Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing

Feasibility and efficacy of simulation training for joint dislocation management in residency

BACKGROUND

Residents in EM training programs are required by the Accreditation Council of Graduate Medical Education (ACGME) to achieve competency in joint dislocation management. Our study group developed three large joint dislocation task trainers and evaluated their feasibility and efficacy in residency training.

METHODS

During the study period, participants attempted reduction of the dislocation task trainers. Study personnel collected data from these attempts, including procedural success, time to hand placement, and time to joint reduction. Hands-on education was then provided. Learners participated a second time during the study period, and collection of data was repeated. Rates of successful joint dislocation reductions were determined and reported with exact 95 % binomial confidence intervals (95 % CI). Medians and upper and lower quartiles for time to hand placement and time to successful reduction were calculated and reported.

RESULTS

Among first-time users, the successful reduction rates for the shoulder, hip and elbow were 63 % (19/30, 95 % CI 43-80 %), 83 % (25/30, 95 % CI 62-94 %), and 90 % (27/30, 95 % CI 73-97 %) respectively. For second-time users, successful reduction rates were 100 % (30/30, 95 % CI 88-100 %) for all joints. Among first-time participants, the median times to achieve successful shoulder, hip, and elbow reduction were 69 s (IQR 32, 92), 35 s (IQR 22, 49), and 16 s (IQR 13, 24) respectively. For second-time users, the median times to reduce these joints were 24 s (IQR 14, 40), 14 s (IQR 11, 17) and 10 s (IQR 7, 12).

CONCLUSION

Our data suggest that large joint dislocation management training is feasible using high-fidelity simulation task trainers. Additional study is planned to assess the potential role of this approach for improving procedural competency in the clinical realm.

Development of a Reliable, Valid Procedural Checklist for Assessment of Emergency Medicine Resident Performance of Emergency Cricothyrotomy

Introduction

Emergency cricothyrotomy is a rare but potentially life-saving procedure performed by emergency physicians. A comprehensive, dichotomous procedural checklist for emergency cricothyrotomy for emergency medicine (EM) resident education does not exist.

Objectives

We aimed to develop a checklist containing the critical steps for performing an open emergency cricothyrotomy, to assess performance of EM residents performing an open emergency cricothyrotomy using the checklist on a simulator, and to evaluate the reliability and validity of the checklist for performing the procedure.

Curricular Design

We developed a preliminary checklist based on literature review and sent it to experts in EM and trauma surgery. A modified Delphi approach was used to revise the checklist and reach consensus on a final version of the checklist. To assess usability of the checklist, we assessed EM residents using a cricothyrotomy task trainer. Scores were determined by the number of correctly performed items. We calculated inter-rater reliability using the Cohen kappa coefficient. Validity was assessed using the Welch t-test to compare the performance of residents who had and had not performed an open emergency cricothyrotomy, and we used analysis of variance to compare performance of postgraduate year (PGY) cohorts.

Impact/Effectiveness

The final 27-item checklist was developed after three rounds of revisions. Inter-rater reliability was strong overall (κ = 0.812) with individual checklist items ranging from slight to nearly perfect agreement. A total of 56 residents participated, with an average score of 14.3 (52.9%). Performance varied significantly among PGY groups (P < 0.001). Residents who had performed an emergency cricothyrotomy previously performed significantly better than those who had not (P = 0.005). The developed checklist, which can be used in procedural training for open emergency cricothyrotomy, suggests that improved training approaches to teaching and assessing emergency cricothyrotomy are needed given the overall poor performance of this cohort.

Twelve tips for developing simulation-based mastery learning clinical skills checklists

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

Mental Practice: Applying Successful Strategies in Sports to the Practice of Emergency Medicine

Emergency physicians are expected to learn and maintain a large and varied set of competencies for clinical practice. These include high acuity, low occurrence procedures that may not be encountered frequently in the clinical environment and are difficult to practice with high fidelity and frequency in a simulated environment. Mental practice is a form of a cognitive walk-through that has been shown to be an effective method for improving motor and cognitive skills, with literature in sports science and emerging evidence supporting its use in medicine. In this article, we review the literature on mental practice in sports and medicine as well as the underlying neuroscientific theories that support its use. We review best-known practices and provide a framework to design and use mental imagery scripts to augment learning and maintaining the competencies necessary for physicians at all levels of training and clinical environments in the practice of emergency medicine.

Impact of Simulation-based Mastery Learning on Management of Massive Hemoptysis

Background

The management of massive hemoptysis is a high-risk, low-volume procedure that is associated with high mortality rates, and pulmonary and critical care medicine (PCCM) fellows often lack training. Simulation-based mastery learning (SBML) is an educational strategy that improves skill but has not been applied to massive hemoptysis management.

Objective

This pilot study aimed to develop a high-fidelity simulator, implement an SBML curriculum, and evaluate the impact on PCCM fellows managing massive hemoptysis.

Methods

We modified a simulator to bleed from segmental airways. Next, we developed an SBML curriculum and a validated 26-item checklist and set a minimum passing standard (MPS) to assess massive hemoptysis management. A cohort of traditionally trained providers was assessed using the checklist. First-year PCCM fellows reviewed a lecture before a pretest on the simulator using the skills checklist and underwent rapid-cycle deliberate practice with feedback. Subsequently, fellows were posttested on the simulator, with additional training as necessary until the MPS was met. We compared pretest and posttest performance and also compared SBML-trained fellows versus traditionally trained providers.

Results

The MPS on the checklist was set at 88%. All first-year PCCM fellows (N = 5) completed SBML training. Mean checklist scores for SBML participants improved from 67.7 ± 8.4% (standard deviation) at pretest to 84.6 ± 6.7% at the initial posttest and 92.3 ± 5.4% at the final (mastery) posttest. Traditionally trained participants had a mean test score of 60.6 ± 13.1%.

Conclusion

The creation and implementation of a massive hemoptysis simulator and SBML curriculum was feasible and may address gaps in massive hemoptysis management training.