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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Prehospital chest tube placement: Which factors are associated with feeling confident to perform the procedure?]

BACKGROUND

The prehospital placement of chest tubes is a rare but potentially life-saving procedure. A high level of subjective confidence with the procedure is essential for emergency medical doctors. This study aims to identify if there is a statistically significant difference in the subjective sense of confidence in prehospital chest tube placement regarding medical experience and qualification, clinical routine, and attendance at simulation courses.

METHODS

Prehospital emergency physicians of three emergency medical services in Southwest Saxony, Greifswald, and Vechta, Germany, were invited to participate in an online survey from January to March 2022 using the online survey service limesurvey. The question "Do you feel confident in chest tube placement?" was used to measure the subjective level of confidence. Answers were compared with data concerning medical qualification, experience in prehospital emergency medicine, clinical routine, and attendance at simulation courses. Statistical analysis was performed using chi-squared test and Fisher's exact test.

RESULTS

Three out of four participants felt confident in chest tube placement (53/71; 74.6%). More than half of the participants reported that they did not perform this procedure regularly (35/53, 66%). Subjective confidence was highest in physicians who regularly place chest tubes during their non-prehospital work (34/37; 91,9%; p<0.001), and more often when participants had clinical routine and attended simulation courses than when none of this applied (p=0.012). Attendance at simulation courses alone was not associated with a higher level of confidence (p=0.002). Specialists showed significantly more often subjective confidence in chest tube placement (p=0.0401).

CONCLUSION

Prehospital chest tube placement is rare, but potentially lifesaving. An adequately high level of subjective confidence in the placement of chest tubes is a key condition for prehospital emergency doctors. Inhospital clinical routine and attendance at simulation courses are significantly associated with high levels of confidence. Our data indicate that working only in prehospital emergency settings without further clinical routine or medical specialization is not sufficient for achieving and ensuring subjective confidence in chest tube placement.

Experience informed procedural skills training

BACKGROUND

Paediatric critical care (PCC) physicians must perform several emergent procedures independently and competently-requiring transition from novice to competent over a 3-year fellowship. However, skill acquisition is not uniform. Individualised training, adapted to the unique experiences and requirements of each trainee, may enhance competency.

APPROACH

An individualised, longitudinal critical procedure course was initiated at a large academic paediatric medical centre in July 2022 for PCC fellows (n = 5). The course, informed by procedural performance profiles (P3) generated through real-time clinical assessments in the paediatric intensive care unit (PICU), was split into three phases: (1) an Initial Simulation Bootcamp-a 2-day introductory session; (2) Quarterly Structured Booster Sessions (QSBS)-spaced repetition of deliberate practice training individualised to each fellow; and (3) an Annual Refresher Training-a core skills and advanced technique training day.

EVALUATION

Fellows began with minimal experience, which formed their initial P3s. Ninety-two percent (166/180) of bedside procedures received real-time feedback, enabling longitudinal P3 modification, which identified focus areas for the QSBS. The sessions were well attended and received. Eighty-nine percent (QSBS #1 5/5, QSBS #2 3/4) of respondents reflected positively on the course's impact on procedural understanding. The course was perceived as more effective than traditional modalities, except bedside training.

IMPLICATION

Implementation of a spaced repetition, deliberate practice course informed by longitudinally tracked real-life performance data is feasible for educators and preferred by trainees. This educational construct can be applied to other clinical skills, bringing precision medicine approach to training.

Developing a Comparative Effective Methodology for Technology Usability During a Simulated Casualty Event

INTRODUCTION

Future combat environments will be complex, making effective care for multi-domain battlefield injuries more challenging. Technology and resources are essential to reduce provider burden enabling more accurate assessments, decision-making support, expanded treatment, and outcome improvements. Experimentation exercises to evaluate concepts and technologies to incorporate into the Army's future force ensure rapid and continuous integration across air, land, sea, space, and cyberspace domains to overmatch adversaries. A medical lane was first integrated on the communications networks for experimentation in 2022. We describe a project to develop a method for empirically comparing devices intended to support combat casualty care through high-fidelity simulation in preparation for an Army experimentation exercise.

METHODS

Six medics participated in a series of high-fidelity simulation medical casualty injury scenarios with and without technology devices. The participants provided usability information about their care delivery experiences using the System Usability Scale and Adapted Telehealth Usability Questionnaire-Telemedicine and Advanced Technology Research Command and qualitative feedback.

RESULTS

A comparative effectiveness design compared the devices regarding their usability, size, weight, and power with the addition of cost, connectivity, and cyber security, and the qualitative feedback this methodology holistically assessed the technologies as they were applied in the combat casualty care scenario.

CONCLUSIONS

Results were used by decision makers to determine technology inclusion in experimentation exercise, develop proof of concept methodology to scale for the exercise, and provide technology developers feedback for iterative updates of their devices before participation in experimentation exercise. This project supports the body of simulation studies conducted to understand combat casualty care. It is one of few empirical medical technology assessments with medical personnel end user input that has been reported. The methodology incorporates a user-centered design for rapid technology improvements before fielding.

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.

Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents

Anesthesiologists may encounter multiple obstacles in communication when attempting to collect information for emergency surgeries. Occult tension pneumothorax that was asymptomatic in the emergency department (ED) could become apparent upon positive pressure ventilation and pose a critical threat to the patient intraoperatively. Here, we describe a simulation exercise that was developed as a curriculum module for the Indiana University (IU) Anesthesiology residency program. It is primarily designed for first-year clinical anesthesia residents (CA-1/PGY-2). It is a 50 min encounter with two scenarios. The first scenario focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scenario focuses on the early diagnosis of tension pneumothorax and subsequent treatment. The residents were given formative feedback and met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, and anaphylaxis. Residents rated the feedback and debriefing as “extremely useful” or “very useful.” Time constraints limit the number of residents who can sit in the “hot seat.” The structure of the mannequin limits the ability to diagnose pneumothorax by auscultation and ultrasound. In the future, the scenarios may also be utilized to educate student anesthesiologist assistants and other non-physician anesthesia learners.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans

Background

Traumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients.

Methods

A retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately.

Results

Proper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated.

Discussion

Long-term strategies may be needed to improve the capabilities and performance of prehospital providers' capabilities in this delicate life-saving procedure.

Level of evidence

IV.

Development of a novel 3D-printed multifunctional thorax model simulator for the simulation-based training of tube thoracostomy

Tube thoracostomy is a high-acuity, low-occurrence (HALO) procedure with significant morbidity when performed incorrectly; this is amendable through simulation. Commercially available trainers exist but often have limited realism or exorbitant cost. Three-dimensional (3D) printing produces realistic and cost-effective models suitable for simulation, but no simulator has been developed for tube thoracostomy. The aim of this paper is to describe the initial development of a multifunctional 3D-printed thorax trainer for the instruction of tube thoracostomy. The thorax model was developed in conjunction with a multi-disciplinary team using 3D-printing capable software. An existing ribcage model was modified and printed in separate elements, including bony portions (ribcage, sternum and clavicles), flexible joints, skin, heart and lungs and then assembled. The total printing cost was $180 CAD. Future research will focus on incorporating the model's ability to simulate other HALO procedures and evaluating it as a training adjunct.

Prolonged, High-Fidelity Simulation for Study of Patient Care in Resource-Limited Medical Contexts and for Technology Comparative Effectiveness Testing

Most high-fidelity medical simulation is of limited duration, used for education and training, and rarely intended to study medical technology. U.S. caregivers working in prehospital, resource-limited settings may need to manage patients for extended periods (hours to days). This "prolonged casualty care" occurs during military, wilderness, humanitarian, disaster, and space medicine. We sought to develop a standardized simulation model that accurately reflects prolonged casualty care in order to study caregiver decision-making and performance, training requirements, and technology use in prolonged casualty care.

DESIGN

Model development.

SETTING

High-fidelity simulation laboratory.

SUBJECTS

None.

INTERVENTIONS

We interviewed subject matter experts to identify relevant prolonged casualty care medical challenges and selected two casualty types to further develop our model: a large thermal burn model and a severe hypoxia model. We met with a multidisciplinary group of experts in prolonged casualty care, nursing, and critical care to describe how these problems could evolve over time and how to contextualize the problems with a background story and clinical environment with expected resource availability. Following initial scenario drafting, we tested the models with expert clinicians. After multiple tests, we selected the hypoxia model for refinement and testing with inexperienced providers. We tested and refined this model until two research teams could proctor the scenario consistently despite subject performance variability.

MEASUREMENTS AND MAIN RESULTS

We developed a 6-8-hour simulation model that represented a 14-hour scenario. This model of pneumonia evolved from presentation to severe hypoxia necessitating advanced interventions including airway, breathing, and shock management. The model included: context description, caregiver orientation scripts, hourly progressive physiology tracks corresponding to caregiver interventions, intervention/procedure-specific physiology tracks, intervention checklists, equipment lists, prestudy checklists, photographs of setups, procedure, telementor, and role player scripts, business rules, and data collection methods.

CONCLUSIONS

This is the first standardized, high-fidelity simulation model of prolonged casualty care described in the literature. It may be used to assess caregiver performance and patient outcomes resulting from that performance during a complex, 14-hour prolonged casualty care scenario. Because it is standardized, the model may be used to compare differences in the impact of new technologies upon caregiver performance and simulated patient outcomes..

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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