The use of simulation in the development of individual cognitive expertise in emergency medicine

Prehospital Airway Management Training and Education: An NAEMSP Position Statement and Resource Document

AbstractAirway management competency extends beyond technical skills to encompass a comprehensive approach to optimize patient outcomes. Initial and continuing education for airway management must therefore extend beyond a narrow focus on psychomotor skills and task completion to include appreciation of underlying pathophysiology, clinical judgment, and higher-order decision making. NAEMSP recommends:Active engagement in deliberate practice should be the guiding approach for developing and maintaining competence in airway management.EMS learners and clinicians must be educated in an escalating approach to airway management, where basic airway maneuvers form the central focus.Educational activities should extend beyond fundamental knowledge to focus on the development of clinical judgment.Optimization of patient outcomes should be valued over performance of individual airway management skills.Credentialing and continuing education activities in airway management are essential to advance clinicians beyond entry-level competency.Initial and continuing education programs should be responsive to advances in the evidence base and maintain adaptability to re-assess content and expected outcomes on a continual basis.

Clinical reasoning: exploring its characteristics and enhancing its learning

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.

In Search of Characterizing Surgical Skill

OBJECTIVE

This paper provides a literature review and detailed discussion of surgical skill terminology. Culminating in a novel model that proposes a set of unique definitions, this review is designed to facilitate shared understanding to study and develop metrics quantifying surgical skill.

DESIGN

Objective surgical skill analysis depends on consistent definitions and shared understanding of terms like performance, expertise, experience, aptitude, ability, competency, and proficiency.

STRUCTURE

Each term is discussed in turn, drawing from existing literature and colloquial uses.

IMPLICATIONS

A new model of definitions is proposed to cement a common and consistent lexicon for future skills analysis, and to quantitatively describe a surgeon's performance throughout their career.

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study

INTRODUCTION

Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).

METHODS

We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.

RESULTS

Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.

CONCLUSION

Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

Evaluation of the impact of a diabetes education eLearning program for school personnel on diabetes knowledge, knowledge retention and confidence in caring for students with diabetes

AIMS

To study the impact of a novel comprehensive eLearning approach in delivering diabetes related education program that includes knowledge and sets of practices to the school personnel in Kuwait to enable them to provide a supportive environment for students with diabetes.

METHODS

The program was designed with three components namely; knowledge, skills and recommendations. The diabetes knowledge was delivered through an interactive eLearning program, the effectiveness of which was assessed using diabetes knowledge questionnaires which were deployed pre- and post-course delivery. Additionally, the participants' knowledge retention and confidence in caring for a student with diabetes were evaluated at 6 or 12 months post-intervention.

RESULTS

A total of 124 public schools' personnel participated in the program. Post e-Learning delivery, diabetes knowledge increased significantly from baseline (p < 0.0001) and knowledge was retained over 6 and 12 months. Average of overall confidence scores in caring for students with diabetes was 61.86% in all items of care.

CONCLUSIONS

Offering eLearning diabetes education for school personnel increases their knowledge which can be retained for up to 12 months and imparts confidence in caring for students with diabetes. This novel approach of delivering diabetes education will help school personnel in managing students with diabetes.

Human Factors and Simulation in Emergency Medicine

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

A Big Data and Learning Analytics Approach to Process-Level Feedback in Cognitive Simulations

Collecting and analyzing large amounts of process data for the purposes of education can be considered a big data/learning analytics (BD/LA) approach to improving learning. However, in the education of health care professionals, the application of BD/LA is limited to date. The authors discuss the potential advantages of the BD/LA approach for the process of learning via cognitive simulations. Using the lens of a cognitive model of radiograph interpretation with four phases (orientation, searching/scanning, feature detection, and decision making), they reanalyzed process data from a cognitive simulation of pediatric ankle radiography where 46 practitioners from three expertise levels classified 234 cases online. To illustrate the big data component, they highlight the data available in a digital environment (time-stamped, click-level process data). Learning analytics were illustrated using algorithmic computer-enabled approaches to process-level feedback.For each phase, the authors were able to identify examples of potentially useful BD/LA measures. For orientation, the trackable behavior of re-reviewing the clinical history was associated with increased diagnostic accuracy. For searching/scanning, evidence of skipping views was associated with an increased false-negative rate. For feature detection, heat maps overlaid on the radiograph can provide a metacognitive visualization of common novice errors. For decision making, the measured influence of sequence effects can reflect susceptibility to bias, whereas computer-generated path maps can provide insights into learners' diagnostic strategies.In conclusion, the augmented collection and dynamic analysis of learning process data within a cognitive simulation can improve feedback and prompt more precise reflection on a novice clinician's skill development.

Quality of Care Provided by Board-Certified Versus Non-Board-Certified Psychiatrists and Neurologists

PURPOSE

To examine associations between board certification of psychiatrists and neurologists and quality-of-care measures, using multilevel models controlling for physician and patient characteristics, and to assess feasibility of linking physician information with patient records to construct quality measures from electronic claims data.

METHOD

The authors identified quality measures and matched claims data from 2006 to 2012 with 942 board-certified (BC) psychiatrists, 868 non-board-certified (nBC) psychiatrists, 963 BC neurologists, and 328 nBC neurologists. Using the matched data, they identified psychiatrists who treated at least one patient with a schizophrenia diagnosis, and neurologists attending patients discharged with a principal diagnosis of ischemic stroke, and analyzed claims from these patients. For patients with schizophrenia who were prescribed an atypical antipsychotic, quality measures were claims for glucose and lipid tests, duration of any antipsychotic treatment, and concurrent prescription of multiple antipsychotics. For patients with ischemic stroke, quality measures were dysphagia evaluation; speech/language evaluation; and prescription of clopidogrel, low-molecular-weight heparin, intravenous heparin, and warfarin (for patients with co-occurring atrial fibrillation).

RESULTS

Overall, multilevel models (patients nested within physicians) showed no statistically significant differences in quality measures between BC and nBC psychiatrists and neurologists.

CONCLUSIONS

The authors demonstrated the feasibility of linking physician information with patient records to construct quality measures from electronic claims data, but there may be only minimal differences in the quality of care between BC and nBC psychiatrists and neurologists, or there may be a difference that could not be measured with the quality measures used.

High-fidelity medical simulation training improves medical students' knowledge and confidence levels in septic shock resuscitation

Background

Septic shock resuscitation bundles have poor compliance worldwide partly due to a lack of knowledge and clinical skills. High-fidelity simulation-based training is a new teaching technology in our faculty which may improve the performance of medical students in the resuscitation process. However, since the efficacy of this training method in our institute is limited, we organized an extra class for this evaluation.

Purpose

The aim was to evaluate the effect on medical students’ knowledge and confidence levels after the high-fidelity medical simulation training in septic shock management.

Methods

A retrospective study was performed in sixth year medical students during an internal medicine rotation between November 2015 and March 2016. The simulation class was a 2-hour session of a septic shock management scenario and post-training debriefing. Knowledge assessment was determined by a five-question pre-test and post-test examination. At the end of the class, the students completed their confidence evaluation questionnaire.

Results

Of the 79 medical students, the mean percentage score ± standard deviation (SD) of the post-test examination was statistically significantly higher than the pre-test (66.83%±19.7% vs 47.59%±19.7%, p<0.001). In addition, the student mean percentage confidence level ± SD in management of septic shock was significantly better after the simulation class (68.10%±12.2% vs 51.64%±13.1%, p<0.001). They also strongly suggested applying this simulation class to the current curriculum.

Conclusion

High-fidelity medical simulation improved the students’ knowledge and confidence in septic shock resuscitation. This simulation class should be included in the curriculum of the sixth year medical students in our institute.

Incorporating simulation into a residency curriculum

The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulation's unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule.

Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.

Emergency medicine residency boot Camp curriculum: a pilot study

Introduction

Establishing a boot camp curriculum is pertinent for emergency medicine (EM) residents in order to develop proficiency in a large scope of procedures and leadership skills. In this article, we describe our program’s EM boot camp curriculum as well as measure the confidence levels of resident physicians through a pre- and post-boot camp survey.

Methods

We designed a one-month boot camp curriculum with the intention of improving the confidence, procedural performance, leadership, communication and resource management of EM interns. Our curriculum consisted of 12 hours of initial training and culminated in a two-day boot camp. The initial day consisted of clinical skill training and the second day included code drill scenarios followed by interprofessional debriefing.

Results

Twelve EM interns entered residency with an overall confidence score of 3.2 (1–5 scale) across all surveyed skills. Interns reported the highest pre-survey confidence scores in suturing (4.3) and genitourinary exams (3.9). The lowest pre-survey confidence score was in thoracostomy (2.4). Following the capstone experience, overall confidence scores increased to 4.0. Confidence increased the most in defibrillation and thoracostomy. Additionally, all interns reported post-survey confidence scores of at least 3.0 in all skills, representing an internal anchor of “moderately confident/need guidance at times to perform procedure.”

Conclusion

At the completion of the boot camp curriculum, EM interns had improvement in self-reported confidence across all surveyed skills and procedures. The described EM boot camp curriculum was effective, feasible and provided a foundation to our trainees during their first month of residency.

What's your best time? Chronometry in the learning of medical procedures

OBJECTIVES

Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments.

METHODS

A selective review of the medical education literature was undertaken to identify how chronometry was used in a broad sampling of medical education research in the learning of medical procedures. We identified prior publications in which time measurement was used either directly as a pedagogic intervention or as an assessment method in a medical school programme.

RESULTS

Our review suggests a number of desirable features of chronometry. For the individual learner, procedural time measurements can demonstrate both improving ability and increasing consistency. Chronometry can enhance instructional designs involving deliberate practice by facilitating overlearning (i.e. learning that goes beyond minimum competence), increasing the challenge level and enhancing self-regulation of learning (e.g. self-competition). Breaking down chronometric data into meaningful interval or split times might further inform instructional designs.

CONCLUSIONS

Chronometry has the potential to contribute to instructional designs and assessment methods in medical procedures training. However, more research is needed to elucidate its full potential and describe possible negative consequences of this widely available but underutilised educational tool.

Diagnostic Reasoning and Decision Making in the Context of Health Information Technology

Diagnostic reasoning and medical decision making have been focal areas of research in the fields of medical education, cognition, and artificial intelligence in medicine. Drawing on several decades worth of research, we propose an integrated summary of prior research on diagnostic reasoning and decision making—in terms of both historical development and theoretical shifts. We also characterize the changes in research and theory resulting from the incorporation and adoption of health information technology in the clinical work place. In this paper, we differentiate between the various forms of diagnostic reasoning and trace the evolution of the various models of reasoning, including knowledge-based, exemplar-based, and visual strategies. We also discuss the effect of clinical expertise on reasoning processes. Within the medical decision-making research, we delineate the various approaches highlighting decision-making errors that arise due to the nature of heuristics and biases and other factors. Although there has been significant progress in our understanding, there is still a need for greater theoretical integration of disparate empirical phenomena. Specifically, there is a need to reconcile the various characterizations of reasoning and to evaluate the similarity and differences in the context of current health care practice. Finally, we discuss the role of human factors research in the study of clinical environments and also in relation to devising approaches and methodologies for understanding, evaluating, and supporting the diagnostic reasoning and decision processes.

A theoretical framework for simulation in nursing: answering Schiavenato's call

The aim of this article was to provide a response that supports and extends Schiavenato's call for a theoretically guided approach to simulation use in nursing education.We propose that a theoretical framework for simulation In nursing must first include, as a basis, a theoretical understanding of human performance and how it is enhanced.This understanding will, in turn, allow theorists to provide a framework regarding the utility, application, and design of the training environment, including internal and external validity. The expert performance approach, a technique that recently has been termed Expert-Performance-based Training (ExPerT), is introduced as a guiding frame work for addressing these training needs. We also describe how the theory of deliberate practice within the framework of ExPerT can be useful for developing effective training methods in health care domains and highlight examples of how deliberate practice has been successfully applied to the training of psychomotor and cognitive skills.

A qualitative analysis of faculty motivation to participate in otolaryngology simulation boot camps

OBJECTIVES/HYPOTHESIS

To characterize factors that motivate faculty to participate in Simulation-Based Boot Camps (SBBC); to assess whether prior exposure to Simulation-Based Medical Education (SBME) or duration (years) of faculty practice affects this motivation.

STUDY DESIGN

Qualitative content analysis of semi-structured interviews of faculty.

METHODS

Interviews of 35 (56%) of 62 eligible faculty including demographic questions, and scripted, open-ended questions addressing motivation. Interviews were recorded, transcribed, de-identified, coded and analyzed using qualitative analysis software. Demographic characteristics were described. Emerging response categories were organized into themes contributing to both satisfaction and dissatisfaction.

RESULTS

Three major themes of faculty motivation emerged: enjoyment of teaching and camaraderie; benefits to residents, patients and themselves; and opportunities to learn or improve their own patient care and teaching techniques. Expense, and time away from work and family, were identified as challenges. Faculty with many versus few years in practice revealed a greater interest in diversity of teaching experiences and techniques. Comparison of faculty with extensive versus limited simulation experience yielded similar motivations.

CONCLUSION

Enjoyment of teaching; benefits to all participants; and opportunities for self-improvement emerged as themes of faculty motivation to participate in SBBC. SBBC have unique characteristics which provide an opportunity to facilitate teaching experiences that motivate faculty.

A two-year experience of an integrated simulation residency curriculum

BACKGROUND

Human Patient Simulation (HPS) is increasingly used in medical education, but its role in Emergency Medicine (EM) residency education is uncertain.

STUDY OBJECTIVES

The objective of this study was to evaluate the perceived effectiveness of HPS when fully integrated into an EM residency didactic curriculum.

METHODS

The study design was a cross-sectional survey performed in 2006, 2 years after the implementation of an integrated simulation curriculum. Fifty-four residents (postgraduate year [PGY] 1-4) of a 4-year EM residency were surveyed with demographic and curricular questions on the perceived value of simulation relative to other teaching formats. Survey items were rated on a bipolar linear numeric scale of 1 (strongly disagree) to 9 (strongly agree), with 5 being neutral. Data were analyzed using Student t-tests.

RESULTS

Forty residents responded to the survey (74% response rate). The perceived effectiveness of HPS was higher for junior residents than senior residents (8.0 vs. 6.2, respectively, p<0.001). There were no differences in perceived effectiveness of lectures (7.8 vs. 7.9, respectively, p=0.1), morbidity and mortality conference (8.5 vs. 8.7, respectively, p=0.3), and trauma conference (8.4 vs. 8.8, respectively, p=0.2) between junior and senior residents. Scores for perceptions of improvement in residency training (knowledge acquisition and clinical decision-making) after the integration of HPS into the curriculum were positive for all residents.

CONCLUSION

Residents' perceptions of HPS integration into an EM residency curriculum are positive for both improving knowledge acquisition and learning clinical decision-making. HPS was rated as more effective during junior years than senior years, while the perceived efficacy of more traditional educational modalities remained constant throughout residency training.

Simulation in emergency medicine training

Simulation provides a range of educational tools that have increasingly been incorporated into emergency medicine (EM) curricula. Standardized patients and some partial task trainers, such as intubation heads, have been used for decades. More recently, a growing number of computer-screen simulations, high-fidelity mannequins, and virtual-reality simulators have expanded the number of procedures and conditions, which can be effectively simulated.The Accreditation Council for Graduate Medical Education transitioned to a competency-based assessment of residency programs in 2001 and included simulation as a method for incorporating the 6 core competencies into graduate medical education curricula. Over the past decade, numerous peer-reviewed publications have promoted simulation as an effective educational tool for each of the core competencies.The advanced technology used to operate many current simulators can erroneously become the focus of efforts to create a simulation-based curriculum. Simulation can most effectively be incorporated into EM curricula through the use of time-proven concepts, which start with defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective. In many, but not all, instances, simulation can be the best tool for achieving EM learning objectives.

Assessment of a new model for femoral ultrasound-guided central venous access procedural training: a pilot study

OBJECTIVES

Repetitive practice with feedback in residency training is essential in the development of procedural competency. Lightly embalmed cadaver laboratories provide excellent simulation models for a variety of procedures, but to the best of our knowledge, none describe a central venous access model that includes the key psychomotor feedback elements for the procedure, namely intravascular contents that allow for determination of correct needle position by either ultrasonographic imaging and/or aspiration or vascular contents.

METHODS

A cadaver was lightly embalmed using a technique that preserves tissue texture and elasticity. We then performed popliteal fossa dissections exposing the popliteal artery and vein. Vessels were ligated distally, and 14-gauge catheters were introduced into the lumen of each artery and vein. The popliteal artery and vein were then infused with 200 mL of icterine/gel and 200 mL of methylene blue/gel, respectively. Physician evaluators then performed ultrasound (US)-guided femoral central venous line placements and rated the key psychomotor elements on a five-point Likert scale.

RESULTS

The physician evaluators reported a median of 10.5 years of clinical emergency medicine (EM) experience with an interquartile range (IQR) of 16 and a median of 10 central lines placed annually (IQR = 10). Physician evaluators rated the key psychomotor elements of the simulated procedure as follows: ultrasonographic image of vascular elements, 4 (IQR = 0); needle penetration of skin, 4.5 (IQR = 1); needle penetration of vein, 5 (IQR = 1); US image of needle penetrating vein, 4 (IQR = 2); aspiration of vein contents, 3 (IQR = 2); passage of dilator into vein, 4 (IQR = 2); insertion of central venous catheter, 5 (IQR = 1); US image of catheter insertion into vein, 5 (IQR = 1); and overall psychomotor feedback of the simulated procedure compared to the evaluators' actual patient experience, 4 (IQR = 1).

CONCLUSIONS

For the key psychomotor elements of central venous access, the lightly embalmed cadaver with intravascular water-soluble gel infusion provided a procedural model that closely simulated clinicians' experience with patients.

Alternatives to the conference status quo: summary recommendations from the 2008 CORD Academic Assembly Conference Alternatives workgroup

Abstract Objective: A panel of Council of Emergency Medicine Residency Directors (CORD) members was asked to examine and make recommendations regarding the existing Accreditation Council of Graduate Medical Education (ACGME) EM Program Requirements pertaining to educational conferences, identified best practices, and recommended revisions as appropriate.

METHODS

Using quasi-Delphi technique, 30 emergency medicine (EM) residency program directors and faculty examined existing requirements. Findings were presented to the CORD members attending the 2008 CORD Academic Assembly, and disseminated to the broader membership through the CORD e-mail list server.

RESULTS

The following four ACGME EM Program Requirements were examined, and recommendations made: 1. The 5 hours/week conference requirement: For fully accredited programs in good standing, outcomes should be driving how programs allocate and mandate educational time. Maintain the 5 hours/week conference requirement for new programs, programs with provisional accreditation, programs in difficult political environs, and those with short accreditation cycles. If the program requirements must retain a minimum hours/week reference, future requirements should take into account varying program lengths (3 versus 4 years). 2. The 70% attendance requirement: Develop a new requirement that allows programs more flexibility to customize according to local resources, individual residency needs, and individual resident needs. 3. The requirement for synchronous versus asynchronous learning: Synchronous and asynchronous learning activities have advantages and disadvantages. The ideal curriculum capitalizes on the strengths of each through a deliberate mixture of each. 4. Educationally justified innovations: Transition from process-based program requirements to outcomes-based requirements.

CONCLUSIONS

The conference requirements that were logical and helpful years ago may not be logical or helpful now. Technologies available to educators have changed, the amount of material to cover has grown, and online on-demand education has grown even more. We believe that flexibility is needed to customize EM education to suit individual resident and individual program needs, to capitalize on regional and national resources when local resources are limited, to innovate, and to analyze and evaluate interventions with an eye toward outcomes.