Primary outcome measures included cognitive knowledge, procedural proficiency, retention, and self-reported comfort and procedural experience. The intervention group was compared with matched-pair historical controls.

RESULTS

Forty-one residents participated in HFS training with 32 matched controls. The HFS group displayed significant initial and overall improvement in knowledge (P < .01), procedural proficiency (P < .05), and group resuscitation performance (P < .01). Significant skill decay occurred in all performance measures (P < .01) with the exception of endotracheal intubation. Compared with controls, the HFS group reported not only greater comfort with most procedures but also performed more than twice the number of successful real-life pediatric intubations (median: 6 vs 3; P = .03).

CONCLUSIONS

Despite significant skill decay, HFS pediatric resuscitation training improved pediatric resident cognitive knowledge, procedural proficiency, and comfort. Residents who completed the course were not only more proficient than historical controls but also reported increased real-life resuscitation experiences and related procedures.

Point-of-care ultrasound education: the increasing role of simulation and multimedia resources

This article reviews the current technology, literature, teaching models, and methods associated with simulation-based point-of-care ultrasound training. Patient simulation appears particularly well suited for learning point-of-care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low-fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High-fidelity simulators are usually high-tech and frequently consist of many computer-generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High-fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low- versus high-fidelity simulators are reviewed. An additional concept used in simulation-based ultrasound training is blended learning. Blended learning may include face-to-face or online learning often in combination with a learning management system. Increasingly, with simulation and Web-based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.

Instructional design affects the efficacy of simulation-based training in central venous catheterization

BACKGROUND

Simulation-based learning is a common educational tool in health care training and frequently involves instructional designs based on Experiential Learning Theory (ELT). However, little research explores the effectiveness and efficiency of different instructional design methodologies appropriate for simulations. The aim of this study was to compare 2 instructional design models, ELT and Guided Experiential Learning (GEL), to determine which is more effective for training the central venous catheterization procedure.

METHODS

Using a quasi-experimental randomized block design, nurse anesthetists completed training under 1 of the 2 instructional design models. Performance was assessed using a checklist of central venous catheterization performance, pass rates, and critical action errors.

RESULTS

Participants in the GEL condition performed significantly better than those in the ELT condition on the overall checklist score after controlling for individual practice time (F[1, 29] = 4.021, P = .027, Cohen's d = .71), had higher pass rates (P = .006, Cohen's d = 1.15), and had lower rates of failure due to critical action errors (P = .038, Cohen's d = .81).

CONCLUSIONS

The GEL model of instructional design is significantly more effective than ELT for simulation-based learning of the central venous catheterization procedure, yielding large differences in effect size.

An integrative OSCE methodology for enhancing the traditional OSCE program at Taipei Medical University Hospital--a feasibility study

BACKGROUND

Continuous development and use of new technologies and methodologies are key features in improving the learning, performance, and skills of medical students and students of all health care professions. Although significant improvements in teaching methodologies have been made in all areas of medicine and health care, studies reveal that students in many areas of health care taking an objective structured clinical examination (OSCE) express difficulties. Thus, this study was planned as a feasibility study to assess the educational effectiveness of an integrated objective structured clinical examination (iOSCE) using both standardized patients and virtual patients.

METHODS

Thirty (30) medical students in their first year of internship at Taipei Medical University volunteered to be part of a feasibility study for demonstrating the concept of iOSCE. They divided themselves into five groups of six students each and were requested to evaluate two cases: 1) a patient with abdominal pain and 2) a patient with headache using a combination of a standardized patient and a virtual patient. For each of the two cases, five stations were designed in which students were given ten minutes per station leading to a final diagnosis and concluded with a debriefing. The five stations were: Station 1) Interacting with the standardized patient. Station 2) Writing the patient note and developing a differential diagnosis. Station 3) Selecting appropriate laboratory and imaging studies. Station 4) Making a final diagnosis and stating the evidence for it. Station 5) Having the debriefing. Each group of 6 students was assigned 2 hours per day for each case. All participants completed a survey regarding the usefulness and efficiency of the iOSCE.

RESULTS

All medical students (30/30; 100%) found the iOSCE program to be very satisfactory, and all expressed that they would like to have further iOSCE experiences if given the opportunity. In terms of ease and helpfulness, the students rated the program an average of 4.4 for the 1st case (abdominal pain) and 4.5 for the 2nd case (headache) on a scale of 1-5, with 5 being the highest and 1 being the lowest score.

CONCLUSIONS

The participants felt that the iOSCE program can offer certain advantages over the traditional OSCE with the SP alone. They cited that the iOSCE provided improved clarity of what was being assessed as well as providing an opportunity to improve their diagnostic reasoning.

Simulation to develop tomorrow's medical registrar

BACKGROUND

 Critical incident analysis reveals that poor performance in 'human-factor' or non-technical skills, such as decision making, leadership, teamwork and situational awareness, are frequently identified as key underlying features leading to adverse events. Simulation technology is a rapidly emerging modality used to develop technical and non-technical skills within specialist training as increasing shift-pattern work reduces work-based exposure and learning opportunities. To date, however, there is little literature regarding its use within core medical training to develop crisis resource management skills and medical registrar competency.

STUDY DESIGN

We present results from a pilot in situ high-fidelity, multidisciplinary, simulation training course in which core medical trainees practised the role of a medical registrar within challenging crisis scenarios.

RESULTS

Twenty-one trainees completed the simulation course. All trainees agreed that the course improved their clinical skills and knowledge, concentrated on key non-technical skills that are important in crisis management and, importantly, would change their clinical practice and improve patient safety. Trainee overall performance strongly correlated with assessment of non-technical skills during the simulation scenario. Trainees invited to return for a repeat session after previous concerns and specific feedback showed a visible improvement in performance, with an objective improvement in self-assessed performance.

CONCLUSION

This pilot programme shows the benefits of a high-fidelity, in situ, multidisciplinary simulation training course for core medical trainees in developing the key crisis resource management skills necessary at medical registrar level. As a historical apprenticeship model of training becomes increasingly variable and absent, we present a novel complimentary training strategy for tomorrow's medical registrars.

Teaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculum

INTRODUCTION

Simulation-based medical education (SBME) is increasingly being utilized for teaching clinical skills in undergraduate medical education. Studies have evaluated the impact of adding SBME to third- and fourth-year curriculum; however, very little research has assessed its efficacy for teaching clinical skills in pre-clerkship coursework. To measure the impact of a simulation exercise during a pre-clinical curriculum, a simulation session was added to a pre-clerkship course at our medical school where the clinical approach to altered mental status (AMS) is traditionally taught using a lecture and an interactive case-based session in a small group format. The objective was to measure simulation's impact on students' knowledge acquisition, comfort, and perceived competence with regards to the AMS patient.

METHODS

AMS simulation exercises were added to the lecture and small group case sessions in June 2010 and 2011. Simulation sessions consisted of two clinical cases using a high-fidelity full-body simulator followed by a faculty debriefing after each case. Student participation in a simulation session was voluntary. Students who did and did not participate in a simulation session completed a post-test to assess knowledge and a survey to understand comfort and perceived competence in their approach to AMS.

RESULTS

A total of 154 students completed the post-test and survey and 65 (42%) attended a simulation session. Post-test scores were higher in students who attended a simulation session compared to those who did not (p<0.001). Students who participated in a simulation session were more comfortable in their overall approach to treating AMS patients (p=0.05). They were also more likely to state that they could articulate a differential diagnosis (p=0.03), know what initial diagnostic tests are needed (p=0.01), and understand what interventions are useful in the first few minutes (p=0.003). Students who participated in a simulation session were more likely to find the overall AMS curriculum useful (p<0.001).

CONCLUSION

Students who participated in a simulation exercise performed better on a knowledge-based test and reported increased comfort and perceived competence in their clinical approach to AMS. SBME shows significant promise for teaching clinical skills to medical students during pre-clinical curriculum.

Simulation training as a mechanism for procedural and resuscitation education for pediatric residents: a systematic review

BACKGROUND

Pediatric residents often finish their training lacking sufficient procedural proficiency and resuscitation experience in the care of critically ill children. Simulation is gaining favor in pediatric residency programs as a modality for procedural and resuscitation education. We reviewed the literature assessing simulation and its role in pediatric resident training.

METHODS

We conducted a Medline and PubMed search of simulation training in pediatric resident education from January 2007 to July 2012.

RESULTS

Eight studies were included and divided into simulated procedural assessments and simulated resuscitation scenario assessments. The studies varied widely in their approach and analysis, and they yielded mixed results.

CONCLUSIONS

Although some studies show the merits of simulation in the procedural and resuscitation training of pediatric residents, more research is needed to assess the effectiveness of simulation as an educational tool. Goals of future simulation research should include creation of validated assessment tools and applying skills learned to patient care outcomes.

Medical simulation is needed in anesthesia training to achieve patient's safety

Many medical schools and hospitals throughout the world are equipped with a simulation center for the purpose of training anesthesiologists to perform both technical and non-technical skills. Because induction, maintenance, and emergence of general anesthesia are critical to patient welfare, various simulation mannequins and tools are utilized for the purpose of training anesthesiologists for safer patient care. Traditionally, anesthesia residency training mostly consisted of didactic lectures and observations. After completion of "traditional" training, anesthesia residents were allowed to perform procedures on patients under supervision. However, simulation would be a more effective training tool for which to teach anesthesiologists the skills necessary to perform invasive procedures, such as endotracheal intubation, central venous catheter insertion, and epidural catheter insertion. Recently, non-technical skills, such as the Anesthesia Non-Technical Skills developed by anesthesiologists from Aberdeen University, have been emphasized as an important training resource. Technical skills and non-technical skills can be learned by anesthesiology residents through a standardized and organized simulation program. Such programs would be beneficial in training anesthesia residents to work efficiently as a team in the operation room.

Technology-enhanced simulation in emergency medicine: a systematic review and meta-analysis

OBJECTIVES

Technology-enhanced simulation is used frequently in emergency medicine (EM) training programs. Evidence for its effectiveness, however, remains unclear. The objective of this study was to evaluate the effectiveness of technology-enhanced simulation for training in EM and identify instructional design features associated with improved outcomes by conducting a systematic review.

METHODS

The authors systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Original research articles in any language were selected if they compared simulation to no intervention or another educational activity for the purposes of training EM health professionals (including student and practicing physicians, midlevel providers, nurses, and prehospital providers). Reviewers evaluated study quality and abstracted information on learners, instructional design (curricular integration, feedback, repetitive practice, mastery learning), and outcomes.

RESULTS

From a collection of 10,903 articles, 85 eligible studies enrolling 6,099 EM learners were identified. Of these, 56 studies compared simulation to no intervention, 12 compared simulation with another form of instruction, and 19 compared two forms of simulation. Effect sizes were pooled using a random-effects model. Heterogeneity among these studies was large (I(2) ≥ 50%). Among studies comparing simulation to no intervention, pooled effect sizes were large (range = 1.13 to 1.48) for knowledge, time, and skills and small to moderate for behaviors with patients (0.62) and patient effects (0.43; all p < 0.02 except patient effects p = 0.12). Among comparisons between simulation and other forms of instruction, the pooled effect sizes were small (≤ 0.33) for knowledge, time, and process skills (all p > 0.1). Qualitative comparisons of different simulation curricula are limited, although feedback, mastery learning, and higher fidelity were associated with improved learning outcomes.

CONCLUSIONS

Technology-enhanced simulation for EM learners is associated with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction. Future research should investigate the features that lead to effective simulation-based instructional design.

Pilot program using medical simulation in clinical decision-making training for internal medicine interns

BACKGROUND

The use of high-fidelity medical simulation in cognitive skills training within internal medicine residency programs remains largely unexplored.

OBJECTIVE

To design a pilot study to introduce clinical decision-making training using simulation into a large internal medicine residency program, explore the practicability of using junior and senior residents as facilitators, and examine the feasibility of using the program to improve interns' clinical skills.

METHODS

Interns on outpatient rotations participated in a simulation curriculum on a voluntary basis. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the wards. One-hour sessions were offered twice monthly from August 2010 to February 2011. Internal medicine residents and simulation faculty served as facilitators.

RESULTS

A total of 36 of 75 total interns volunteered to participate in the program, with 42% attending multiple sessions. Of all participants, 88% rated the sessions as "excellent," 97% felt that the program improved their ability to function as an intern and generate a plan, and 81% reported improvement in differential diagnosis skills.

CONCLUSIONS

Simulation training was well received by the learners and improved self-reported clinical skills. Using residents as facilitators, supervised by faculty, was well received by the learners and enabled the implementation of the curriculum in a large training program. Simulation can provide opportunities for deliberate practice, and learners perceive this modality to be effective.

Reflections on the consensus process: a leadership role for emergency medicine in educational scholarship and practice across health care

In just a few decades, emergency medicine (EM) has assumed a leadership role in medical education across many academic medical centers. This rapid evolution suggests medical education as a natural priority area for EM scholarship. This year's Academic Emergency Medicine consensus conference provides an ideal forum to focus on educational research as a core element of the specialty's academic portfolio.

Emergency Medicine resident anesthesia training in a private vs. academic setting

BACKGROUND

Airway management is an essential part of any Emergency Medicine (EM) training program. Academic centers typically provide training to many learners at various training levels in a number of medical specialties during anesthesiology rotations. This potentially creates competition for intubation procedures that may negatively impact individual experiences.

OBJECTIVES

We hypothesized that residents would report higher numbers of intubations and improved educational value in a private practice, rather than an academic, anesthesiology rotation.

METHODS

EM residents' anesthesiology training was evaluated pre and post a change in training setting from an academic institution to a private practice institution. Outcome measures included the number of self-reported intubations, resident ratings of the rotation, and the number of positive comments. Residents' evaluation was measured with: a 14-item evaluation; subjective comments, which two blinded reviewers rated as positive, negative, or neutral; and transcripts from structured interviews to identify themes related to training settings.

RESULTS

The number of intubations increased significantly in the private practice setting (4.6 intubations/day vs. 1.5 intubations/day, p < 0.001). Resident evaluations improved significantly with the private practice experience (mean scores of 3.83 vs. 2.23, p-values <0.05). Residents' impressions were also significantly higher for the private practice setting with respect to increased educational value, greater use of adjunct airway devices, and directed teaching.

CONCLUSIONS

Number of intubations performed and residents' rating of the educational value were more favorable for a private practice anesthesiology rotation. Alternative settings may provide benefit for training in areas that have competition among trainees.

Medical simulation technology: educational overview, industry leaders, and what's missing

Modern medical simulation technology (MST) debuted in 1960 with the development of Resusci Annie (Laerdal 2007), which assisted students in the acquisition of proper ventilation and compression techniques used during basic life support. Following a steady stream of subsequent technological advances and innovations, MST manufacturers are now able to offer training aids capable of facilitating innovative learning in such diverse areas as human patient simulators, simulated clinical environments, virtual procedure stations, virtual medical environments, electronic tutors, and performance recording. The authors list a number of the most popular MSTs presently available while citing evaluative efforts undertaken to date regarding the efficacy of MST to the medical profession. They conclude by proposing a variety of simulation innovations of prospective interest to both medical and technology personnel while offering healthcare administrators a series of recommended considerations when planning to integrate MST into existing medical systems.