Training on a vascular interventional simulator: an observational study

The role of high-fidelity simulation in the acquisition of endovascular surgical skills: a systematic review

INTRODUCTION

The widespread introduction of minimally invasive endovascular techniques in cardiovascular surgery has necessitated a transition in the psychomotor skillset of trainees and surgeons. Simulation has previously been used in surgical training; however, there is limited high quality evidence regarding the role of simulation-based training on the acquisition of endovascular skills. This systematic review aimed to systematically appraise the currently available evidence regarding endovascular high-fidelity simulation interventions, to describe the overarching strategies used, the learning outcomes addressed, the choice of assessment methodology, and the impact of education on learner performance.

METHODS

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using relevant keywords to identify studies evaluating simulation in the acquisition of endovascular surgical skills. References of review articles were screened for additional studies.

RESULTS

A total of 1081 studies were identified (474 after removal of duplicates). There was marked heterogeneity in methodologies and reporting of outcomes. Quantitative analysis was deemed inappropriate due to the risk of serious confounding and bias. Instead, a descriptive synthesis was performed, summarising key findings and quality components. Eighteen studies were included in the synthesis (15 observational, 2 case-control and 1 randomised control studies). Most studies measured procedure time, contrast usage, and fluoroscopy time. Other metrics were recorded to a lesser extent. Significant reductions were noted in both procedure and fluoroscopy times with the introduction of simulation-based endovascular training.

CONCLUSION

The evidence regarding the use of high-fidelity simulation in endovascular training is very heterogeneous. The current literature suggests simulation-based training leads to improvements in performance, mostly in terms of procedure and fluoroscopy time. High-quality randomised control trials are needed to establish the clinical benefits of simulation training, sustainability of improvements, transferability of skills and its cost-effectiveness.

Die Etablierung eines neuen Forschungskonzepts an einem universitären Standort

Neben der klinischen Tätigkeit haben an einem universitären Standort Forschung und Lehre einen großen Stellenwert. Durch die Etablierung eines neuen Forschungslabors an der Universitätsklinik für Gefäßchirurgie der Medizinischen Universität Innsbruck wurden die infrastrukturellen Voraussetzungen zur Gestaltung eines neuen Forschungsschwerpunkts geschaffen. Die Kooperation mit nationalen und internationalen Partnern war für diesen Prozess essenziell. Nicht nur in der Planung und Ausstattung der Räumlichkeiten, sondern auch in der Entwicklung von Studienprotokollen und zur kritischen Diskussion von Ergebnissen ist der Aufbau eines Netzwerkes von großer Bedeutung. Durch die Etablierung der experimentellen Gefäßchirurgie Innsbruck ist nun die Realisierung von Projekten der Grundlagenforschung und der translationalen Forschung an diesem universitären Standort möglich. Zudem spielt die Lehrforschung eine immer größere Rolle, insbesondere um die Ausbildungsstruktur möglichst praxisnah zu gestalten, Nachwuchs anzuwerben und die immer komplexer werdenden Techniken auch praxisnah zu vermitteln.

Continued Validation of Ultrasound Guidance Targeting Tasks: Relationship with Procedure Performance

RATIONALE AND OBJECTIVES

To determine if deliberative practice with novel ultrasound guidance targeting tasks improves simulated procedural skill.

MATERIALS AND METHODS

In a nonrandomized interventional trial first year medical students practiced the previous described dowel and straw targeting tasks 1 hour a week for 4 weeks (training group) or had no training (controls). Afterward, they each performed a simulated amniocentesis (AMN) and chorionic villus sampling (CVS) procedure. Procedures were scored using a global rating scale (GRS) and compared between groups with Mann-Whitney U tests. Two-way random effects intraclass correlation coefficients for the inter- and intra-rater variability were calculated for each item in both GRS's.

RESULTS

The training group (n = 22) had higher scores on several aspects and overall performance of AMN compared to controls (n = 15). There were no differences between groups for CVS. The inter-rater and intra-rater reliability of the GRS's for both AMN and CVS ranged from 0.16 to 0.89 with most values demonstrating good to excellent agreement.

CONCLUSION

This study demonstrates validity evidence in the content and internal structure domains for the AMN and CVS simulators and their accompanying GRS's. Repetitive practice of the targeting tasks improved student performance in simulated AMN, but modifications are needed for it to be relevant to other procedures such as CVS.

Do Video Games Predict an Early Advanced Capacity to Learn Interventional Radiology Skills?

PURPOSE

To elucidate the relationship between video game (VG) play and interventional radiology (IR) technical skills in medical students.

MATERIALS AND METHODS

Twenty medical students recruited at our institution's IR symposium completed a survey to ascertain demographics and prior VG experience, then participated in a 3-part trial of skills assessing IR and VG skill and visuospatial aptitude (VSA). IR skill was evaluated via an endovascular simulation task, VG skill by performance on three separate VGs, and VSA using the Cube Comparison test. Regression analysis was tested the strength of relationship between IR skill and VG experience, VG skill, and VSA, respectively, and participants were stratified by IR skill to top and bottom halves for survey-response comparison.

RESULTS

There was no correlation between either VG skill or visuospatial aptitude and IR skill (r = -0.22, p = 0.35; and r = 0.14, p = 0.57). Greater number of years playing VGs correlated with superior IR skill (Spearman's rho=-0.45, p<0.05). Students who selected IR as their specialty of interest had extensive VG experience, playing for > 15 years (n = 4, 80%), at least 10 hours per week at their peak (n = 3, 60%), and reported being either "skilled" or "highly skilled" at VGs (n = 3, 60%).

CONCLUSIONS

In our study, though limited by power, number of years playing VGs correlated positively with IR skills in medical students. Prior VG experience may predict an early advanced capacity to learn IR skills and an interest in the specialty.

Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology

Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.

Training in Interventional Radiology: A Simulation-Based Approach

Innovations in medical technology have revolutionised both medical and surgical practice. Indeed, with such innovations, training for specific specialties has become more advanced and streamlined. However, despite these novel approaches to train students and specialist trainees, training for interventional radiology (IR) is lagging. While the reason for this lag remains contentious, one of the primary reasons for this issue may be the lack of standardisation for IR training due to a scarcity of specific guidelines for the delivery of IR procedural training. Interventional radiologists manage a vast array of conditions and perform various procedures. However, training for each procedure is largely dependent on the centre and access to a range of cases. Recently, the use of simulation technology has allowed this issue to be addressed. Simulation technology allows trainees to participate in a range of procedures regardless of their centre and availability of cases. Specialties such as cardiology and vascular surgery have already adopted simulation-based technology for trainees and have commented positively on this approach. However, simulation-based training is still lacking in the IR training pathway. Here, we evaluate why IR training can benefit from a more simulation-based approach. We further consider the cost-effectiveness of implementing simulation-based training nationally. Finally, we outline the potential pitfalls that may arise of introducing simulation-based training for IR trainees. We conclude that despite its disadvantages, simulation training will prove to be more cost-efficient and allow standardisation of IR training.

Review of Simulation Training in Interventional Radiology

Simulation training has evolved and is now able to offer numerous training opportunities to supplement the practice of and overcome some of the shortcomings of the traditional Master-Apprentice model currently used in medical training. Simulation training provides new opportunities to practice skills used in clinical procedures, crisis management scenarios, and everyday clinical practice in a risk-free environment. Procedural and nonprocedural skills used in interventional radiology can be taught with the use of simulation devices and technologies. This review will inform the reader of which clinical skills can be trained with simulation, the types of commercially available simulators and their educational validity, and the assessment tools used to evaluate simulation training.

Evidence for Endovascular Simulation Training: A Systematic Review

BACKGROUND

Simulation training in endovascular surgery provides opportunities for trainees to practice and learn from non-patient based experience. Several types of endovascular simulators are available commercially. Previous studies on endovascular simulation training can be categorized into trials in which only a simulator was used when measuring performance metrics or "trials within simulation"; patient specific procedure rehearsals; and randomized, controlled trials (RCTs) or translational studies.

OBJECTIVES

To examine whether endovascular simulation training can improve surgeon techniques and patient outcomes in real clinical settings.

METHODS

A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed and Embase. Review articles, and papers that were not related to endovascular surgery and not within the scope of interest were excluded. References of review articles were further screened according to the exclusion criteria.

RESULTS

In total, 909 records were identified and 290 duplicates were removed. Thirty-one were included in the qualitative analysis. Twenty-three were trials within simulation and most of them found statistically significant improvements in procedure time, fluoroscopy time, and contrast volume. Five were patient specific procedure rehearsals and showed that simulation significantly affected the fluoroscopy angle and improved performance metrics. Three were RCTs and revealed mainly positive results on a Global Rating Scale and procedure specific rating scale.

CONCLUSIONS

Contemporary evidence shows that performance metrics within endovascular simulations improve with simulation training. Successful translation to in vivo situations is observed in patient specific procedure rehearsals and RCTs on real procedures. However, there is no level I evidence to show that predictive validity of simulation can definitively improve patient outcomes. Current literature supports the idea that there is a beneficial role of simulation in endovascular training. Future studies are needed to confirm the efficacy of simulation in endovascular surgical training and to see if simulation is superior to traditional training in the operating theatre.

Conventional Medical Education and the History of Simulation in Radiology

Simulation is a promising method for improving clinician performance, enhancing team training, increasing patient safety, and preventing errors. Training scenarios to enrich medical student and resident education, and apply toward competency assessment, recertification, and credentialing are important applications of simulation in radiology. This review will describe simulation training for procedural skills, interpretive and noninterpretive skills, team-based training and crisis management, professionalism and communication skills, as well as hybrid and in situ applications of simulation training. A brief overview of current simulation equipment and software and the barriers and strategies for implementation are described. Finally, methods of measuring competency and assessment are described, so that the interested reader can successfully implement simulation training into their practice.

The impact of stress factors in simulation-based laparoscopic training

BACKGROUND

This study aimed to quantify learner reactions manifesting from a realistic contextual stressor while training with a laparoscopic simulator, and to identify learner-derived stress-modifying behaviors. Stress factors are known to affect cognitive and psychomotor performance. Simulation-based medical training typically occurs in environments that are relatively stress free compared with the applied context. Training is most effective when it occurs in a highly faithful context, so the inclusion of typical clinical stressors in simulated laparoscopic learning environments may be beneficial.

METHODS

Preclinical medical students (N = 27) completed tasks using a laparoscopic simulator under the following 2 conditions: faculty direct observation (stressor) and unobserved (no stressor). The data included simulator performance, blood pressure, real-time heart rates, videotaped behavior, and pre/post surveys of latent anxiety and stress factors associated with participating in the research (eg, STAI 9).

RESULTS

Physiologic and behavioral manifestations of stress were observed for all participants during the stressor condition and during poor performance on simulator tasks. Stress was highest during periods of poor performance under the stressor condition. Focusing on the task itself mitigated stress reactions and improved performance on the simulator.

CONCLUSION

Stress reactions can be induced in a laboratory setting where simulation-based training occurs. Stressors imposed on the learner during simulation-based training may help support the acquisition of stress management skills that are necessary in the applied clinical setting. A ramped-up sequence of acquiring technical skills and clinical decision making, followed by stress management techniques, may lead to a more efficient transfer of learning from the simulated context to the clinical area.