Testing of a Complete Training Model for Chest Tube Insertion in Traumatic Pneumothorax

Assessing Chest Tube Insertion Skills Using a Porcine Rib Model-A Validity Study

INTRODUCTION

Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework.

METHODS

A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method.

RESULTS

Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established.

CONCLUSION

A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact.

Construction and Evaluation of a Realistic Low-Cost Model for Training in Chest-Tube Insertion

INTRODUCTION

Emergency thoracostomy is applied in life-threatening situations. Simulation plays a pivotal role in training in invasive techniques used mainly in stressful situations. Currently available commercial simulation models for thoracostomy have various drawbacks.

METHODS

We designed a thoracostomy phantom from discarded hospital materials and pigskin with underlying flesh. The phantom can be used alone for developing technical skills or mounted on an actor in simulation scenarios. Medical students, intensive care unit (ICU) and emergency department teams, and thoracostomy experts evaluated its technical fidelity and usefulness for achieving learning objectives in workshops.

RESULTS

The materials used to construct the phantom cost €47. A total of 12 experts in chest-tube placement and 73 workshop participants (12 ICU physicians and nurses, 20 emergency physicians and nurses, and 41 fourth-year medical students) evaluated the model. All groups rated the model's usefulness and the sensation of perforating the pleura highly. Experts rated the air release after pleura perforation lower than other groups. Lung reexpansion was the lowest rated item in all groups. Ratings of the appearance and feel of the model correlated strongly among all groups and experts. The ICU professionals rated the resistance encountered in introducing the chest drain lower than the other groups.

CONCLUSIONS

This low-cost, reusable, transportable, and highly realistic model is an attractive alternative to commercial models for training in chest-tube insertion skills.

Simulation-based procedure training (SBPT) in rarely performed procedures: a blueprint for theory-informed design considerations

Simulation-based procedure training is now integrated within health professions education with literature demonstrating increased performance and translational patient-level outcomes. The focus of published work has been centered around description of such procedural training and the creation of realistic part-task models. There has been little attention with regards to design consideration, specifically around how simulation and educational theory should directly inform programme creation. Using a case-based approach in cardiology as an example, we present a blueprint for theory-informed simulation-based procedure training linking learning needs analysis and defining suitable objectives to matched fidelity. We press the importance of understanding how to implement and utilise task competence benchmarking in practice, and the role of feedback and debriefing in cycles of repeated practice. We conclude with evaluation and argue why this should be considered part of the initial design process rather than an after-thought following education delivery.

Development and validation of the first performance assessment scale for interdisciplinary chest tube insertion: a prospective multicenter study

PURPOSE

Chest tube insertion requires interdisciplinary teamwork including an emergency surgeon or physician in conjunction with a nurse. The purpose of the study was to validate an interdisciplinary performance assessment scale for chest tube insertion developed from literature analysis.

METHODS

This prospective study took place in the simulation center of the University of Paris. The participants included untrained emergency/intensivist residents and trained novice emergency/intensivist physicians with less than 2 years of clinical experience and 6 months following training in thoracostomy, and nursing students. Each interdisciplinary pair participated in a high-fidelity simulation session. Two independent observers (O1 and O2) evaluated 61 items. Internal coherence using the Cronbach's α coefficient, intraclass correlation coefficient (ICC), and correlation of scores by regression analysis (R2) were analyzed. Comparison between O1 and O2 mean scores used a t test and F test for SDs. p Value < 0.05 was significant.

RESULTS

From an initial selection of 11,277 articles, 19 were selected to create the initial scale. The final scale comprises 61 items scored out of 80, including 24 items for nursing items, 24 items for medical competence, and 13 mixed items for the competence of both. 40 simulations including 80 participants were evaluated. Cronbach's α = 0.76, ICC = 0.92, R2 = 0.88. There was no difference between the observers' assessments of means (p = 0.82) and SDs (p = 0.92). Score was 51.6 ± 5.9 in the group of untrained residents and nursing student, and 57.2 ± 2.8 in the trained group of novice physicians and nursing students (p = 0.0003).

CONCLUSIONS

This first performance assessment scale for interdisciplinary chest tube insertion is valid and reliable.

Bariatric Surgical Simulation: Evaluation in a Pilot Study of SimLife, a New Dynamic Simulated Body Model

Background

The demand for bariatric surgery is high and so is the need for training future bariatric surgeons. Bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. In order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. The aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and Roux in Y gastric bypass).

Aim

A face validation study of SimLife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. The objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process.

Methods

SimLife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °C and ventilation.

Results

Twenty-four residents and chief residents from 3 French University Digestive Surgery Departments were enrolled in this study. Based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model’s ability to be learning tool as 8.78.

Conclusion

The use of the SimLife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons.

Development and Review of the Chest Tube High-Feedback Educational Simulation Trainer (CHEST)

INTRODUCTION

Emergency medicine physicians must receive training in chest tube placement. This life-saving skill must be completed quickly and competently to prevent morbidity and mortality. Training on live patients is no longer an appropriate or acceptable practice. Current training devices have been noted to be costly, may be difficult to store, or may require time-consuming cleanup or setup.

METHODS

Fifteen Chest tube High-feedback Educational Simulation Trainers were created. Frames were made from wood and PVC, and soft tissue layers were designed using silicone and polyurethane foam. Nine training sites volunteered to test the model and provided feedback on the acceptability of the task trainer for skill training.

RESULTS

Survey findings demonstrated that the model was realistic for teaching, portable, and was easy to use and maintain. In our model, the outer skin was noted to tear easily, thus limiting its use for suture training. Overall programs reported that they would use this model if it was available for the same or lower cost than current models.

CONCLUSIONS

An inexpensive task trainer was created that was easy to store, quick to set up, durable, easy to clean, and rated as effective at training the skill of chest tube insertion.

Competence in pleural procedures

Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, with most cases resulting from congestive heart failure, pneumonia, and cancer. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Invasive procedures such as pleural drainage, ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in determining specific diagnosis of pleural diseases. Management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training program, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and pleural effusions of different etiologies and even in palliation of symptomatic in malignant pleural effusion. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspecting the pleural space. It could be a diagnostic procedure in pleural effusions (suspected malignant pleural effusion, infective pleural disease such as empyema or tuberculosis) or therapeutic procedure (chemical pleurodesis or opening of loculation in empyema). Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis. In parapneumonic complex effusion, MT obviates the need for surgery in most cases. Thoracoscopy training should be considered being as important as bronchoscopy training for interventional pulmonology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.

A novel method for improving chest tube insertion skills among medical interns. Using biomaterial-covered mannequin

Objectives:

To develop a low-cost biomaterial-covered chest tube simulation model and assess its possible usefulness for developing the chest tube insertion skills among medical interns.

Methods:

This mannequin-based interventional study was performed in a University hospital setting. We included 63 physicians performing emergency medicine internship at the Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey, between January 2015 and March 2015. A dummy was prepared for training simulation using a display mannequin. Medical interns received instruction concerning pneumothorax and the chest tube procedure. A total of 63 medical interns participating in this interventional study were asked to insert a chest tube in a biomaterial-covered mannequin. A senior trainee scored their performance using a check list and the mean of the total scores was calculated (21 items; total score, 42).

Results:

The mean procedural score was 40.9 ± 1.3 of a possible 42. The maximum score of 42 was achieved by 39.7% of the medical interns, while another 33.3% achieved a score of 41. Of the participants, 85% succeeded in inserting the tube via an appropriate technique, achieving a score of 40 or more.

Conclusion:

Our results indicated that this model could be useful for effective training of medical interns for chest tube insertion, which is an important skill in emergency medicine. This biomaterial-covered model is inexpensive and its use can potentially be widened to improve training methods without significant financial demand.

Communicating Value in Simulation: Cost-Benefit Analysis and Return on Investment

Value-based health care requires a balancing of medical outcomes with economic value. Administrators need to understand both the clinical and the economic effects of potentially expensive simulation programs to rationalize the costs. Given the often-disparate priorities of clinical educators relative to health care administrators, justifying the value of simulation requires the use of economic analyses few physicians have been trained to conduct. Clinical educators need to be able to present thorough economic analyses demonstrating returns on investment and cost-effectiveness to effectively communicate with administrators. At the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes," our breakout session critically evaluated the cost-benefit and return on investment of simulation. In this paper we provide an overview of some of the economic tools that a clinician may use to present the value of simulation training to financial officers and other administrators in the economic terms they understand. We also define three themes as a call to action for research related to cost-benefit analysis in simulation as well as four specific research questions that will help guide educators and hospital leadership to make decisions on the value of simulation for their system or program.

Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax

Background

Chest tube insertion is required for most cases of traumatic pneumothorax. However, this procedure entails risks of potentially life-threatening complications. A "surgical" approach is widely recommended to minimize these risks. Simulation-based education has previously been used in surgical chest tube insertion, but not been subjected to rigorous evaluation.

Methods

The primary objective was to evaluate the success rate of surgical chest tube insertion in a task trainer (previously published). Secondary objectives were to assess performance with a performance assessment scale (previously designed), to measure the time of insertion, and to seek out a correlation between the learner's status, experience, and performance and success rate. Participants were surveyed for realism of the model and satisfaction; 65 participants (18 residents, 47 senior physicians) were randomized into SIM+ or SIM- groups. Both groups received didactic lessons. The SIM+ group was assigned deliberate practice on the model under supervision. Both groups were assessed on the model 1 month later.

Results

There was no difference between the SIM+ (n = 34) and SIM- (n = 31) groups regarding status (p = 0.44) or previous surgical insertion (p = 0.12). Success rate was 97 % (SIM+) and 58 % (SIM-), p = 0.0002. Performance score was 16.29 ± 1.82 (SIM+) and 11.39 ± 3.67 (SIM-), p = 3.13 × 10^-8. SIM+ presented shorter dissection time than SIM- (p = 0.047), but procedure time was similar (p = 0.71). Status or experience was not correlated with success rate, performance score, procedure time, or dissection time. SIM+ gained more self-confidence, judged the model more realistic, and were more satisfied than SIM-.

Conclusions

Simulation-based education significantly improved the success rate and performance of surgical chest tube insertion on a traumatic pneumothorax model.