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

The effect of different retraining intervals for immediate life support training: A randomized controlled trial

BACKGROUND

The optimal retraining intervals for Immediate Life Support (ILS) are unclear. This study aimed to explore the effects of different retraining intervals for simulation-based, short-duration ILS courses.

METHODS

In this randomized controlled study, junior residents and nurses were recruited and assigned to three groups. After receiving initial simulation-based ILS training, the groups underwent retraining at different intervals: 3 months, 6 months, and 1 year. Each one-hour retraining session included an 8-min in-situ resuscitation simulation on a high-fidelity manikin, followed by debriefing. One year after the initial training, all participants completed a paper-based test and self-efficacy questionnaires on teamwork performance, in addition to a resuscitation simulation. Blinded evaluators assessed performance by reviewing simulation videos using validated checklists.

RESULTS

Eighty-two out of 89 participants completed the study. They had similar characteristics, including age and years of work experience. The 6-month group had fewer resuscitation experiences in the past year. One year after the initial training, there were significant differences in the median skill performance scores across the groups (3-month vs. 6-month vs. 1-year: 31 vs. 28 vs. 23.5, p < 0.01). The 3-month group outperformed the 6-month group (p = 0.04), and the 6-month group outperformed the 1-year group (p = 0.01). The 3-month group also had significantly higher knowledge scores and performed best in self-evaluated teamwork performance.

CONCLUSION

Our study shows that a 3-month retraining interval achieved the greatest effect for healthcare professionals with limited resuscitation experience in simulation-based, short-duration ILS retraining courses.

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

The impact of electronic health records on the ordering of medical tests

BACKGROUND

Healthcare facilities often encounter patients with incomplete records from previous visits, leading to duplicated tests. Recent Electronic Health Records (EHR) investments aim to address this issue. This study examines how viewing patient information via OFEK EHR affects the frequency of tests ordered by the physician. The OFEK system, developed in Clalit Health Services, is an advanced online medical records system used in hospitals. It was expanded to all hospitals and HMOs starting in 2013, allowing medical information to be shared and accessed in the Israeli healthcare system.

METHODS

The study was conducted at the Israel Center for Medical Simulation (MSR), with 26 physicians engaged in encounters with simulated patients (SP). The SPs provided relevant clinical histories and signs for two abdominal pain cases. The physicians ordered diagnostic tests, and after receiving the tests' results they set a final diagnosis and could order additional tests. They had randomized access to the OFEK system to vary test-ordering patterns. In both scenarios, we examined three key variables to see if access to the OFEK system influenced the decision to order diagnostic tests ("QTestsBefore" - the number of tests ordered by the physician after the patient visit; "QTestsAfters" - the number of tests ordered by the physician after receiving the results of the first round; "QSumTests" - The total number of tests).

RESULTS

In the study group with access to the OFEK EHR, an average of 5.5 tests were ordered, compared to 6.85 in the control group (p-value = 0.01). Ordinary Least Squares regressions confirmed that the overall number of tests, particularly the second round ordered after receiving initial results, was significantly lower with OFEK. Additionally, years of clinical practice also correlated with fewer ordered tests.

CONCLUSIONS

The findings show that the OFEK EHR system reduces the number of medical examinations by allowing physicians to access medical histories and past tests, which supports efficient decision-making. This leads to fewer ordered medical tests and, thus, reduces the time procedures patients spend in EDs or hospitals. Efficient decision-making and fewer redundant medical tests can improve patient flow, free up resources, and reduce overcrowding in emergency departments.

Simulation-Based Training in Clinical Event Debriefing Improves Leadership Performance

OBJECTIVES

Clinical event debriefing (CED) improves healthcare team performance and patient outcomes. Most pediatric emergency medicine (PEM) physicians do not receive formal training in leading CED. Our objectives were to develop a CED curriculum and evaluate its effect on performance, knowledge, comfort, and clinical practice.

METHODS

This was a single group pre-post-retention study. We developed a hybrid curriculum with simulation, an interactive module, and individual feedback. We invited faculty and fellows from the PEM division of our hospital to participate. During an in-person training day, participants led standardized clinical simulation scenarios followed by simulated CED with immediate feedback on their leadership performance. They watched an interactive module between scenarios. Participants returned for a retention assessment 2-6 months later with a third simulation and debrief. Participants completed surveys measuring attitudes, experiences, and knowledge. Participants also evaluated the curriculum.The primary outcome was CED leadership performance using a novel 21-item tool that we developed, the Debrief Leadership Tool for Assessment (DELTA). A blinded, trained rater measured performance with DELTA. Secondary outcomes included changes in knowledge and comfort and changes in clinical practice.

RESULTS

Twenty-seven participants enrolled and completed all parts of the curriculum and assessments. Debrief leadership performance improved by a mean of 3.7 points on DELTA pre-training to post-training (95% confidence interval = 2.7, 4.6, P < 0.01) and by 1.4 points from pre-training to retention (95% confidence interval = 0.1, 2.8, P = 0.03). Knowledge and comfort also significantly improved from pre-training to post-training and were sustained at retention. Most (67%) participants changed their clinical practice of CED after completing the curriculum. All participants would recommend the training to other PEM physicians.

CONCLUSIONS

A hybrid simulation-based curriculum in leading CED for PEM physicians was associated with improvement in CED leadership performance, knowledge, and comfort. PEM physicians incorporated training into their clinical practice.

The effect of a team-based blended simulation training program on cardiopulmonary resuscitation on healthcare professionals' perception, performance, and costs: a mixed-method study

BACKGROUND

The quality of Cardio Pulmonary Resuscitation (CPR) and Automated External Defibrillations (AED) treatment provided by individual practitioners is the most important factor in surviving an in-hospital cardiac arrest (IHCA); therefore, healthcare professionals (HCPs) require sufficient resuscitation competency. This study aimed to analyze the effects of a blended team-based CPR and AED simulation training (riAniMO program) on HCPs performance, satisfaction and perception on transferability, and costs.

METHODS

The riAniMO is based on a multimedia training program with video lessons and a virtual CPR resuscitation simulation, and a team-based CPR and AED simulation. The study utilized a mixed-method design. The quantitative phase involved a retrospective cohort study with a comparison group to assess the impact of the riAniMO. Meanwhile, the qualitative phase involved four focus groups (FGs) to investigate the viewpoints of professionals on the strengths and limitations of the riAniMO. We compared the 845 HCPs who participated in the BLSD (Basic Life Support- early Defibrillation) re-training program with ERC (European Resuscitation Council) approach and the 1,167 who participated in the riAniMO re-training program. BLSD re-training took place between January and December 2019 and riAniMO re-training took place between January and December 2022.

RESULTS

From quantitative analysis, a slight increase in the number of HCPs satisfied with retraining in the riAniMO group compared to the BLSD group was found. However, the percentage of HCPs certified decreased by 9% in the riAniMo group (90.2%) compared to the BLSD group (99.2%). The RiAniMO approach resulted in cost savings by training 322 more healthcare providers and saving € 61.7 per participant. From the FG analysis, five themes emerged: 1) Realism in Learning: Experimenting in your own operating context and using your own devices; 2) Strength of the working group and multidisciplinarity; 3) Improved perception of training burden; 4) Facilitator as consultant and guide, which provides real-time situational feedback; 5) Transparency on evaluations and certifications for the simulations.

CONCLUSIONS

The riAniMO approach maintained high standards in terms of HCPs' satisfaction and performance and seemed to be cost-saving. Further studies are necessary to verify the long-term effectiveness of training methods for team-based CPR and AED simulation.

A novel blended and interprofessional approach to pediatric emergency training: self-assessment, perception, and perceived long-term effects

BACKGROUND

We developed a blended training program at a tertiary pediatric center based on hospital-specific emergency guidelines, profession-specific Virtual Patients (VPs), and interprofessional team training. Using this novel approach, we addressed differing educational needs of medical and nursing staff and intrinsic cognitive overload among participants, aiming for harmonization of in-house emergency proceedings.

METHODS

Self-assessments of pediatric emergency knowledge and skills were conducted before (T1) and after (T2) preparation using VPs, as well as after the team training day (T3). At T3, participants completed questionnaires on the training approach, its components, and learning impact. Ten months after the training, a follow-up survey (T4) queried perceived benefits within and beyond emergency situations.

RESULTS

A total of 56 medical staff and 56 nursing staff members participated in the pilot phase. Of these, N = 55 (98%) and N = 48 (85%), respectively, returned self-assessments; questionnaires were completed by N = 55 (98%) and N = 51 (91%), respectively. In both groups, 57 participants (50.9%) completed the follow-up survey. After team training (T3), both groups had statistically significant increased knowledge and skill scores compared with those at T1. Regarding the blended approach and its components, medical and nursing staff alike rated the entire course and its guidelines, the preparatory VPs, and the team training very highly. Participants felt being better prepared for pediatric emergencies. Perceived strengths of the training approach were in the triangulation of teaching methods and its interprofessionalism. More training scenarios were requested, as well as recurrent training. In the follow-up, participants reported improved confidence and calmness, as well as improved communication and collaboration when involved in an emergency. Beyond emergencies, benefits were reported in daily routines.

CONCLUSIONS

Our blended approach was perceived as being effective in improving preparedness among medical and nursing house staff. This approach permits customization of content and deliberate practice to improve pediatric critical care.

Development, Evaluation, and Implementation of a Cost-Effective, Novel Lateral Canthotomy Simulation Model for Training Emergency Medicine Physicians

This study proposes a new, low-cost lateral canthotomy simulation model for the purpose of improving training among emergency medicine physicians. This model is important for the rehearsal and honing of skills necessary in such a critical procedure, in cases where this procedure needs to be done in a sensitive situation where an ophthalmologist is not readily available. We surveyed 15 emergency residents before and after the training on comfort and proficiency in performing lateral canthotomy with a standardized Likert scale. Results show a significant increase in comfort and familiarity with the procedure post training, with average comfort levels increasing from 2.4 at pre-training to approximately 3.87 at post training. These findings would, therefore, indicate that the novel simulation model effectively bridges the proficiency gap and should then translate into better preparedness with the potential to improve patient outcomes in emergency settings.

A Comparison of Telesimulation Using the Virtual Resus Room and In Situ Simulation in Pediatric Emergency Medicine

OBJECTIVES

During the COVID-19 pandemic, there was a marked shift toward telesimulation in medical education. Limited studies exist comparing the effectiveness of online and offline simulation education. The goals of this study are to evaluate active learners' perceived effectiveness of telesimulation versus in situ simulation and to identify potential shortcomings of existing online teaching platforms.

METHODS

Through participant evaluations after a simulation, we compared telesimulation using the Virtual Resus Room (VRR) to in situ simulation in the domains of (1) self-efficacy, (2) fidelity, (3) educational value, and (4) teaching quality. Study subjects included medical and pharmacy residents and medical students completing their pediatric emergency medicine rotation at two children's hospitals as well as nurses, nurse practitioners, and physician assistants who were recently hired and orienting to their new roles in the emergency department. Learners used a modified Michigan Standard Simulation Experience Scale to evaluate either a telesimulation or in situ simulation case. Survey responses were compared using Wilcoxon rank sum tests with Bonferroni correction for multiple comparisons.

RESULTS

In overall assessment, in situ simulation was rated higher than telesimulation. There were significant differences noted related to perceived realism, utility in training device-related skills, and utility in training team-building skills. All P values were less than 0.0036. There were no significant differences between simulation types in perception of physical examination fidelity, instructor adequacy, or self-efficacy.

CONCLUSIONS

Telesimulation using the VRR is comparable to in situ simulation in learners' perception of improvement in self-efficacy and of teaching quality for pediatric emergency medicine topics. However, participants felt less able to practice tactile and communication skills virtually. Further innovation is needed to improve learners' experience with fidelity and educational value.

Enhancing the competencies of obstetrical nurses and midwives in high-risk pregnancy management through simulation-based training in Lao people's democratic republic: A pilot study

BACKGROUND

Simulation-based training has been widely used as a valuable strategy for learning and evaluating clinical skills at different levels of nursing and midwifery education. The impact of simulation training on intensive management for high-risk pregnancy in a low-resource setting has been limited.

AIM

To examine the effect of simulation-based training with low-fidelity mannequins on obstetrical nurses and midwives' knowledge, attitude, and skills for high-risk pregnancy management in a low-resource setting.

METHOD

During September 2023, twenty-five obstetrical nurses or midwives who worked in five tertiary public hospitals in Vientiane Prefecture participated in the three-day training workshops for intensive management in high-risk pregnant women and newborns that used a simulation-based training approach integrating problem-based learning. The evaluated criteria of knowledge, attitudes, and skills pre- and post-test scores were statistically compared.

FINDINGS

Workshop trainees demonstrated an increase significantly in knowledge for high-risk pregnancy management (p = 0.012), attitude toward high-risk pregnancy management (p = 0.000), and attitude toward simulation-based training design (p = 0.002). The clinical skills were used on the simulation performance checklist, and the pre-posttest gain in overall performance scores had a statistically significant difference (p = 0.000). The mean score of postpartum hemorrhage management skills was 11.48±2.23, which increased the highest score among all skills.

CONCLUSIONS

The simulation-based training in high-risk pregnancy management improves the knowledge, attitude, and skills of nurses and midwives in low-resource settings. Next steps include direct observation of trainees in the clinical setting to assess their competence in ensuring patient safety, achieving positive pregnancy outcomes, and enhancing satisfaction.

TEAMs go VR-validating the TEAM in a virtual reality (VR) medical team training

BACKGROUND

Inadequate collaboration in healthcare can lead to medical errors, highlighting the importance of interdisciplinary teamwork training. Virtual reality (VR) simulation-based training presents a promising, cost-effective approach. This study evaluates the effectiveness of the Team Emergency Assessment Measure (TEAM) for assessing healthcare student teams in VR environments to improve training methodologies.

METHODS

Forty-two medical and nursing students participated in a VR-based neurological emergency scenario as part of an interprofessional team training program. Their performances were assessed using a modified TEAM tool by two trained coders. Reliability, internal consistency, and concurrent validity of the tool were evaluated using intraclass correlation coefficients (ICC) and Cronbach's alpha.

RESULTS

Rater agreement on TEAM's leadership, teamwork, and task management domains was high, with ICC values between 0.75 and 0.90. Leadership demonstrated strong internal consistency (Cronbach's alpha = 0.90), while teamwork and task management showed moderate to acceptable consistency (alpha = 0.78 and 0.72, respectively). Overall, the TEAM tool exhibited high internal consistency (alpha = 0.89) and strong concurrent validity with significant correlations to global performance ratings.

CONCLUSION

The TEAM tool proved to be a reliable and valid instrument for evaluating team dynamics in VR-based training scenarios. This study highlights VR's potential in enhancing medical education, especially in remote or distanced learning contexts. It demonstrates a dependable approach for team performance assessment, adding value to VR-based medical training. These findings pave the way for more effective, accessible interdisciplinary team assessments, contributing significantly to the advancement of medical education.

Comparison of simulation and video-based training for acute asthma

BACKGROUND

Emergency medicine is particularly well suited to simulation training. However, evidence for the efficacy of simulation-based medical training remains limited especially to manage high-risk cases such as acute asthma.

OBJECTIVE

The objective of our study was to compare the performance of high-fidelity simulation (HFS) and interactive video-case challenge-based training (IVC) for final-year medical students in the management of acute asthma.

METHODS

This was a prospective randomized controlled study conducted at the emergency department (ED) of Monastir University hospital ( Tunisia). 69 final-year medical students were randomized to HFS (n = 34) and IVC (n = 35) training on acute asthma topic. The study was conducted over a 1-week period. Efficacy of each teaching method was compared through the use of multiple-choice questionnaires (MCQ) before (pre-test), after (post-test) training and a simulation scenario test conducted 1 week later. The scenario was based on acute asthma management graded on predefined critical actions using two scores: the checklist clinical score (range 0 to 30), and the team skills score (range 0 to 16). Student satisfaction was also evaluated with the Likert 5 points scale. Two years after the post-test, both groups underwent a third MCQ testing to assess sustainability of knowledge.

RESULTS

There were no differences in age between groups. There was no statistically significant difference between the HFS and IVC groups pre-test scores (p = 0.07). Both groups demonstrated improvement in MCQ post-test from baseline after training session; the HFS MCQ post-test score increased significantly more than the IVC score (p < 0.001). The HFS group performed better than the IVC group on the acute asthma simulation scenario (p < 0.001). Mean checklist clinical score and mean team skills score were significantly higher in HFS group compared to IVC group (respectively 22.9 ± 4.8 and 11.5 ± 2.5 in HFS group vs 19.1 ± 3 and 8.4 ± 3.1 in IVC group) (p < 0.001). After 2 years, MCQ post-test scores decreased in both groups but the decrease was lower in HFS group compared to the IVC group.

CONCLUSION

High-fidelity simulation-based training was superior to interactive video-case challenge for teaching final year medical students,and led to more long-term knowledge retention in the management of simulated acute asthma patients.

TRIAL REGISTRATION

The study was registered at www.

CLINICALTRIALS

gov NCT02776358 on 18/05/2016.

Transformative Learning, Priming, and Simulation Timing: A Randomized Controlled Pilot Study Among Emergency Medicine Residents

Background Traditionally, learning is thought to occur best when prerequisite cognitive background information is delivered before simulation training. More recent studies have attempted to analyze the transformative nature of simulation by placing simulation before didactics. However, these studies were flawed as they provided background on the subject before the simulation itself. Our study aims to isolate the transformative effect of simulation and answer the question of whether lecture or simulation should come first. Methodology We designed a novel simulation session and accompanying lecture for 18 Emergency Medicine residents in all three years of training regarding a subject they were entirely unfamiliar with, the emergent management of a left ventricular assist device (LVAD). The residents were randomized into two groups. One group had the lecture (8/18) before their simulation, while the other group (10/18) had the simulation first and the lecture afterward, testing the motivational nature. Thereafter, both groups responded to a post-session survey with Likert-style and open-ended comment questions to assess the reaction to the session and a knowledge-based multiple-choice question test. Results Both groups did not score significantly differently on either the immediate post-test or a retention post-test that we administered four weeks later. Three of eight participants reported in open comments that they were much more comfortable with a lecture-first than a simulation-first format. Conclusions Despite controlling for some of the limitations of previous studies, our results including learners' preferences do not support a transformation in the sequence of clinical skills learning. Until other larger studies prove the opposite, we recommend continuing with the lecture followed by the simulation sequence as per existing conceptual simulation learning frameworks.

Efficacy of high-fidelity simulation in advanced life support training: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Simulation is an increasingly used novel method for the education of medical professionals. This study aimed to systematically review the efficacy of high-fidelity (HF) simulation compared with low-fidelity (LF) simulation or no simulation in advanced life support (ALS) training.

METHODS

A comprehensive search of the PubMed, Chinese Biomedicine Database, Embase, CENTRAL, ISI, and China Knowledge Resource Integrated Database was performed to identify randomized controlled trials (RCTs) that evaluated the use of HF simulation in ALS training. Quality assessment was based on the Cochrane Handbook for Systematic Reviews of Interventions version 5.0.1. The primary outcome was the improvement of knowledge and skill performance. The secondary outcomes included the participants' confidence and satisfaction at the course conclusion, skill performance at one year, skill performance in actual resuscitation, and patient outcomes. Data were synthesized using the RevMan 5.4 software.

RESULTS

Altogether, 25 RCTs with a total of 1,987 trainees were included in the meta-analysis. In the intervention group, 998 participants used HF manikins, whereas 989 participants received LF simulation-based or traditional training (classical training without simulation). Pooled data from the RCTs demonstrated a benefit in improvement of knowledge [standardized mean difference (SMD) = 0.38; 95% confidence interval (CI): 0.18-0.59, P = 0.0003, I2 = 70%] and skill performance (SMD = 0.63; 95% CI: 0.21-1.04, P = 0.003, I2 = 92%) for HF simulation when compared with LF simulation and traditional training. The subgroup analysis revealed a greater benefit in knowledge with HF simulation compared with traditional training at the course conclusion (SMD = 0.51; 95% CI: 0.20-0.83, P = 0.003, I2 = 61%). Studies measuring knowledge at three months, skill performance at one year, teamwork behaviors, participants' satisfaction and confidence demonstrated no significant benefit for HF simulation.

CONCLUSIONS

Learners using HF simulation more significantly benefited from the ALS training in terms of knowledge and skill performance at the course conclusion. However, further research is necessary to enhance long-term retention of knowledge and skill in actual resuscitation and patient's outcomes.

Exploring barriers and enablers to simulation-based training in emergency departments: an international qualitative study (BEST-ED Study)

INTRODUCTION

Simulation-based training (SBT) has gained significant traction within emergency medicine. The growing body of evidence describes the benefits that SBT can bring. However, identifying barriers and enablers when establishing successful SBT programmes in busy emergency departments (EDs), and ensuring longevity of such programmes, can be difficult.

OBJECTIVE

We aim to identify barriers and enablers to SBT in busy EDs.

METHODS

We explored and analysed the thoughts, experience and opinions of professionals involved in SBT and organisational support. 32 participants across 15 international sites were invited to a semistructured interview process. We included participants from a variety of backgrounds, from clinical staff to management staff. Transcribed interview data was classified and coded based on capability, opportunity and motivation behaviour (COM-B) domains and analysed based on theoretical domains framework. Frequency of the most mentioned thematic domain among participants is reported.

RESULTS

The interview data revealed several common themes, including the following: knowledge and skills (90%), support and leadership (96%), mental barriers (87.5%), local culture (96.6%), dedicated space (65.2%), time constraints (46.8%), social influence (87.5%), education (90.6%), professional development (68.75%), exams (59.3%) and personal goals (93.75%). Management staff was observed to prioritise resource, staffing and flow, while the clinical cohort tended to focus on specialty and personal development when it came to simulation training in the ED.

CONCLUSION

Potential barriers and enablers to SBT and in situ simulation for EDs were identified through interviews conducted in this study. The central themes in terms of barriers and enablers were local culture, leadership, individual needs, resources and optimisation. A tailored approach is vital for establishing a successful SBT and in situ simulation programme.

Fostering Adaptive Expertise Through Simulation

Technology-enhanced simulation has been used to tackle myriad challenges within health professions education. Recently, work has typically adopted a mastery learning orientation that emphasizes trainees' sequential mastery of increasingly complex material. Doing so has privileged a focus on performance and task completion, as captured by trainees' observable behaviors and actions. Designing simulation in these ways has provided important advances to education, clinical care, and patient safety, yet also placed constraints around how simulation-based activities were enacted and learning outcomes were measured. In tracing the contemporary manifestations of simulation in health professions education, this article highlights several unintended consequences of this performance orientation and draws from principles of adaptive expertise to suggest new directions. Instructional approaches grounded in adaptive expertise in other contexts suggest that uncertainty, struggle, invention, and even failure help learners to develop deeper conceptual understanding and learn innovative approaches to novel problems. Adaptive expertise provides a new lens for simulation designers to think intentionally around how idiosyncrasy, individuality, and inventiveness could be enacted as central design principles, providing learners with opportunities to practice and receive feedback around the kinds of complex problems they are likely to encounter in practice. Fostering the growth of adaptive expertise through simulation will require a fundamental reimagining of the design of simulation scenarios, embracing the power of uncertainty and ill-defined problem spaces, and focusing on the structure and pedagogical stance of debriefing. Such an approach may reveal untapped potential within health care simulation.

Measured task load in directed observers versus active participants undergoing high-fidelity simulation education in a critical care setting

Objectives

The use of directed observers in high-fidelity simulation education is increasingly common. While evidence suggests similar educational outcomes for directed observers compared to active participants in technical skills, it remains uncertain if this benefit also exists for senior clinicians, especially in mental workload. We sought to compare the workload between active participants and directed observers using an objective measure.

Methods

We performed a prospective, repeated-measures observational study during the New South Wales Ambulance Aeromedical Operations induction training from 2019 to 2020. Participants included senior critical care doctors, paramedics, and nurses undergoing high-fidelity simulation of prehospital and interhospital aeromedical missions. Task load was measured using the National Aeronautics and Space Administration task load index (NASA-TLX) administered following each simulation debrief. Prehospital and interhospital simulations were compared separately by building a multilevel model for complete case and all study data. Post hoc comparisons of NASA-TLX score for each group were performed using estimated marginal means (EMMs).

Results

We enrolled 70 participants, comprising 49 physicians (70%), 19 paramedics (27%), and two flight nurses (3%). From the complete case analysis, statistically significant differences were observed for total NASA-TLX scores between active participants and directed observers in both prehospital (participant EMM 78, observer EMM 65, estimated difference -13, 95% confidence interval [CI] -20 to -7) and interhospital simulations (participant EMM 69, observer EMM 59, estimated difference -10, 95% CI -16 to -3). When all available data were included, the pattern of results did not change.

Conclusions

In our sample of senior clinicians, the task load experienced by both active participants and directed observers in high-fidelity simulation education was high for both prehospital and interhospital simulation exercises. The statistically significant differences we report are unlikely to be practically significant. Our results support the use of directed observers when resource limitations do not allow all course attendees to participate in every simulation.

Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators

INTRODUCTION

In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit's performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA).

METHODS

This retrospective study was conducted by reviewing Siriraj Hospital's CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients' outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters.

RESULTS

There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance.

CONCLUSION

CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room

Background

Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum.

Methods

EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues.

Results

Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively.

Conclusions

Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.

Technology-enhanced simulation in emergency medicine: Updated systematic review and meta-analysis 1991-2021

Background

Over the past decade, the use of technology-enhanced simulation in emergency medicine (EM) education has grown, yet we still lack a clear understanding of its effectiveness. This systematic review aims to identify and synthesize studies evaluating the comparative effectiveness of technology-enhanced simulation in EM.

Methods

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Web of Science, and Scopus to identify EM simulation research that compares technology-enhanced simulation with other instructional modalities. Two reviewers screened articles for inclusion and abstracted information on learners, clinical topics, instructional design features, outcomes, cost, and study quality. Standardized mean difference (SMD) effect sizes were pooled using random effects.

Results

We identified 60 studies, enrolling at least 5279 learners. Of these, 23 compared technology-enhanced simulation with another instructional modality (e.g., living humans, lecture, small group), and 37 compared two forms of technology-enhanced simulation. Compared to lecture or small groups, we found simulation to have nonsignificant differences for time skills (SMD 0.33, 95% confidence interval [CI] -0.23 to 0.89, n = 3), but a large, significant effect for non-time skills (SMD 0.82, 95% CI 0.18 to 1.46, n = 8). Comparison of alternative types of technology-enhanced simulation found favorable associations with skills acquisition, of moderate magnitude, for computer-assisted guidance (compared to no computer-assisted guidance), for time skills (SMD 0.50, 95% CI -1.66 to 2.65, n = 2) and non-time skills (SMD 0.57, 95% CI 0.33 to 0.80, n = 6), and for more task repetitions (time skills SMD 1.01, 95% CI 0.16 to 1.86, n = 2) and active participation (compared to observation) for time skills (SMD 0.85, 95% CI 0.25 to 1.45, n = 2) and non-time skills (SMD 0.33 95% CI 0.08 to 0.58, n = 3).

Conclusions

Technology-enhanced simulation is effective for EM learners for skills acquisition. Features such as computer-assisted guidance, repetition, and active learning are associated with greater effectiveness.

Students and simulation facilitators' experiences and perceptions of a distraction and interruption simulation: a mixed-methods study

BACKGROUND

While distractions and interruptions are leading causes of errors during medication preparation, most nursing students are not taught how to manage distractions in a highly-interruptive environment. To help prepare nursing students to manage distractions and interruptions in clinical practice, we developed, implemented, and evaluated a medication preparation distraction and interruption simulation.

OBJECTIVES

To explore student and simulation facilitators experiences and perceptions of a distraction and interruption simulation.

DESIGN

A sequential explanatory mixed-methods design was adopted including surveys, interviews, and focus groups.

SETTING

A mid-sized research intensive western Canadian university.

PARTICIPANTS

A total of 112 third year nursing students who engaged in the distraction and interruption simulation, and five simulation facilitators who facilitated the distraction and interruption simulation, participated in this study.

METHODS

Students were invited to complete a cross sectional survey following the distraction and interruption simulation and were then invited to participate in focus groups. Simulation facilitators were invited to participate in one-on-one interviews following facilitating the distraction and interruption simulation. All data were collected between June and December 2020.

RESULTS

Data from surveys, interviews, and focus groups were delineated into 4 themes related to the phases of the simulation. The prebriefing provided an overview of the simulation and helped create psychological safety that was imperative for learning about potential medication errors when being distracted and interrupted. The simulation scenario had a high degree of fidelity and helped students implement strategies to manage distractions and interruptions. The structured debrief provided an opportunity for meaningful reflection. The impact of the simulation was apparent as students articulated the balance between speed versus safety and new strategies developed to manage distractions and interruptions in clinical practice.

CONCLUSION

This study supports the use of simulation to develop key skills for managing distractions and interruptions during medication preparation in clinical practice.

Effectiveness of speak-up training programs for clinical nurses: A scoping review

BACKGROUND

Speaking up about patient safety concerns is critical when bedside nurses encounter unsafe situations. Training programs that encourage nurses' speaking up behavior have been introduced, but there is limited evidence regarding whether such training leads to behavior change or improves patient safety.

OBJECTIVE

The aim of this review was to identify the effectiveness of speak-up training programs for clinical nurses, focusing on program content and outcomes.

DESIGN

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to the Cochrane and Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines.

METHODS

This study used bibliographic databases of PubMed, Embase, PsycINFO, Scopus, ProQuest Dissertations and Theses Global for the English language, and NDSL, KCI, RISS, KISS, and DBpia for the Korean language. The literature search used a combination of keywords and subject headings related to speak-up training programs for nurses or any type of nurse training program with an assertiveness component. Training outcomes were evaluated according to the 4-level Kirkpatrick model.

RESULTS

A total of 4808 references were retrieved, of which 21 articles were selected. These 21 studies were conducted in different parts of the world and published from 1981 to 2020. Speak-up training primarily increased some degree of nurses' levels of assertiveness and speak-up behavior, and also led to secondary outcomes such as job stress, work motivation, and communication conflicts. Most studies (n = 19) applied traditional training formats which consisted of multi-session lectures and practice, whereas three studies applied new methodologies such as high-fidelity simulations and online learning. According to the Kirkpatrick model, five studies assessed reactions to speak-up training (level 1), all studies evaluated learning as a result of training (level 2), two studies measured the effect of speak-up training on nurses' behavior (level 3), and one study evaluated nurses' results (level 4) while no studies evaluated patient-level outcomes.

CONCLUSIONS

Speak-up training for nurses can improve their levels of assertiveness or speak-up behaviors. Despite inconsistent or mixed findings, speak-up training has the potential to improve nurses' psychological well-being, leading to positive organizational performance. New training methods are directed at specialized education for clinical situations. Future speak-up training should consist of training programs based on real clinical situations in which team members participate together to comprehensively evaluate the effect of training on behavioral changes of health professionals as well as patient safety.

Psychological safety of remotely facilitated simulation compared with in-person-facilitated simulation: an <i>in situ</i> experimental controlled trial

The COVID-19 pandemic motivated simulation educators to attempt various forms of distance simulation in order to maintain physical distancing and to rapidly deliver training and ensure systems preparedness. However, the perceived psychological safety in distance simulation remains largely unknown. A psychologically unsafe environment can negatively impact team dynamics and learning outcomes; therefore, it merits careful consideration with the adoption of any new learning modality.

Between October 2020 and April 2021, 11 rural and remote hospitals in Alberta, Canada, were enrolled by convenience sampling in in-person-facilitated simulation (IPFS) (n = 82 participants) or remotely facilitated simulation (RFS) (n = 66 participants). Each interprofessional team was invited to attend two COVID-19-protected intubation simulation sessions. An

There was no statistically significant difference between RFS and IPFS total scores on the

Psychological safety can be established and maintained with RFS. Furthermore, in this study, RFS was shown to be comparable to IPFS in improving psychological safety among rural and remote interdisciplinary teams, providing simulation educators another modality for reaching any site or team.

Anxiety and Performance in Prehospital Emergency Care Simulation Assessments

INTRODUCTION

Anxiety experienced by students participating in simulations may impede their learning and performance. The added anxiety brought about by the socioevaluative nature of simulation assessments may accentuate this effect. This study aimed to assess the relationship between anxiety experienced by emergency care students and performance in an authentic prehospital emergency care simulation assessment.

METHODS

The State-Trait Anxiety Inventory (STAI) was completed before and after a simulation assessment by 58 emergency care students across all academic years of study of a 4-year degree program in prehospital emergency care. The state anxiety component of the STAI was plotted together with marks obtained by each student using a standardized assessment tool, and curve estimation was used to determine the nature of the relationship between state anxiety scores and marks.

RESULTS

Mean preassessment STAI scores were lower than mean postassessment scores (48.74 vs. 57.74), but mean scores from both groups were greater than normal mean scores for college students. The relationship of both preassessment and postassessment STAI scores with assessment marks was best described by a quadratic curve suggesting that performance was better at both the lower and higher ends of the range of STAI scores compared with the middle. Postassessment STAI scores provided a better fit with simulation assessment marks.

CONCLUSIONS

This study did not confirm the expected decrease in performance associated with increasing anxiety but rather suggests that some students may have the ability to respond positively to the highest levels of anxiety during simulation assessments.

High-Fidelity Patient Simulation Incorporated Into a Flipped Classroom Improves Students' Long-Term Knowledge Retention of Acute Organophosphorus Pesticide Poisoning

INTRODUCTION

The flipped classroom (FC) approach and high-fidelity patient simulation (HFPS) training have shown promising effects in short-term acquisition or long-term retention of knowledge in medical education. In this study, we aimed to explore the incorporation of HFPS into the FC and the impact on the long-term (3 months after classes) knowledge retention of medical undergraduate students learning about acute organophosphorus pesticide poisoning (AOPP).

METHODS

Eighty-two fifth-year medical students were randomly divided into an HFPS group (HG, n = 40) and an FC group (FG, n = 42). A postclass quiz and preinternship quiz were performed to assess the short-term knowledge acquisition and long-term (3 months after classes) knowledge retention of both groups of students. Feedback questionnaires were administered immediately after the class and before the internship to assess the students' self-perceived competency.

RESULTS

In the postclass quiz, the scores achieved by the students from the HG and FG were 15.58 ± 2.69 and 14.62 ± 2.19, respectively. No significant difference was found between the 2 groups (P = 0.19). In the preinternship quiz, the scores achieved by the students from the HG (14.50 ± 2.16) were significantly higher than those achieved by the students from the FG (11.40 ± 2.07, P < 0.001). There was no significant difference between the postclass quiz and preinternship quiz scores achieved by the HG students (P = 0.05). However, scores in the preinternship quiz showed a significant decline compared with the postclass quiz for the FG students (P < 0.001). Students in the HG gave significantly higher scores for self-perceived confidence in dealing with AOPP patients in the forthcoming internship on the postclass and preinternship questionnaires.

CONCLUSIONS

The incorporation of HFPS into the FC approach could improve students' long-term knowledge retention of AOPP and enhance their confidence in caring for these patients in their internship.

Feasibility of an Interprofessional, Simulation-Based Curriculum to Improve Teamwork Skills, Clinical Skills, and Knowledge of Undergraduate Medical and Nursing Students in Uganda: A Cohort Study

INTRODUCTION

Many deaths in Sub-Saharan Africa are preventable with provision of skilled healthcare. Unfortunately, skills decay after training. We determined the feasibility of implementing an interprofessional (IP) simulation-based educational curriculum in Uganda and evaluated the possible impact of this curriculum on teamwork, clinical skills (CSs), and knowledge among undergraduate medical and nursing students.

METHODS

We conducted a prospective cohort study over 10 months. Students were divided into 4 cohorts based on clinical rotations and exposed to rotation-specific simulation scenarios at baseline, 1 month, and 10 months. We measured clinical teamwork scores (CTSs) at baseline and 10 months; CSs at baseline and 10 months, and knowledge scores (KSs) at baseline, 1 month, and 10 months. We used paired t tests to compare mean CTSs and KSs, as well as Wilcoxon rank sum test to compare group CS scores.

RESULTS

One hundred five students (21 teams) participated in standardized simulation scenarios. We successfully implemented the IP, simulation-based curriculum. Teamwork skills improved from baseline to 10 months when participants were exposed to: (a) similar scenario to baseline {baseline mean CTS = 55.9% [standard deviation (SD) = 14.4]; 10-month mean CTS = 88.6%; SD = 8.5, P = 0.001}, and (b) a different scenario to baseline [baseline mean CTS = 55.9% (SD = 14.4); 10-month CTS = 77.8% (SD = 20.1), P = 0.01]. All scenario-specific CS scores showed no improvement at 10 months compared with baseline. Knowledge was retained in all scenarios at 10 months.

CONCLUSIONS

An IP, simulation-based undergraduate curriculum is feasible to implement in a low-resource setting and may contribute to gains in knowledge and teamwork skills.

Flexible Bronchoscopy Simulation as a Tool to Improve Surgical Skills in Otolaryngology Residency

Objective

To evaluate the benefits of simulation to teach flexible bronchoscopy.

Study Design

A prospective cohort study to assess the bronchoscopic skills of residents in an otolaryngology training program using a commercially available bronchoscopy simulator.

Setting

Tertiary care otolaryngology residency program.

Methods

Thirty-two otolaryngology residents and 4 expert faculty across 2 academic institutions were assessed on 3 flexible bronchoscopy tasks: diagnostic bronchoscopy, foreign body removal, and tracheal lesion biopsy. Performance was evaluated with a modified version of the validated Bronchoscopy Skills and Tasks Assessment Tool. At 1 of the 2 academic institutions, an additional tool was implemented to evaluate the simulator.

Results

There was a correlation between postgraduate training year and time taken to complete tasks, including bronchoscopy, foreign body extraction, and passing through the glottis (P < .001, P = .04, and P < .01, respectively). There was a significant difference between residents and faculty laryngologists for a range of skills and tasks, including percentage of time in middle lumen, contact with bronchial walls, inadvertent esophagus entry, and biopsy of healthy tissue (P < .001, P = .003, P < .001, and P < .001). Additionally, increasing postgraduate level was correlated with a higher percentage of time in the center of the lumen and reduced time to task completion (P = .05 and P < .001). Of 32 residents, 20 evaluated the simulator on its realism, with an average score of 4.1 of 5.

Conclusion

The commercially available flexible bronchoscopy simulator provides a valid assessment of bronchoscopic skill and is a useful tool for practicing bronchoscopy in a safe, controlled environment.

Level of Evidence

Individual cohort study.

Use of Virtually Facilitated Simulation to Improve COVID-19 Preparedness in Rural and Remote Canada

Background

The Alberta Health Services' Provincial Simulation Program (eSIM) is Canada's largest simulation program. The eSIM mobile simulation program specializes in delivering simulation-based education (SBE) to rural and remote communities (RRC). During the COVID-19 pandemic, a quality improvement project involving rapid cycle in situ virtually facilitated simulation (VFS) for COVID-19 airway management and health systems preparedness in RRC was successfully implemented.

Methods

Between April 24 and July 31, 2020, a team of six rural simulationists (four nurses and two physicians) provided 24 VFS sessions with virtual debriefing to 200 health care providers distributed across 11 RRC in Alberta and the Northwest Territories, covering a geographic area of approximately 169,028 km².

Results

Video analysis of sequential VFS rapid cycle sessions using a standardized observational tool indicated decreased personal protective equipment (PPE) breaches by 36.6% between the first and third cycles. Teams demonstrated increased competency with airway management such as correct use of bag-valve-mask ventilation, and implementation of health system process improvements, such as incorporation of an intubation checklist. Improvements occurred on average over 2.2 rapid cycles completed within 1.3 weeks per RRC. Postsession self-reported participant electronic surveys indicated self-reported improvement in clinical management, teamwork behavior, and health systems issues outcome measures which were categorized based on the Crisis Resource Management and Systems Engineering Initiative for Patient Safety (SEIPS) frameworks. Of the 48 survey respondents, 86.1% reported that VFS was equivalent or superior to in-person simulation. The cost of VFS was 62.9% lower than comparable in-person SBE.

Conclusion

VFS provides a rapidly mobilizable and cost-effective way of delivering high-quality SBE to geographically isolated communities.

Simulation-based research in emergency medicine in Canada: Priorities and perspectives

OBJECTIVE

Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).

METHODS

Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.

RESULTS

Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.

CONCLUSION

This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

The Effect of Teaching Nontechnical Skills in Advanced Life Support: A Systematic Review

OBJECTIVES

The objective of this study was to evaluate the effect of nontechnical skills (NTS) training on performance in advanced life support (ALS) simulation. Furthermore, we aimed to determine the ideal frequency of training sessions for an optimal retention and the value of debriefing.

METHODS

A systematic search was performed using PubMed, EMBASE, WoS, ERIC, CINAHL, and the Cochrane Library conducted through August 1, 2018. All primary studies mentioning NTS in ALS education were included. Three reviewers independently extracted data on study design and outcome. The MERSQI approach was used to evaluate the overall quality of evidence.

RESULTS

Of the 10,723 identified articles, 40 studies were included with a combined total of 3,041 participants, ranging from students to experts. Depending on the focus of the study, articles were categorized in NTS (n = 25), retention (n = 8), and feedback (n = 10). Incorporating NTS during ALS simulation showed significant improvements in timing for performing critical first steps. Furthermore, good leadership skills had a favorable effect on overall technical performance and teamwork during simulation improved team dynamics and performance. Finally, debriefing also had a beneficial effect on team performance. One particular type of debriefing does not appear to be superior to other types of debriefing.

CONCLUSION

Team simulation training resulted in improved NTS and a reduction in the time required to complete a simulated cardiac arrest. Therefore, a formal NTS program should be introduced into ALS courses. Feedback and repetitive practice are key factors to train NTS. The impact of training on team behaviors can persist for at least 3 to 6 months. In conclusion, understanding and improving NTS may help to create more effective teams. The effect on patient outcome requires further investigation.

Optimizing e-learning in oncology during the COVID-19 pandemic and beyond

The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted cancer care, research and residency training in oncology worldwide. Many countries canceled exams, shortened their residency program and medical school tenure. Traditional teaching and learning method has faced significant disruption during this time and the situation has pushed us to adapt to e-learning. Most national and international cancer meetings were converted into a virtual platform during this time. E-learning ensures a safe environment to maintain education during a pandemic. Digital technology-based learning is likely to be used effectively in oncology training even after the pandemic ends. Stakeholders should work towards standardizing e-learning into routine educational modules and create a system of credibility and accountability.

Simulation-based team training in time-critical clinical presentations in emergency medicine and critical care: a review of the literature

BACKGROUND

The use of simulation-based team training has increased over the past decades. Simulation-based team training within emergency medicine and critical care contexts is best known for its use by trauma teams and teams involved in cardiac arrest. In the domain of emergency medicine, simulation-based team training is also used for other typical time-critical clinical presentations. We aimed to review the existing literature and current state of evidence pertaining to non-technical skills obtained via simulation-based team training in emergency medicine and critical care contexts, excluding trauma and cardiac arrest contexts.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Before the initiation of the study, the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database. We conducted a systematic literature search of 10 years of publications, up to December 17, 2019, in the following databases: PubMed/MEDLINE, EMBASE, Cochrane Library, and CINAHL. Two authors independently reviewed all the studies and extracted data.

RESULTS

Of the 456 studies screened, 29 trials were subjected to full-text review, and 13 studies were included in the final review. None of the studies was randomized controlled trials, and no studies compared simulation training to different modalities of training. Studies were heterogeneous; they applied simulation-training concepts of different durations and intensities and used different outcome measures for non-technical skills. Two studies reached Kirkpatrick level 3. Out of the remaining 11 studies, nine reached Kirkpatrick level 2, and two reached Kirkpatrick level 1.

CONCLUSIONS

The literature on simulation-based team training in emergency medicine is heterogeneous and sparse, but somewhat supports the hypothesis that simulation-based team training is beneficial to teams' knowledge and attitudes toward non-technical skills (Kirkpatrick level 2). Randomized trials are called for to clarify the effect of simulation compared to other modalities of team training. Future research should focus on the transfer of skills and investigate improvements in patient outcomes (Kirkpatrick level 4).

Pitfalls in Emergency Medicine: Survey-Based Identification of Learning Objectives for Targeted Simulation Curricula by Emergency Department Staff

INTRODUCTION

The emergency department is a complex practice environment into which numerous factors may introduce both human and system error. Emergency physicians have to assemble and manage multidisciplinary teams with a moment's notice to manage critically ill patients. The EM training programs across Canada are diverse with considerable variation among programs. Acquisition of both high acuity low occurrence (HALO) and crisis resource management (CRM) skills are crucial to the development of proficient emergency room physicians. Physicians and allied health workers were surveyed to identify potential causes of error in local emergency departments and to find simulation-driven solutions.

METHODS

An anonymous survey was prepared to evaluate potential pitfalls of emergency care in St. John's, NL, Canada. It was distributed electronically to 108 medical staff, including physicians, nurses, and postgraduate year three (PGY3) residents. Respondents were asked about their experience with simulation education, and whether or not they feel that there is an opportunity for it in postgraduate emergency medicine training.

RESULTS

The response rate was 30%. Communication - with the emergency department team, consulting services, and patients - was identified as a potential topic for simulation, along with interruptions. Burnout, busy department, departmental crowding, end of shift handover, and incomplete/missing patient medical history were identified as topics that should be included in the emergency medicine curriculum. Following a review with the simulation expert panel, it was determined that end of shift handover could also be incorporated as a simulation in the existing curriculum.

DISCUSSION

This survey looked at pitfalls in emergency medicine through a CRM lens. Six pitfalls were identified as important for patient safety, but not best addressed with simulation. These could be incorporated into the half-day curriculum as didactic lectures. Four important patient safety pitfalls were identified that could potentially be addressed with simulation and incorporated in the existing emergency medicine simulation curriculum.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

Background

The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.

Methods/design

A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.

Discussion

Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

[Simulation curricular content in postgraduate emergency medicine: A multicentre Delphi study]

OBJECTIVES

There is increasing evidence to support integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum exists. Using Delphi methodology, we aimed to identify and establish content validity for adult EM curricular content best suited for simulation-based training, to inform national postgraduate EM training.

METHODS

A national panel of experts in EM simulation iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed. Topics scoring <2/4 were removed and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥ 3.5/4 were considered "core" curricular topics, while those rated 3.0-3.5 were considered "extended" curricular topics.

RESULTS

Forty-five experts from 13 Canadian centres participated. Two hundred eighty potential curricular topics, in 29 domains, were generated from a systematic literature review, relevant educational documents and Delphi panellists. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in eight domains, reached consensus as "core" curricular topics. Thirty-five additional topics, in 14 domains, reached consensus as "extended" curricular topics.

CONCLUSIONS

Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.

Establishing a Low-Resource Simulation Emergency Medicine Curriculum in Nepal

INTRODUCTION

High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment.

METHODS

We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases.

RESULTS

All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training.

DISCUSSION

Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potentially play a supportive role in developing an emergency medicine curriculum.

Use of simulation training to teach the ABCDE primary assessment: an observational study in a Dutch University Hospital with a 3-4 months follow-up

OBJECTIVES

To investigate short-term and long-term effectiveness of simulation training to acquire a structured Airway Breathing Circulation Disability Exposure (ABCDE) approach for medical emergencies; and to examine which skills were learnt and maintained best.

DESIGN

An observational study with a 3-4 months follow-up.

SETTING

Skills center of the University Medical Center Groningen.

PARTICIPANTS

Thirty voluntary participants (21 females and 9 males; 27±2.77 years) of a simulation-based course.

INTERVENTION

A 2-day ABCDE-teaching course for residents and non-residents. The course encompasses 24 simulations in which participants perform primary assessments of acute ill patients. Video recordings were taken of each participant performing a primary assessment, before (T1), directly after (T2) and 3-4 months after the intervention (T3).

MAIN OUTCOME MEASURES

Physicians' performance in the ABCDE primary assessment at T1, T2 and T3. Two observers scored the primary assessments, blinded to measurement moment, using an assessment form to evaluate the performance with regard to skills essential for a structured ABCDE approach. The Friedman and Wilcoxon signed-rank test were used to compare physicians' performances on the subsequent measurement moments.

RESULTS

The mean ranks on the total primary assessment at T1, T2 and T3 were 1.14, 2.62 and 2.24, respectively, and were significantly different, (p<0.001).The mean ranks on the total primary assessment directly after the course (T2 vs T1 p<0.001) and 3-4 months after the course (T3 vs T1 p<0.001) were significantly better than before the course. Certain skills deteriorated during the follow-up. Strikingly, most skills that decrease over time are Crew Resources Management (CRM) skills.

CONCLUSION

A course using simulation training is an effective educational tool to teach physicians the ABCDE primary assessment. Certain CRM skills decrease over time, so we recommend organising refresher courses, simulation team training or another kind of simulation training with a focus on CRM skills.

Barriers and Solutions to Advancing Emergency Medicine Simulation-based Research: A Call to Action

Simulation technology has successfully improved patient safety and care quality through training and assessment of individuals, teams, and health care systems. Emergency medicine (EM) continues to be a leader and pioneer of simulation, including administration of simulation-based fellowships and training programs. However, EM simulation-based research has been limited by low rates of publication and poor methodologic rigor. The Society for Academic Emergency Medicine (SAEM) Simulation Academy is leading efforts to improve the quality of scholarship generated by the EM simulation community and to foster successful research careers for future generations of EM simulationists. Through a needs assessment survey of our membership and a year-long consensus-based approach, we identified two main clusters of barriers to simulation-based research: lack of protected time and dedicated resources and limited training and mentorship. As a result, we generated four position statements with implications for education, training, and research in EM simulation and as a call to action for the academic EM community. Recommendations include expansion of funding opportunities for simulation-based research, creation of multi-institutional simulation collaboratives, and development of mentorship and training pathways that promote rigor in design and methodology within EM simulation scholarship.

Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine

OBJECTIVES

Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation. The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.

METHODS

The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.

RESULTS AND ANALYSIS

Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.

CONCLUSIONS/IMPLICATIONS FOR EDUCATORS

We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.