A Review of Anesthesia Simulation in Low-Income Countries

Anaesthesiologists' perspectives of the need for nurse anaesthetists in South Africa

BACKGROUND

 South Africa faces a significant shortage of anaesthesiologists, compromising healthcare access and increasing anaesthesia-related risks. Addressing this issue requires sustainable, locally relevant solutions aligned with global surgery initiatives to enhance surgical care access.

OBJECTIVES

 This study explores anaesthesiologists' perspectives on the necessity of nurse anaesthetists in South Africa and offers recommendations for developing their practice.

METHOD

 A qualitative, descriptive, and contextual design was employed, using purposive and snowball sampling methods. The population consisted of anaesthesiologists registered with the Health Professions Council of South Africa (HPCSA). Data were collected through in-depth, semi-structured interviews conducted face-to-face and online. Analysis followed Colaizzi's seven-step method, supported by an independent coder.

RESULTS

 Findings revealed diverse perspectives, ranging from support for independent, well-trained nurse anaesthetists under supervision or as assistants, to complete opposition to nurse anaesthetists administering anaesthesia. Participants emphasised that the anaesthesiology specialist community should define nurse anaesthetists' scope of practice, which must be regulated. Training should align with diplomate anaesthetists' standards and involve anaesthesiologists supported by nursing educators.

CONCLUSION

 This pioneering research addresses a critical gap in South Africa's healthcare system by exploring the introduction of nurse anaesthetists to mitigate the shortage of anaesthesia providers.Contribution: Its findings hold the potential to inform policy and practice, contributing to the advancement of anaesthesia services and addressing a pressing healthcare need in South Africa.

Anaesthetic practices at Gulu Regional Referral Hospital in Northern Uganda, who does what and where? A retrospective study

BACKGROUND

Hospitals such as the Gulu Regional Referral Hospital (GRRH) in northern Uganda, like many other regions of sub-Saharan Africa, lack the anaesthetists needed to provide adequate analgesia during surgical procedures. The GRRH has not employed any anaesthesiologist for many years. Instead, anaesthesia is carried out by non-physician anaesthetic officers (AO) and other healthcare workers (HWs). In this setting, peripheral regional anaesthesia (pRA) is a safe and resource-efficient alternative that HWs and AOs could use. The study aimed to evaluate surgical procedures, anaesthetic practices, and staffing at Gulu Regional Referral Hospital in Northern Uganda. The objective was to identify the appropriate audience for pRA training and the corresponding training content.

METHODS

A retrospective review was conducted on surgical procedures and their anaesthetic management in three departments of GRRH during 2019. The possibility of performing pRA was determined based on the surgical site, infection status, and the type of surgical procedure being performed. A pRA was considered adequate when conditions for pRA were met and pRA was carried out. Chi-square test was used to compare categorical data. A bivariable logistic regression analysis was performed to identify the factors associated with the administration of peripheral regional anaesthesia and the qualifications of medical staff.

RESULTS

A total of 804 procedures were recorded [67% in accident and emergency (A&E), 31% in operating room (OR), and 2% on the surgical ward]. Anaesthesia was recorded in 82% of cases. Of these, 86% were documented in regional and local anaesthesia. Anaesthetic officers carried out anaesthesia in 20% of all cases and in all cases in the operating room. HWs with more than 2 years of training performed adequate pRA more frequently than HWs with less than 1 year of experience [Odds ratio (OR) = 2.586; 95% CI 1.336-5.005; p = 0.005]. The last group, however, performed significantly more procedures in A&E than in other departments (89%, p < 0.001). Of the 209 procedures that could have been performed with pRA, 85 were found to be inadequately anaesthetised. 79% (67) of these were performed in the emergency department. In 45% of cases with inadequate anaesthesia, patients received local anaesthesia instead of appropriate pRA. Pain control was absent in 18% of cases, and 20% of cases received presumably unnecessary general anaesthesia or sedation. In 17% of cases, additional administration of ketamine and/or midazolam was required due to insufficient pRA.

CONCLUSIONS

The data show that pRA procedures are already used at GRRH, especially by HWs with high level of training in the OR. In A&E, which is primarily staffed by doctors with less than 1-year training, there is a potential to increase the administration of adequate pain relief by implementing simple nerve blocks into routine clinical practice. Therefore, doctors and staff in A&E would benefit from needs-based training in pRA.

Building Global Partnerships: A Qualitative Exploration of In-Person Training for HealthCare Simulation Educators Working in Low-Resource Settings

INTRODUCTION

Effective educational initiatives can elevate the quality of patient care globally. Simulation-based education is widely used in high-resource settings, but barriers exist to its widespread use in low-resource settings. Vital Anesthesia Simulation Training (VAST) overcomes these barriers by offering immersive, low-cost portable simulation along with simulation facilitator training. During the COVID-19 pandemic, in-person courses were stopped for more than 2 years. Postpandemic, a 3-day VAST SIMposium was hosted in Rwanda to unite 42 VAST facilitators from 12 widespread countries to introduce new and revised course materials and to rejuvenate dormant skills. The purpose of this study was to explore how the VAST SIMposium influenced perceived development of skills, confidence, and engagement in a community of practice for simulation educators working in low-resource settings.

METHODS

This qualitative study involved in-depth interviews with a purposive sample of 16 VAST SIMposium attendees. Transcripts of audio recordings were analyzed using inductive thematic analysis.

RESULTS

Six themes were identified during data analysis: 1) Diversity with shared passion for medical education; 2) Supportive in-person learning environment; 3) Simulation-based education relevant to low-resource settings; 4) Camaraderie; 5) Building knowledge, skills, and confidence; and 6) Being part of a community of practice.

CONCLUSION

The SIMposium rejuvenated passion, knowledge, skills, and, most importantly, strengthened global connections and partnerships. These collaborations will benefit areas that are underrepresented in simulation and will ultimately improve patient outcomes. A SIMposium of this format is an efficient and effective way to foster sustainable global dissemination of simulation-based global health education.

Assessing Healthcare Simulation Facilitation: A Scoping Review of Available Tools, Validity Evidence, and Context Suitability for Faculty Development in Low-Resource Settings

SUMMARY STATEMENT

Assessment tools support simulation facilitation skill development by guiding practice, structuring feedback, and promoting reflective learning among educators. This scoping review followed a systematic process to identify facilitation assessment tools used in postlicensure healthcare simulation. Secondary objectives included mapping of the validity evidence to support their use and a critical appraisal of their suitability for simulation faculty development in low-resource settings. Database searching, gray literature searching, and stakeholder engagement identified 11,568 sources for screening, of which 72 met criteria for full text review. Thirty sources met inclusion; 16 unique tools were identified. Tools exclusively originated from simulation practice in high-resource settings and predominantly focused on debriefing. Many tools have limited validity evidence supporting their use. In particular, the validity evidence supporting the extrapolation and implications of assessment is lacking. No current tool has high context suitability for use in low-resource settings.

The impact of surgical simulation and training technologies on general surgery education

The landscape of general surgery education has undergone a significant transformation over the past few years, driven in large part by the advent of surgical simulation and training technologies. These innovative tools have revolutionized the way surgeons are trained, allowing for a more immersive, interactive, and effective learning experience. In this review, we will explore the impact of surgical simulation and training technologies on general surgery education, highlighting their benefits, challenges, and future directions. Enhancing the technical proficiency of surgical residents is one of the main benefits of surgical simulation and training technologies. By providing a realistic and controlled environment, With the use of simulations, residents may hone their surgical skills without compromising patient safety. Research has consistently demonstrated that training with simulations enhances surgical skills., reduces errors, and enhances overall performance. Furthermore, simulators can be programmed to mimic a wide range of surgical scenarios, enabling residents to cultivate the essential critical thinking and decision-making abilities required to manage intricate surgical cases. Another area of development is incorporating simulation-based training into the wider surgical curriculum. As simulation technologies become more widespread, they will need to be incorporated into the fabric of surgical education, rather than simply serving as an adjunct to traditional training methods. This will require a fundamental shift in the way surgical education is delivered, with a greater emphasis on simulation-based training and assessment.

Simulation-based education in the Pacific Islands: educational experience, access, and perspectives of healthcare workers

BACKGROUND

The World Health Organization (WHO) recommends simulation-based education (SBE) to acquire skills and accelerate learning. Literature focusing on SBE in the Pacific Islands is limited. The aim of this study was to determine Pacific Island healthcare workers' experiences, perspectives, and access to SBE.

METHODS

This was a cross-sectional survey of Pacific Island healthcare workers. We designed an online questionnaire based on existing literature and expert consultation. The questionnaire included Likert scales, multiple-choice, multi-select and open-ended questions. Participants were healthcare workers recruited from professional networks across the region. Descriptive statistics and relative frequencies summarized data, and comparative testing included unpaired t-tests, Mann-Whitney U, Chi-squared and Fisher's exact tests. Free-text responses were presented to illustrate findings.

RESULTS

Responses from 56 clinicians working in 11 Pacific Island countries were included. Fifty were medical doctors (89%), including 31 (55%) surgeons. Participants reported experience with scenario-based simulation (73%), mannequins (71%), and simulated patients (61%). Discrepancies were identified between previous simulation experience and current access for simulated patients (P = 0.002) and animal-based part-task trainers (P = 0.002). SBE was seen as beneficial for procedural skills, communication, decision-making and teamwork. Interest in further SBE was reported by most participants (96%). Barriers included equipment access (59%), clinical workload (45%) and COVID-19 restrictions (45%).

CONCLUSION

Some Pacific Island healthcare workers have experience with SBE, but their ongoing access is predominantly limited to low-technology modalities. Despite challenges, there is interest in SBE initiatives. These findings may inform planning for SBE in the Pacific Islands and may be considered prior to programme implementation.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries

SUMMARY STATEMENT

Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

Effect of simulation-based emergency airway management education on the knowledge, skills and perceived confidence of medical interns

Background

An effective airway management education program is a crucial part of the undergraduate medical education curriculum. Theoretical instructions and practical demonstrations are the major modalities of medical education in Nepal. Simulation-based education (SBE) programs have not yet been implemented effectively. The authors aimed to determine the effects of an SBE program on the knowledge, skills, and perceived confidence of medical interns regarding emergency airway management.

Methods

This mixed methods study comprised both quantitative and qualitative components. The study participants were 47 medical interns who had participated in the SBE program.

Results

The mean age of the 47 participants was 24.74 years. There were 33 (70.21%) male and 14 (29.79%) female participants. The knowledge, skills, and perceived confidence scores of the participants for airway management preparation, basic airway management, endotracheal intubation, and laryngeal mask airway (LMA) insertion improved significantly following the SBE program (P<0.001). Analysis of the participants' feedback indicated that they largely approved of the SBE program. The majority of students and faculty expressed a willingness to include similar programs in the undergraduate medical education curriculum.

Conclusion

This study demonstrated through quantitative and qualitative metrics that SBE can enhance the knowledge, skills, and perceived confidence in performing emergency airway management among medical interns. The authors recommend measures to include and effectively implement SBE in the undergraduate medical education curriculum of Nepal.

Difficult airway simulation-based training for anaesthesiologists: efficacy and skills retention within six months

BACKGROUND

The aim of this study was to evaluate how anaesthesiologists manage a "cannot intubate, can ventilate" (CI) and "cannot intubate, cannot ventilate" (CICV) scenarios, and how following simulation training will affect their guideline adherence, skills and decision-making immediately after training and 6 months later.

METHODS

A prospective controlled study was conducted from July to December 2022. Anaesthesiologists who applied for the continuous medical education course "Difficult Airway Management" were involved in the study. Each volunteer participated in two simulation scenarios (CI, CICV) with structural debriefing after each scenario. After the first simulation round, volunteers were trained in difficult airway management according to DAS guidelines, using the same equipment as during the simulation. The participants repeated the simulation scenarios the day after the training and six months later. The primary and secondary endpoints were compared between three rounds: initial simulation (Group 1), immediately after training (Group 2), and six months after training (Group 3).

RESULTS

A total of 24 anaesthesiologists consented to participate in the study and completed the initial survey form. During the first session, 83.3% of participants had at least one major deviation from the DAS protocol. During the first CICV scenario, 79% of participants made at least one deviation from the DAS protocol. The second time after simulation training, significantly better results were achieved: the number of anaesthesiologists, who attempted more than 3 laryngoscopies decreased (OR = 7 [1.8-26.8], p = 0.006 right after training and OR = 3.9 [1.06-14.4], p = 0.035 6 month later); the number, who skipped the supralaryngeal device attempt, call for help and failure to initiate surgical airway also decreased. Simulation training also significantly decreases the time to call for help, cricothyroidotomy initiation time, and mean desaturation time and increases the odds ratio of successful cricothyroidotomy (OR 0.02 [0.003-0.14], p < 0.0001 right after training and OR = OR 0.02 [0.003-0.16] 6 months after training).

CONCLUSIONS

Anaesthesiologists usually display major deviations from DAS guidelines while managing CI and CICV scenarios. Simulation training improves their guideline adherence, skills, and decision-making when repeating the simulation immediately after training and 6 months later.

STUDY REGISTRATION

NCT05913492, clinicaltrials.gov, 22/06/2023.

Simulation in Anesthesia for Perioperative Neuroscience: Present and Future

The brain's sensitivity to fluctuations in physiological parameters demands precise control of anesthesia during neurosurgery, which, combined with the complex nature of neurosurgical procedures and potential for adverse outcomes, makes neuroanesthesia challenging. Neuroanesthesiologists, as perioperative physicians, work closely with neurosurgeons, neurologists, neurointensivists, and neuroradiologists to provide care for patients with complex neurological diseases, often dealing with life-threatening conditions such as traumatic brain injuries, brain tumors, cerebral aneurysms, and spinal cord injuries. The use of simulation to practice emergency scenarios may have potential for enhancing competency and skill acquisition amongst neuroanesthesiologists. Simulation models, including high-fidelity manikins, virtual reality, and computer-based simulations, can replicate physiological responses, anatomical structures, and complications associated with neurosurgical procedures. The use of high-fidelity simulation can act as a valuable complement to real-life clinical exposure and training in neuroanesthesia.

Skill Translation Following the Vital Anesthesia Simulation Training Facilitator Course: A Qualitative Study

BACKGROUND

Simulation-based education (SBE) is common in resource-rich locations, but barriers exist to widespread implementation in low-resource settings (LRSs). Vital Anesthesia Simulation Training (VAST) was developed to offer low-cost, immersive simulation to teach core clinical practices and nontechnical skills to perioperative health care teams. To promote sustainability, courses in new locations are preceded by the VAST Facilitator Course (VAST FC) to train local faculty. The purpose of this study was to explore the experiences of VAST FC graduates in translating postcourse knowledge and skills into their workplaces.

METHODS

This qualitative study used focus group interviews with 24 VAST FC graduates (from 12 low- and middle-income and 12 high-income countries) to explore how they had applied new learning in the workplace. Focus groups were conducted by videoconferencing with data transcribed verbatim. Data were analyzed using inductive thematic analysis.

RESULTS

Enabler themes for knowledge and skill translation following facilitator training were (1) the structured debriefing framework, (2) the ability to create a supportive learning environment, and (3) being able to meaningfully discuss nontechnical skills. Two subthemes within the debriefing framework were (1.1) knowledge of conversational techniques and (1.2) having relevance to clinical debriefing. Barrier themes limiting skill application were (1) added time and effort required for comprehensive debriefing, (2) unsupportive workplaces, and (3) lack of opportunities for mentorship and practice postcourse.

CONCLUSIONS

Participants found parallels between SBE debriefing conversations, clinical event debriefing, and feedback conversations and were able to apply knowledge and skills in a variety of settings post course. This study supports the relevance of simulation facilitator training for SBE in LRSs.

Identification of a partnership model between a university, for-profit, and not-for-profit organization to address health professions education and health inequality gaps through simulation-based education: A scoping review protocol

INTRODUCTION

Healthcare providers in rural and remote (R&R) areas of Canada do not have the same access to skills development and maintenance opportunities as those in urban areas. Simulation-based education (SBE) is an optimal technique to allow healthcare providers to develop and maintain skills. However, SBE is currently limited mainly to universities or hospital-based research laboratories in urban areas. The purpose of this scoping review is to identify a model, or components of a model, that outline how a university research laboratory can collaborate with a for profit and not-for-profit organization to facilitate the diffusion of SBE into R&R healthcare provider training.

METHODS AND ANALYSIS

This scoping review will be guided by the methodological framework introduced by Arksey and O'Malley in 2005 and the Methodology for Joanna Briggs Institute Scoping Reviews. Ovid MEDLINE, PsycINFO, Scopus, Web of Science, and CINAHL will be searched for relevant articles published between 2000 and 2022, in addition to grey literature databases and manual reference list searches. Articles describing a partnership model or framework between academic institutions and non-profit organizations with a simulation or technology component will be included. Titles and abstracts will be screened, followed by a full-text screening of articles. Two reviewers will participate in the screening and data extraction process for quality assurance. Data will be extracted, charted, and summarized descriptively to report key findings on potential partnership models.

CONCLUSION

This scoping review will provide an understanding on the extent of existing literature regarding the diffusion of simulators for healthcare provider training through a multi-institutional partnership. This scoping review will benefit R&R parts of Canada by identifying gaps in knowledge and determining a process to deliver simulators to train healthcare providers. Findings from this scoping review will be submitted for publication in a scientific journal.

Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial)

BACKGROUND

Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers.

OBJECTIVE

This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training.

METHODS

Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider's Guide (VR group) or the digitized HBB Provider's Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider's Guide or the digitized HBB Provider's Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical).

RESULTS

A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048).

CONCLUSIONS

The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries.

Qualities of Effective Vital Anaesthesia Simulation Training Facilitators Delivering Simulation-Based Education in Resource-Limited Settings

BACKGROUND

Lack of access to safe and affordable anesthesia and surgical care is a major contributor to avoidable death and disability across the globe. Effective education initiatives are a viable mechanism to address critical skill and process gaps in perioperative teams. Vital Anaesthesia Simulation Training (VAST) aims to overcome barriers limiting widespread application of simulation-based education (SBE) in resource-limited environments, providing immersive, low-cost, multidisciplinary SBE and simulation facilitator training. There is a dearth of knowledge regarding the factors supporting effective simulation facilitation in resource-limited environments. Frameworks evaluating simulation facilitation in high-income countries (HICs) are unlikely to fully assess the range of skills required by simulation facilitators working in resource-limited environments. This study explores the qualities of effective VAST facilitators; knowledge gained will inform the design of a framework for assessing simulation facilitators working in resource-limited contexts and promote more effective simulation faculty development.

METHODS

This qualitative study used in-depth interviews to explore VAST facilitators' perspectives on attributes and practices of effective simulation in resource-limited settings. Twenty VAST facilitators were purposively sampled and consented to be interviewed. They represented 6 low- and middle-income countries (LMICs) and 3 HICs. Interviews were conducted using a semistructured interview guide. Data analysis involved open coding to inductively identify themes using labels taken from the words of study participants and those from the relevant literature.

RESULTS

Emergent themes centered on 4 categories: Persona, Principles, Performance and Progression. Effective VAST facilitators embody a set of traits, style, and personal attributes (Persona) and adhere to certain Principles to optimize the simulation environment, maximize learning, and enable effective VAST Course delivery. Performance describes specific practices that well-trained facilitators demonstrate while delivering VAST courses. Finally, to advance toward competency, facilitators must seek opportunities for skill Progression.Interwoven across categories was the finding that effective VAST facilitators must be cognizant of how context, culture, and language may impact delivery of SBE. The complexity of VAST Course delivery requires that facilitators have a sensitive approach and be flexible, adaptable, and open-minded. To progress toward competency, facilitators must be open to self-reflection, be mentored, and have opportunities for practice.

CONCLUSIONS

The results from this study will help to develop a simulation facilitator evaluation tool that incorporates cultural sensitivity, flexibility, and a participant-focused educational model, with broad relevance across varied resource-limited environments.

Toward interprofessional team training for surgeons and anesthesiologists using virtual reality

Purpose

In this work, a virtual environment for interprofessional team training in laparoscopic surgery is proposed. Our objective is to provide a tool to train and improve intraoperative communication between anesthesiologists and surgeons during laparoscopic procedures.

Methods

An anesthesia simulation software and laparoscopic simulation software are combined within a multi-user virtual reality (VR) environment. Furthermore, two medical training scenarios for communication training between anesthesiologists and surgeons are proposed and evaluated. Testing was conducted and social presence was measured. In addition, clinical feedback from experts was collected by following a think-aloud protocol and through structured interviews.

Results

Our prototype is assessed as a reasonable basis for training and extensive clinical evaluation. Furthermore, the results of testing revealed a high degree of exhilaration and social presence of the involved physicians. Valuable insights were gained from the interviews and the think-aloud protocol with the experts of anesthesia and surgery that showed the feasibility of team training in VR, the usefulness of the system for medical training, and current limitations.

Conclusion

The proposed VR prototype provides a new basis for interprofessional team training in surgery. It engages the training of problem-based communication during surgery and might open new directions for operating room training.

Electronic supplementary material

The online version of this article (10.1007/s11548-020-02276-y) contains supplementary material, which is available to authorized users.