Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia

Contemporary training methods in regional anaesthesia: fundamentals and innovations

Over the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation-based education, deliberate practice and curriculum design based on competency-based progression. Moving into the future, we present the latest innovations in web-based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.

Use of a simulation-based mastery learning curriculum to improve ultrasound-guided vascular access skills of pediatric anesthesiologists

BACKGROUND

Pediatric vascular access is inherently challenging due to the small caliber of children's vessels. Ultrasound-guided intravenous catheter insertion has been shown to increase success rates and decrease time to cannulation in patients with difficult intravenous access. Although proficiency in ultrasound-guided intravenous catheter insertion is a critical skill in pediatric anesthesia, there are no published competency-based training curricula.

AIMS

The objective of this study was to evaluate the performance of pediatric anesthesiologists who participated in a novel ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum.

METHODS

Pediatric anesthesia attendings, fellows, and rotating residents participated in the ultrasound-guided intravenous catheter insertion simulation-based mastery learning curriculum from August 2019 to February 2020. The 2-hour curriculum consisted of participants first undergoing a simulated skills pretest followed by watching a video on ultrasound-guided intravenous catheter insertion and deliberate practice on a simulator. Subsequently, all participants took a post-test and were required to meet or exceed a minimum passing standard. Those who were unable to meet the minimum passing standard participated in further practice until they could be retested and met this standard. We compared pre to post-test ultrasound-guided intravenous catheter insertion skills and self-confidence before and after participation in the curriculum.

RESULTS

Twenty-six pediatric anesthesia attendings, 12 fellows, and 38 residents participated in the curriculum. At pretest, 16/76 (21%) participants were able to meet or exceed the minimum passing standard. The median score on the pretest was 21/25 skills checklist items correct and improved to 24/25 at post-test (95% CI 3.0-4.0, P < .01). Self-confidence significantly improved after the course from an average of 3.2 before the course to a postcourse score of 3.9 (95% CI 0.5-0.9, P < .01; 1 = Not all confident, 5 = Very confident).

CONCLUSIONS

Simulation-based mastery learning significantly improved anesthesiologists' ultrasound-guided intravenous catheter insertion performance in a simulated setting.

Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents

Proficiency in ultrasound-guided regional anesthesia (UGRA) requires the practitioner to acquire cognitive and technical skills. For anesthesiology residents, an assortment of challenges has been identified in learning UGRA skills. Currently, a validated UGRA curriculum for residents does not exist, and the level of UGRA proficiency achieved during residency training can vary considerably. Simulated practice has been shown to enhance proficiency in UGRA, and a competency-based education with simulation training has been endorsed for anesthesiology residents. The objective of this review is to outline simulation-based training that can be implemented in a UGRA curriculum and to explore educational tools like gamification to facilitate competency in regional anesthesiology.

The effects of graduate competency-based education and mastery learning on patient care and return on investment: a narrative review of basic anesthetic procedures

BACKGROUND

Despite the widespread implementation of competency-based education, evidence of ensuing enhanced patient care and cost-benefit remains scarce. This narrative review uses the Kirkpatrick/Phillips model to investigate the patient-related and organizational effects of graduate competency-based medical education for five basic anesthetic procedures.

METHODS

The MEDLINE, ERIC, CINAHL, and Embase databases were searched for papers reporting results in Kirkpatrick/Phillips levels 3-5 from graduate competency-based education for five basic anesthetic procedures. A gray literature search was conducted by reference search in Google Scholar.

RESULTS

In all, 38 studies were included, predominantly concerning central venous catheterization. Three studies reported significant cost-effectiveness by reducing infection rates for central venous catheterization. Furthermore, the procedural competency, retention of skills and patient care as evaluated by fewer complications improved in 20 of the reported studies.

CONCLUSION

Evidence suggests that competency-based education with procedural central venous catheterization courses have positive effects on patient care and are both cost-effective. However, more rigorously controlled and reproducible studies are needed. Specifically, future studies could focus on organizational effects and the possibility of transferability to other medical specialties and the broader healthcare system.

Validation of the imperial college surgical assessment device for spinal anesthesia

Background

Traditionally, technical proficiency for spinal anesthesia has been assessed using observational scales such as global rating scales or task specific checklists. However more objective metrics are required in order to improve novice’s training programs. The aim of this study is to validate the hand motion analysis of the Imperial College Surgical Assessment Device (ICSAD) in a simulated model of spinal anesthesia.

Methods

Three groups of physicians with different levels of experience were video recorded performing a spinal anesthesia in a simulated lumbar puncture torso. Participants’ technical performance was assessed with ICSAD, a Global Rating Scale (GRS) and a specific Checklist. Differences between the 3 groups were determined by Kruskal-Wallis test with post hoc Dunn’s correction for multiple comparisons. Spearman correlation coefficient between ICSAD variables and the scores of the observational scales were calculated to establish concurrent validity.

Results

Thirty subjects participated in the study: ten novice (first year residents), 10 intermediate (third year residents) and 10 experts (attending anesthesiologists). GRS scores were significantly higher in experts, than intermediates and novices. Regarding total path length, number of movements and procedural time measured with ICSAD, all groups had significant differences between them (p = 0.026, p = 0.045 and p = 0.005 respectively). Spearman correlation coefficient was −0,46 (p = 0.012) between total path length measured with ICSAD and GRS scores.

Conclusions

This is the first validation study of ICSAD as an assessment tool for spinal anesthesia in a simulated model. Using ICSAD can discriminate proficiency between expert and novices and correlates with previously validated GRS. Its use in the assessment of spinal anesthesia proficiency provides complementary data to existing tools. Our results could be used to design future training programs with reliable goals to accomplish.

Electronic supplementary material

The online version of this article (10.1186/s12871-017-0422-3) contains supplementary material, which is available to authorized users.

Conveying practical clinical skills with the help of teaching associates-a randomised trial with focus on the long term learning retention

BACKGROUND

Ensuring that all medical students achieve adequate clinical skills remains a challenge, yet the correct performance of clinical skills is critical for all fields of medicine. This study analyzes the influence of receiving feedback by teaching associates in the context of achieving and maintaining a level of expertise in complex head and skull examination.

METHODS

All third year students at a German university who completed the obligatory surgical skills lab training and surgical clerkship participated in this study. The students were randomized into two groups.

CONTROL GROUP

lessons by an instructor and peer-based practical skills training. Intervention group: training by teaching associates who are examined as simulation patients and provided direct feedback on student performance. Their competency in short- and long-term competence (directly after intervention and at 4 months after the training) of head and skull examination was measured. Statistical analyses were performed using SPSS Statistics version 19 (IBM, Armonk, USA). Parametric and non-parametric test methods were applied. As a measurement of correlation, Pearson correlations and correlations via Kendall's-Tau-b were calculated and Cohen's d effect size was calculated.

RESULTS

A total of 181 students were included (90 intervention, 91 control). Out of those 181 students 81 agreed to be videotaped (32 in the control group and 49 in the TA group) and examined at time point 1. At both time points, the intervention group performed the examination significantly better (time point 1, p = <.001; time point 2 (rater 1 p = .009, rater 2 p = .015), than the control group. The effect size (Cohens d) was up to 1.422.

CONCLUSIONS

The use of teaching associates for teaching complex practical skills is effective for short- and long-term retention. We anticipate the method could be easily translated to nearly every patient-based clinical skill, particularly with regards to a competence-based education of future doctors.

The future of regional anesthesia education: lessons learned from the surgical specialty

PURPOSE

Application of ultrasound in regional anesthesia has now become the standard of care and its use has shown to reduce complications. Nevertheless, gaining expertise in ultrasound-guided regional anesthesia requires the acquisition of new cognitive and technical skills. In addition, due to a reduction in resident working hours and enforcement of labour laws and directives across various states and countries, trainees perform and witness fewer procedures. Together, these issues create challenges in the teaching and learning of ultrasound-guided regional anesthesia in the time-based model of learning.

PRINCIPAL FINDINGS

The challenges of teaching ultrasound-guided regional anesthesia are similar to those experienced by our surgical counterparts with the advent of minimally invasive surgery. In order to overcome these challenges, our surgical colleagues used theories of surgical skills training, simulation, and the concept of deliberate practice and feedback to shift the paradigm of learning from experience-based to competency-based learning.

CONCLUSION

In this narrative review, we describe the theory behind the evolution of surgical skills training. We also outline how we can apply these learning theories and simulation models to a competency-based curriculum for training in ultrasound-guided regional anesthesia.

Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We?

There have been colossal technological advances in the use of simulation in anesthesiology in the past 2 decades. Over the years, the use of simulation has gone from low fidelity to high fidelity models that mimic human responses in a startlingly realistic manner, extremely life-like mannequin that breathes, generates E.K.G, and has pulses, heart sounds, and an airway that can be programmed for different degrees of obstruction. Simulation in anesthesiology is no longer a research fascination but an integral part of resident education and one of ACGME requirements for resident graduation. Simulation training has been objectively shown to increase the skill-set of anesthesiologists. Anesthesiology is leading the movement in patient safety. It is rational to assume a relationship between simulation training and patient safety. Nevertheless there has not been a demonstrable improvement in patient outcomes with simulation training. Larger prospective studies that evaluate the improvement in patient outcomes are needed to justify the integration of simulation training in resident education but ample number of studies in the past 5 years do show a definite benefit of using simulation in anesthesiology training. This paper gives a brief overview of the history and evolution of use of simulation in anesthesiology and highlights some of the more recent studies that have advanced simulation-based training.

Using an Instructional Design Model to Teach Medical Procedures

Educators are often tasked with developing courses and curricula that teach learners how to perform medical procedures. This instruction must provide an optimal, uniform learning experience for all learners. If not well designed, this instruction risks being unstructured, informal, variable amongst learners, or incomplete. This article shows how an instructional design model can help craft courses and curricula to optimize instruction in performing medical procedures. Educators can use this as a guide to developing their own course instruction.

Simulation in teaching regional anesthesia: current perspectives

The emerging subspecialty of regional anesthesiology and acute pain medicine represents an opportunity to evaluate critically the current methods of teaching regional anesthesia techniques and the practice of acute pain medicine. To date, there have been a wide variety of simulation applications in this field, and efficacy has largely been assumed. However, a thorough review of the literature reveals that effective teaching strategies, including simulation, in regional anesthesiology and acute pain medicine are not established completely yet. Future research should be directed toward comparative-effectiveness of simulation versus other accepted teaching methods, exploring the combination of procedural training with realistic clinical scenarios, and the application of simulation-based teaching curricula to a wider range of learner, from the student to the practicing physician.