Comparative study of a simulated incident with multiple victims and immersive virtual reality

Using High-Fidelity Virtual Reality for Mass-Casualty Incident Training by First Responders - A Systematic Review of the Literature

INTRODUCTION

First responders' training and learning regarding how to handle a mass-casualty incident (MCI) is traditionally based on reading and/or training through computer-based scenarios, or sometimes through live simulations with actors. First responders should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. High-fidelity virtual reality (VR) is a promising tool to use for realistic and repeatable simulation training, but it needs to be further evaluated. The aim of this literature review was to provide a comprehensive description of the use of high-fidelity VR for MCI training by first responders.

METHODS

A systematic integrative literature review was used according to Whittemore and Knafl's descriptions. Databases investigated were PubMed, CINAHL Complete, Academic Search Ultimate, Web of Science, and ERIC to find papers addressing the targeted outcome. The electronic search strategy identified 797 potential studies. Seventeen studies were deemed eligible for final inclusion.

RESULTS

Training with VR enables repetition in a way not possible with live simulation, and the realism is similar, yet not as stressful. Virtual reality offers a cost-effective and safe learning environment. The usability of VR depends on the level of immersion, the technology being error-free, and the ease of use.

CONCLUSIONS

This integrative review shows that high-fidelity VR training should not rule out live simulation, but rather serve as a complement. First responders became more confident and prepared for real-life MCIs after training with high-fidelity VR, but efforts should be made to solve the technical issues found in this review to further improve the usability.

Applied distance learning methods in disaster preparedness: A systematic review

Nowadays, accidents and disasters are one of the most important issues facing humans. Training is an important feature in disasters and distance learning is a suitable method for education in every place and at every time. The aim of this study is to determine distance learning methods in disaster preparedness. This study was conducted to this question: what types of distance learning methods can use in disaster preparedness?". In this study, all published English language papers, with no time limit, were extracted by the end of December 2021 through search in PubMed, Scopus, Google scholar, ISI WOS (Web of Science), and Embase. The primary search used "distance learning", "disaster" and their MeSH terms. Quality appraisal carried out with CASP. Information in the articles including study time, study population, e-learning methods, and type of disasters or emergencies were extracted. Based on the search, 46 studies were carried out between 2002 and 2021. The most studied target group in the studies was health professionals and the content of the courses was attributed to disaster preparedness as well as biological disasters. Regarding e-learning methods, the most used method was 'simulation'. At the time of disasters, including pandemics, disruption in education may be long-term and may require overlapping response and recovery periods. And virtual education during a disaster may be rejected or endorsed by individuals or groups based on cultural, ideological, or prejudicial issues. Distance education can be used for effective disaster education in different phases of the disaster cycle, depending on the available facilities and infrastructure.

A Comparison of Virtual Reality to Traditional Simulation in Health Professions Education: A Systematic Review

ABSTRACT

With the increasing availability of virtual reality (VR) and its lower overall costs of use, the objective of this review was to compare VR to traditional simulation in terms of learning outcomes. Studies were included if they met the following criteria: ( a ) research study (of any design), ( b ) focused on learners in health professions, and ( c ) compared VR with traditional simulation. Studies were excluded for the following reasons: ( a ) not a research study, ( b ) focused on learners outside health professions, ( c ) used screen-based or computer-based simulation, ( d ) used a task trainer, and ( e ) did not involve a comparison of VR to traditional simulation. The searches were run on November 11 and 12, 2021, in CINAHL via EBSCO, Ovid Embase, ERIC via EBSCO, IEEE Xplore, Ovid Medline, Ovid PsycINFO, Scopus, and Web of Science Core Collection. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided the review. A team of researchers applied Kirkpatrick's Levels, Melnyk's Levels of Evidence, and Critical Appraisal Skills Programme guidelines to assess the level of evidence and look for bias. Fifteen studies were reviewed including 11 randomized controlled trials. The lead researcher synthesized the study results into 3 categories: (1) traditional simulation performed better, (2) VR performed better, and (3) comparable outcomes. There is insufficient evidence to endorse one form of simulation (VR or traditional) as more effective at this time. The body of evidence contained too few studies to draw meaningful conclusions to answer the guiding question. The studies covered a large range of modalities, learner groups, and healthcare topics, preventing a meta-analysis. Based on the literature and experience, we recommend that VR experiences be proctored, include debriefing, have a backup plan for cybersickness or myopia, and have time and costs documented. Use of VR is likely to expand; thus, research is needed to inform the best contexts and applications.

Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis

Objective

An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work.

Results

Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes.

Conclusion

There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

Virtual Reality Training in Disaster Medicine: A Systematic Review of the Literature

SUMMARY STATEMENT

Disaster medicine (DM) training aims to recreate stressful, mass casualty scenarios faced by medical professionals in the field with high fidelity. Virtual (VR) and augmented reality (AR) are well suited to disaster training as it can provide a safe, socially distant simulation with a high degree of realism. The purpose of this literature review was to summarize the current use of VR or AR for simulation training of healthcare providers in DM education. A systematic review of peer-reviewed articles was performed from January 1, 2000, to November 21, 2020, on PubMed, Embase, and OVID. Exclusion criteria included non-English articles, computer-generated models without human participants, or articles not relating to DM, VR or AR. Thirty-two articles were included. Triage accuracy was evaluated in 17 studies. Participants reported improved confidence and positive satisfaction after the simulations. The studies suggest VR or AR can be considered for disaster training in addition to other, more traditional simulation methods. More research is needed to create a standardized educational model to incorporate VR and AR into DM training and to understand the relationship between disaster simulation and improved patient care.

Virtual Reality and Augmented Reality Training in Disaster Medicine Courses for Students in Nursing: A Scoping Review of Adoptable Tools

Nurses and paramedics play a pivotal role when mass casualty incidents (MCI) occur, yet they often feel unprepared for such events. Implementation strategies for training activities, including virtual reality (VR) and augmented reality (AR) simulations, offer realistic and immersive learning experiences, enhancing skills and competencies for nursing students. The aim of this work was to investigate the adopted tools in studies on VR and AR simulations for training nursing and paramedic students in managing MCI. A scoping review was performed following the PRISMA-ScR statement, and the search strategy was conducted through five electronic databases from December 2022 to March 2023. Of 162 records identified, 27 full texts were screened and, six studies were included in this review. These studies involved students who were assigned to different training methods, including immersive VR simulation, written instruction, and traditional lecture. VR and AR and immersive simulation generally show promising evidence in enhancing practical skills and knowledge in MCI management. VR and AR showed to be promising in disaster education and preparedness training, offering different levels of immersiveness and engagement, encouraging active and experiential learning. Further research is needed to determine their long-term effectiveness. The choice of training method should consider program goals, target population, and available resources.

A scoping review of metaverse in emergency medicine

BACKGROUND

Interest in the metaverse has been growing worldwide as the virtual environment provides opportunities for highly immersive and interactive experiences. Metaverse has gradually gained acceptance in the medical field with the advancement of technologies such as big data, the Internet of Things, and 5 G mobile networks. The demand for and development of metaverse are different in diverse subspecialties owing to patients with varying degrees of clinical disease. Hence, we aim to explore the application of metaverse in acute medicine by reviewing published studies and the clinical management of patients.

METHOD

Our review examined the published articles about the concept of metaverse roadmap, and four additional domains were extracted: education, prehospital and disaster medicine, diagnosis and treatment application, and administrative affairs.

RESULTS

Augmented reality (AR) and virtual reality (VR) integration have broad applications in education and clinical training. VR-related studies surpassed AR-related studies in the emergency medicine field. The metaverse roadmap revealed that lifelogging and mirror world are still developing fields of the metaverse.

CONCLUSION

Our findings provide insight into the features, application, development, and potential of a metaverse in emergency medicine. This study will enable emergency care systems to be better equipped to face future challenges.

Metaverse applied to musculoskeletal pathology: Orthoverse and Rehabverse

The Metaverse is 'an integrated network of 3D virtual worlds.' It incorporates digitally created realities into the real world, involves virtual copies of existing places and changes the physical reality by superimposing digital aspects, allowing its users to interact with these elements in an immersive, real-time experience. The applications of the Metaverse are numerous, with an increasing number of experiences in the field of musculoskeletal disease management. In the field of medical training, the Metaverse can help facilitate the learning experience and help develop complex clinical skills. In clinical care, the Metaverse can help clinicians perform orthopedic surgery more accurately and safely and can improve pain management, the performance of rehabilitation techniques and the promotion of healthy lifestyles. Virtualization can also optimize aspects of healthcare information and management, increasing the effectiveness of procedures and the functioning of organizations. This optimization can be especially relevant in departments that are under significant care provider pressure. However, we must not lose sight of the fundamental challenges that still need to be solved, such as ensuring patient privacy and fairness. Several studies are underway to assess the feasibility and safety of the Metaverse.

First Responder Virtual Reality Simulator to train and assess emergency personnel for mass casualty response

As mass casualty incidents continue to escalate in the United States, we must improve frontline responder performance to increase the odds of victim survival. In this article, we describe the First Responder Virtual Reality Simulator, a high-fidelity, fully immersive, automated, programmable virtual reality (VR) simulation designed to train frontline responders to treat and triage victims of mass casualty incidents. First responder trainees don a wireless VR head-mounted display linked to a compatible desktop computer. Trainees see and hear autonomous, interactive victims who are programmed to simulate individuals with injuries consistent with an explosion in an underground space. Armed with a virtual medical kit, responders are tasked with triaging and treating the victims on the scene. The VR environment can be made more challenging by increasing the environmental chaos, adding patients, or increasing the acuity of patient injuries. The VR platform tracks and records their performance as they navigate the disaster scene. Output from the system provides feedback to participants on their performance. Eventually, we hope that the First Responder system will serve both as an effective replacement for expensive conventional training methods as well as a safe and efficient platform for research on current triage protocols.

The affordances of clinical simulation immersive technology within healthcare education: a scoping review

Whilst clinical simulation is established as an effective education tool within the healthcare community, the inability to offer authentic educational learning environments remains problematic. Advances in technology such as immersive virtual reality offer new opportunities to enhance traditional practice to an extent that may transform learning. However, with traditional clinical simulation stress and anxiety can both hinder performance and learning, yet it is unknown what nuances are applicable within a clinical virtual simulation environment. Determining potential benefits, drawbacks (including related stress and anxiety) and affordances of immersive technology clinical simulation designs may help provide an understanding of its usefulness. The aim of this scoping review is to investigate the range and nature of evidence associated with immersive virtual reality clinical simulation and education design. In addition, the review will describe authentic immersive technology clinical simulation use and reported stress response measurements. A search of seven electronic database and grey literature was performed in accordance with the Joanna Briggs Institute methodology. A key term search strategy was employed with five themes identified and investigated: (1) Healthcare professionals, (2) Clinical simulation, (3) Immersive virtual reality, (4) Stress/anxiety and (5) Authentic learning design. Application of the search strategy resulted in a hit total of 212 articles. Twelve articles met inclusion criteria. With most literature focusing on procedural performance and non-transferable education needs, there was a paucity of research that specifically investigated immersive virtual reality clinical simulation education and related stress. Therefore, this scoping review contributes new understandings by providing valuable insight and potential research gaps into current immersive virtual reality clinical simulation, its relationship to stress and the education design models currently being utilised to develop these concepts.

Exploring Key Factors Influencing Nursing Students' Cognitive Load and Willingness to Serve Older Adults: Cross-sectional Descriptive Correlational Study

BACKGROUND

Virtual learning environments (VLEs) use a virtual environment to support learning activities. VLEs are commonly used to overcome the temporal and spatial restrictions of learning activities held in conventional face-to-face classrooms. In VLEs, students can participate in learning activities using the internet, and teachers can provide assistive learning tools during the process.

OBJECTIVE

The purpose of this study was to investigate the relationships among nursing students' mental load, cognitive load, and affective learning outcomes in terms of their willingness to serve older adults in an interaction-based educational virtual reality (VR) learning environment.

METHODS

This study used a cross-sectional method. A total of 130 students participated in interaction-based VR learning and completed related questionnaires. Descriptive and inferential statistics and stepwise regression for data analysis were used.

RESULTS

The research results revealed that in the dimension of willingness to use VR learning materials, perceived usefulness received the highest score (mean 4.42, SD 0.45). In the dimension of nursing ability, students scored the highest in information management and application ability to care for case patients (mean 4.35, SD 0.54). Correlation analysis revealed that cognitive load during learning and willingness to serve older adults were negatively correlated, whereas willingness to use VR learning materials was positively correlated with nursing ability and willingness to serve older adults. Analyzing the regression coefficients of predictor variables revealed that willingness to use VR learning materials (β=.23; t₂=2.89, P=.005) and cognitive load during learning (β=-.35; t₂=-.4.30, P<.001) were predictive factors of nursing students' willingness to serve older adults.

CONCLUSIONS

This study demonstrated that students' willingness to use VR learning materials and their cognitive load during learning affected their willingness to care for older adults. Therefore, the components of mental or cognitive load generate inconsistent predictive effects on affective variables and willingness to serve older adults.

Desktop Virtual Reality Versus Face-to-Face Simulation for Team-Training on Stress Levels and Performance in Clinical Deterioration: a Randomised Controlled Trial

BACKGROUND

Simulation-based education can equip healthcare providers with the ability to respond to and manage stressors associated with rapidly deteriorating patient situations. However, little is known about the benefits of using virtual reality (VR) for this purpose.

OBJECTIVE

To compare between desktop VR and face-to-face simulation in stress responses and performance outcomes of a team-based simulation training in managing clinical deterioration.

DESIGN

A randomised controlled study METHOD: The study was conducted on 120 medical and nursing students working in interprofessional teams. The teams were randomly assigned to participate in a 2-h simulation using either the desktop VR or face-to-face simulation with simulated patient (SP). Biophysiological stress response, psychological stress, and confidence levels were measured before and after the simulation. Performance outcomes were evaluated after the simulation using a deteriorating patient scenario.

RESULTS

The systolic blood pressure and psychological stress response were significantly increased among participants in VR and SP groups; however, no significant differences were found between the groups. There was also no significant difference in confidence and performance outcomes between participants in the VR and SP groups for both medical and  nursing students. Although the psychological stress response was negatively correlated (r = -0.43; p < 0.01) with confidence levels, there was no association between stress response and performance score.

CONCLUSION

Despite being less immersive, the desktop VR was capable of inducing psychological and physiological stress responses by placing emotional, social, and cognitive demands on learners. Additionally, by ensuring close alignment between the simulation tasks and the clinical tasks (i.e. functional fidelity), the desktop VR may provide similar performance outcomes as conventional simulation training. This evidence is timely given the rise in the use of virtual learning platforms to facilitate training during the COVID-19 pandemic where face-to-face training may not be feasible.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov NCT04330924.

Top Research Priorities in Prehospital Care in Spain

OBJECTIVE

The objective is to identify research priorities in prehospital care in Spain.

METHOD

This was a Delphi-type study of three rounds with a panel of experts made up of members of the Red de Investigación en Emergencias Prehospitalarias (RINVEMER; Prehospital Emergency Research Network) Network and the Sociedad Española de Medicina de Urgencias y Emergencias (SEMES; Spanish Society of Emergency Medicine) Emergency Secretariat. In the first round, each participant identified up to 15 priorities. In the second round, they scored the 30 thematic areas on a Likert scale. In the third round, they ordered and scored from one to ten the first ten priorities among those that obtained a median greater than or equal to four in the second round. After adding the assigned scores, the ten priorities with the highest total score were obtained.

RESULTS

The ten identified research priorities were: special clinical codes and time-dependent conditions; mass-casualty incident (MCI) coordination and management; innovation in Emergency Medical Services (EMS); human factor in decision making; triage, analysis, and management of calls in the Emergency Call Center; new technologies, telemedicine, and emergencies; adverse events, clinical safety, and quality in emergencies; cardiac arrest; continuous education and training (methodology, quality, and evaluation); and big data and emergencies.

CONCLUSIONS

The research priorities perceived by emergency professionals are related to clinical care and organizational aspects of EMS, in addition to the need to incorporate innovative aspects and new data analysis technologies.

Efficacy of Computer-Based Simulation as a Modality for Learning Pediatric Disaster Triage for Pediatric Emergency Nurses

SUMMARY STATEMENT

Pediatric disaster triage (PDT) is challenging for healthcare personnel. Mistriage can lead to poor resource utilization. In contrast to live simulation, screen-based simulation is more reproducible and less costly. We hypothesized that the screen-based simulation "60 Seconds to Survival" (60S) to learning PDT will be associated with improved triage accuracy for pediatric emergency nursing personnel.During this prospective observational study, 138 nurse participants at 2 tertiary care emergency departments were required to play 60S at least 5 times over 13 weeks. Efficacy was assessed by measuring the learners' triage accuracy, mistriage, and simulated patient outcomes using JumpStart.Triage accuracy improved from a median of 61.1 [interquartile range (IQR) = 48.5-72.0] to 91.7 (IQR = 60.4-95.8, P < 0.0001), whereas mistriage decreased from 38.9 (IQR = 28.0-51.5) to 8.3 (IQR = 4.2-39.6, P < 0.0001), demonstrating a significant improvement in accuracy and decrease in mistriage. Screen-based simulation 60S is an effective modality for learning PDT by pediatric emergency nurses.

Training of Medical Students for Mass Casualty Incidents Using Table-Top Gamification

INTRODUCTION

"Table-top" exercises can improve knowledge and skills related to mass casualty incidents (MCIs) with little logistical efforts. We aim to evaluate the learning process of 5th year medical school students related to MCI response using table-top simulation and measure their methodology perception.

METHODS

A theoretical part plus an MCI simulation board exercise was organized. Knowledge pretest and 1 mo after posttest was scored, and an assessment questionnaire with 27 questions with a Likert-type scale with 3 dimensions: methodology, knowledge acquisition, and skills acquisition was administered. Students did not receive any written or training material between pretest and posttest.

RESULTS

A total of 108 (80%) completed the evaluation questionnaire, pretest, and posttest. For the pretest, average grade was 4.25 (SD = 1.71) and 42% passed, and for the posttest, average grade was 8.33 (SD = 1.28) and 97 % pass (P < 0.0001). All variables measuring methodology perception scored more than 8, except for the duration of the exercise (7.3). Most knowledge acquisition scored above 9. Self-perception skill acquisition scores were slightly lower, although all above 7.

CONCLUSIONS

"Table-top" methodology is useful for acquiring knowledge and skills related to MCI response. Retention of knowledge is very high. Students consider that this methodology can be very useful for medical studies. Active or nonactive role is a factor that only influences final results in specific items.

Effect of Immersive Virtual Reality on Post-Baccalaureate Nursing Students’ In-Dwelling Urinary Catheter Skill and Learning Satisfaction

A fundamental skill required from nursing students is how to manage the insertion of in-dwelling urinary catheters, and this skill is a core competency for nurses. However, practice with conventional test models is insufficient for learning this skill and leads to inadequate proficiency among students. To address this problem, this study created an immersive virtual reality (IVR) scheme, based on the theory of situated learning, to simulate clinical situations. Innovative approaches were adopted to design clinical cases, construct three-dimensional environments, design character dialogs, and integrate artificial intelligence voice recognition. The effect of these design elements on students’ in-dwelling urinary catheter skills and learning satisfaction was explored. First, nursing experts assessed the quality of the IVR scheme. Over a 4-week period, 43 students in a post-baccalaureate nursing program used conventional test models to practice the management of in-dwelling urinary catheters in female patients, and their learning was supplemented by at least two practice sessions with IVR. Data were collected from in-class observation records, a questionnaire survey on student satisfaction, and focused group interviews. The results showed that the participating students were highly satisfied with the IVR scheme and stated that it provided a pleasurable learning experience and exerted a positive impact on them. The IVR scheme provided situations closely resembling real clinical environments, helping the students to memorize the steps for catheter management. The students also noted that the IVR scheme should incorporate other nursing skills, such as empathetical and solicitous care and patient companionship. This enables nursing students to fulfill their role and care for patients in clinical settings.

A Qualitative Assessment of Studies Evaluating the Classification Accuracy of Personnel Using START in Disaster Triage: A Scoping Review

Background

Mass casualty incidents (MCIs) can occur as a consequence of a wide variety of events and often require overwhelming prehospital and emergency support and coordinated emergency response. A variety of disaster triage systems have been developed to assist health care providers in making difficult choices with regards to prioritization of victim treatment. The simple triage and rapid treatment (START) triage system is one of the most widely used triage algorithms; however, the research literature addressing real-world or simulation studies documenting the classification accuracy of personnel using START is lacking.

Aims and Objectives

To explore the existing literature related to the current state of knowledge about studies assessing the classification accuracy of the START triage system.

Design

Scoping review based on Arksey and O'Malley's methodological framework and narrative synthesis based on methods described by Popay and colleagues were performed.

Results

The literature search identified 1,820 citations, of which 32 studies met the inclusion criteria. Thirty were peer-reviewed articles and 28 published in the last 10 years (i.e., 2010 and onward). Primary research studies originated in 13 countries and included 3,706 participants conducting triaging assessments involving 2,950 victims. Included studies consisted of five randomized controlled trials, 17 non-randomized controlled studies, eight descriptive studies, and two mixed-method studies. Simulation techniques, mode of delivery, contextual features, and participants' required skills varied among studies. Overall, there was no consistent reporting of outcomes across studies and results were heterogeneous. Data were extracted from the included studies and categorized into two themes: (1) typology of simulations and (2) START system in MCIs simulations. Each theme contains sub-themes regarding the development of simulation employing START as a system for improving individuals' preparedness. These include types of simulation training, settings, and technologies. Other sub-themes include outcome measures and reference standards.

Conclusion

This review demonstrates a variety of factors impacting the development and implementation of simulation to assess characteristics of the START system. To further improve simulation-based assessment of triage systems, we recommend the use of reporting guidelines specifically designed for health care simulation research. In particular, reporting of reference standards and test characteristics need to improve in future studies.

How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis

Background

Using traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation.

Objective

The aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance.

Methods

We conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration.

Results

Of the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration.

Conclusions

Technical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations.

METASTART: A Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the Simple Triage and Rapid Treatment (START) Algorithm for Disaster Triage

INTRODUCTION

The goal of disaster triage at both the prehospital and in-hospital level is to maximize resources and optimize patient outcomes. Of the disaster-specific triage methods developed to guide health care providers, the Simple Triage and Rapid Treatment (START) algorithm has become the most popular system world-wide. Despite its appeal and global application, the accuracy and effectiveness of the START protocol is not well-known.

OBJECTIVES

The purpose of this meta-analysis was two-fold: (1) to estimate overall accuracy, under-triage, and over-triage of the START method when used by providers across a variety of backgrounds; and (2) to obtain specific accuracy for each of the four START categories: red, yellow, green, and black.

METHODS

A systematic review and meta-analysis was conducted that searched Medline (OVID), Embase (OVID), Global Health (OVID), CINAHL (EBSCO), Compendex (Engineering Village), SCOPUS, ProQuest Dissertations and Theses Global, Cochrane Library, and PROSPERO. The results were expanded by hand searching of journals, reference lists, and the grey literature. The search was executed in March 2020. The review considered the participants, interventions, context, and outcome (PICO) framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accuracy outcomes are presented as means with 95% confidence intervals (CI) as calculated using the binomial method. Pooled meta-analyses of accuracy outcomes using fixed and random effects models were calculated and the heterogeneity was assessed using the Q statistic.

RESULTS

Thirty-two studies were included in the review, most of which utilized a non-randomized study design (84%). Proportion of victims correctly triaged using START ranged from 0.27 to 0.99 with an overall triage accuracy of 0.73 (95% CI, 0.67 to 0.78). Proportion of over-triage was 0.14 (95% CI, 0.11 to 0.17) while the proportion of under-triage was 0.10 (95% CI, 0.072 to 0.14). There was significant heterogeneity of the studies for all outcomes (P < .0001).

CONCLUSION

This meta-analysis suggests that START is not accurate enough to serve as a reliable disaster triage tool. Although the accuracy of START may be similar to other models of disaster triage, development of a more accurate triage method should be urgently pursued.

A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents

Background

There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool.

Methods

The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system.

Results

There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria.

Conclusions

This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00932-z.

A mixed-methods feasibility study to assess the acceptability and applicability of immersive virtual reality sepsis game as an adjunct to nursing education

BACKGROUND

Virtual Reality (VR) simulation has been a topic of interest in recent years as an innovative strategy for healthcare education. Although there are a handful of studies evaluating VR simulation on knowledge, motivation, and satisfaction; there is a paucity of evidence to evaluate the effectiveness, acceptability and usability of 'Immersive' VR (IVR) simulation in nursing students.

OBJECTIVES

A two-stage sequential mixed-methods feasibility study underpinned by gaming theory investigated; (1) the impact of IVR sepsis game on pre-registration nurses' self-efficacy and, (2) their perceptions of the acceptability and applicability of IVR sepsis game as an adjunct to nursing simulation education.

METHODS

The IVR simulation intervention was designed in collaboration with serious game specialists. Stage one collated pre and post-intervention self-efficacy scores with 19 pre-registration nurses using the validated instrument, Nursing Anxiety and Self-Confidence with Clinical Decision Making (NASC-CDM©) scale. Stage two used a descriptive qualitative approach to explore student nurses' perceptions of the game.

RESULTS

In stage one, pre and post-test scores revealed significant increase in self-confidence (26.1%, P < 0.001) and a significant decrease in anxiety (23.4%, P < 0.001). Stage two qualitative responses revealed four over-arching themes: acceptability, applicability, areas of improvement of IVR sepsis game and limitations of IVR game.

CONCLUSION

IVR simulation show promise as an adjunct for nurse simulation and it appears to increase self-efficacy in pre-registration nursing students. Further testing with a sufficiently powered sample size will ratify findings and provide effective solutions to distance and online learning.

Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review

Background

Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment.

Objective

We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs).

Methods

We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD).

Results

A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs.

Conclusions

The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education.

Use of high-fidelity simulation technology in disasters: an integrative literature review

New innovative high‐fidelity simulation (HFS) technologies, including augmented reality and virtual reality, have begun being used for disaster response and preparedness. However, few studies have assessed the merit of these technologies in disaster simulation. This integrative literature review of 21 studies assesses the role of HFS technology in disaster. Most studies used a quantitative methodology (71.4%), followed by mixed (19%) or qualitative methods (9.6%). Nearly 60% covered only disaster preparedness phase, whereas 10% addressed disasters in middle‐income countries without including low‐income nations. The four most frequently mentioned technologies were immersive virtual reality simulation, computerized virtual reality simulation, full‐scale simulation, and augmented reality wearable smart glasses simulation. Nearly 50% of the studies used technology for purposes other than disaster simulation education, including telemedicine (14.3%), risk planning (14.3%), high‐risk map generation for preparedness purposes (9.5%), or rehabilitation medicine (4.8%). HFS technologies must be further evaluated outside of high‐income countries and in different disaster phases to better understand their full potential in disaster simulation. Future research should consider different health professions and more robust protocols to assist disaster response professionals and agencies in the adoption of HFS technologies.

360 virtual reality pediatric mass casualty incident: A cross sectional observational study of triage and out-of-hospital intervention accuracy at a national conference

OBJECTIVE

With adolescent mass casualty incidents (MCI) on the rise, out-of-hospital readiness is critical to optimize disaster response. We sought to test the feasibility and acceptability of a 360 Virtual Reality (360 VR) platform for disaster event decisionmaking.

METHODS

This was a cross-sectional observational assessment of a subject's ability to triage and perform out-of-hospital interventions using a 360 VR MCI module. A convenience sample of attendees was recruited over 1.5 days from the American College of Emergency Physicians (ACEP) national conference in San Diego, CA.

RESULTS

Two hundred and seven (207) subjects were enrolled. Ninety-six (46%) subjects identified as attendings, 66 (32%) as residents, 13 (6%) as medical students, 4 (2%) as emergency medical technicians and 28 (14%) as other. When comparing mean scores between groups, physicians who were <40 years old had mean scores higher than physicians who were >40 years old (8.7 vs 6.5, P < 0.001). Residents achieved higher scores than attendings (8.6 vs 7.5, P = 0.005). Based on a 5-point Likert scale, participants felt the 360 VR experience was engaging (median = 5) and enjoyable (median = 5). Most felt that 360 VR was more immersive than mannequin-based simulation training (median = 5).

CONCLUSION

We conclude that 360 VR is a feasible platform for assessing triage and intervention decisionmaking for adolescent MCIs. It is well received by subjects and may have a role as a training and education tool for disaster readiness. In this era of distanced learning, 360 VR is an attractive option for future immersive educational experiences.

Sort, Assess, Life-Saving Intervention, Triage With Drone Assistance in Mass Casualty Simulation: Analysis of Educational Efficacy

Introduction

Mass casualty incident (MCI) simulation and triage are educational methods used to provide high fidelity training to first response teams. Simulation and triage need to be as effective as possible to train professionals for true emergencies involving mass casualty. Although MCI simulation and triage have been used in the pre-professional setting (i.e. medical school, nursing school, etc.), more data is required regarding quality improvement of these simulations. This study focuses on quality improvement of MCI simulation and triage in the pre-professional training. In order to evaluate simulation quality to optimize future triage simulations, this study had three specific aims: (1) assess participant accuracy of triage after training in Sort, Assess, Life-Saving Interventions, Triage/Transport (SALT); (2) evaluate the role of stress and confidence in participants of triage simulation; (3) determine trainees’ perception of unmanned aerial vehicles (drones) in the setting of mass casualty simulation.

Methods

A total of 44 attendees of the University of Central Florida (UCF) College of Medicine Global Health Conference participated in this study across three groups. Each group was provided a 15-minute lecture on SALT protocol. After the training, the participants continued to a 30-minute simulation in which they were asked to accurately triage up to 46 patient-actors. Each participants’ triage designations were compared to the previously assigned designations of each patient-actor. Pre- and post-simulation surveys were collected and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM Corp., Chicago, IL). All other data were analyzed using descriptive statistics. 

Results

Qualitative and Likert data for the simulation were collected from 44 participants. Given a total of 1,113 triage scores (average of 25.29 triage designations per person), there was data to support that novice learners in this study tended to under-triage using the SALT protocol after 15-minute SALT training, with an overall accuracy of 52.43%. Survey data showed that confidence in mass casualty triage improved post-simulation, improving from median 3/10 to 5/10. Most participants were unaware of the use of unmanned aerial vehicles in MCI but most had positive opinions of their usefulness in MCI after the simulation, with a median score of 8/10.

Conclusions

Participant accuracy of triage after undergoing a 15-minute training in SALT triage was 52.43%, with a non-statistically significant tendency to under-triage. This accuracy level is consistent with other studies of SALT triage in MCI, but the tendency to undertriage requires further study for validation. Stress levels during the simulation were significantly elevated, while post-simulation confidence increased significantly from pre-simulation. The perception of drone utility in MCI was favorable among participants in this study, indicating drones may be useful for first response teams in future mass casualty simulations.

Immersive Virtual Reality Medical Simulation: Autonomous Trauma Training Simulator

Background

Medical and traumatic emergencies can be intimidating and stressful. This is especially true for early-career medical personnel.Training providers to respond effectively to medical emergencies before being confronted with a real scenario is limited by unnatural or high-cost training modalities that fail to realistically replicate the stress and gravity of real-world trauma management. Immersive virtual reality (IVR) may provide a unique training solution. 

Methods

We created a working group of 10 active duty or former military emergency medicine physicians and two technical experts. We hosted 10 meetings to facilitate the development process. The program was developed with financial support from the Telemedicine and Advanced Technology Research Center (TATRC), through the primary vendor Exonicus, Inc, with support from Anatomy Next Inc, and Kitware, Inc. Development was completed using an agile project management style, which allowed our team to review progress and provide immediate feedback on previous milestones throughout its completion. The working group completed the resulting four simulation scenarios to evaluate perceived realism and training potential. Finally, testing of the technology platform off the network in a deployed role 3 was conducted.

Results

Upon completion, we created four IVR scenarios based on the highest mortality battlefield injuries: hemorrhage, tension pneumothorax, and airway obstruction. The working group unanimously indicated a high level of realism and potential training usefulness. Throughout this process, there have been a number of lessons learned and we present those here to show what we have created as well as provide guidance to others creating IVR training solutions. 

Conclusion

Our team developed trauma scenarios that, to our knowledge, are the only IVR trauma scenarios to run autonomously without instructor input. Furthermore, we provide a potential template for the creation of future autonomous IVR training programs. This framework may offer a dynamic starting point as more teams seek to leverage the capabilities IVR offers.